How To Use CPT Code 92540

CPT 92540 is a code used for basic vestibular evaluation, which includes four specific tests to check balance disorders. This article will cover the description, procedure, qualifying circumstances, usage, documentation requirements, billing guidelines, historical information, similar codes, and examples of CPT 92540 procedures.

1. What is CPT 92540?

CPT 92540 is a medical code used to describe a basic vestibular evaluation, which is a series of tests performed by healthcare providers to assess the vestibular, or balance, portion of the inner ear. These tests are essential for diagnosing and treating balance disorders, such as vertigo and dizziness. The code represents both the technical and professional components of the service.

2. 92540 CPT code description

The official description of CPT code 92540 is: “Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording.”

3. Procedure

  1. Spontaneous Nystagmus Test: The provider preps the patient’s skin and applies electrodes to record nystagmus using electronystagmography (ENG) or an infrared system. The patient looks at specific targets, and the provider measures eye movements.
  2. Positional Nystagmus Test: The provider moves the patient’s head into at least four different positions and records eye movements using ENG or an infrared system.
  3. Optokinetic Nystagmus Test: The provider presents a large visual field stimulus, such as stripes or random dots, to generate optokinetic nystagmus. The eye movements are recorded using ENG or an infrared system.
  4. Oscillating Tracking Test: The provider records eye movements using ENG or an infrared system while the patient views a moving target in their visual field.

After completing the tests, the provider calculates the magnitude and direction of nystagmus, reviews the data, prints the recordings, and prepares a report of the diagnostic results and interpretation.

4. Qualifying circumstances

Patients who are experiencing symptoms of balance disorders, such as dizziness, vertigo, or unsteadiness, may be eligible to receive CPT 92540 services. Healthcare providers should perform a thorough evaluation of the patient’s medical history, symptoms, and physical examination findings to determine if the vestibular evaluation is necessary and appropriate for the patient’s condition.

5. When to use CPT code 92540

It is appropriate to bill CPT 92540 when a healthcare provider performs a basic vestibular evaluation to diagnose and treat balance disorders. The provider must perform all four tests included in the code description and document the results and interpretation in the patient’s medical record.

6. Documentation requirements

To support a claim for CPT 92540, healthcare providers must document the following information in the patient’s medical record:

  • Indication for the vestibular evaluation, including the patient’s symptoms and relevant medical history
  • Details of each test performed, including the method used for recording eye movements (ENG or infrared system)
  • Results of each test, including the magnitude and direction of nystagmus
  • Provider’s interpretation of the test results and any relevant clinical findings
  • Diagnostic conclusions and recommendations for treatment or further evaluation

7. Billing guidelines

When billing for CPT 92540, follow these guidelines:

  • Do not report CPT 92540 in conjunction with 92270, 92541, 92542, 92544, or 92545.
  • If reporting only the professional component, append modifier 26 to the code.
  • If reporting only the technical component, append modifier TC to the code, unless the hospital provided the technical component.
  • Do not append a professional or technical modifier when reporting a global service in which one provider renders both components.

8. Historical information

CPT 92540 was added to the Current Procedural Terminology system on January 1, 2010. There have been no updates to the code since its addition.

9. Similar codes to CPT 92540

Five similar codes to CPT 92540 include:

  • CPT 92541: Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording
  • CPT 92542: Positional nystagmus test, minimum of 4 positions, with recording
  • CPT 92544: Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording
  • CPT 92545: Oscillating tracking test, with recording
  • CPT 92270: Electro-oculography with interpretation and report

These codes differ from CPT 92540 as they represent individual tests or procedures related to vestibular evaluation, whereas CPT 92540 encompasses all four tests in a comprehensive evaluation.

10. Examples

Here are 10 detailed examples of CPT 92540 procedures:

  1. A patient with a history of vertigo undergoes a basic vestibular evaluation to determine the cause of their symptoms.
  2. A patient with recurrent dizziness has a vestibular evaluation to rule out an inner ear disorder.
  3. A patient with a history of falls undergoes a vestibular evaluation to assess their balance and risk of future falls.
  4. A patient with Meniere’s disease has a vestibular evaluation to monitor the progression of their condition.
  5. A patient with a head injury undergoes a vestibular evaluation to assess the impact of the injury on their balance and coordination.
  6. A patient with a vestibular schwannoma has a vestibular evaluation to determine the extent of their balance dysfunction.
  7. A patient with a history of migraines and dizziness undergoes a vestibular evaluation to assess the relationship between their symptoms.
  8. A patient with a suspected vestibular neuritis has a vestibular evaluation to confirm the diagnosis and guide treatment.
  9. A patient with a history of ototoxic medication use undergoes a vestibular evaluation to assess the impact on their balance function.
  10. A patient with a family history of balance disorders has a vestibular evaluation to determine their risk of developing a similar condition.

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