How To Use CPT Code 92549

CPT 92549 describes the computerized dynamic posturography sensory organization test (CDP-SOT) with motor control test (MCT) and adaptation test (ADT). This article will cover the description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information, similar codes and billing examples.

1. What is CPT Code 92549?

CPT 92549 can be used to describe the computerized dynamic posturography sensory organization test (CDP-SOT) with motor control test (MCT) and adaptation test (ADT). This code represents both the technical and professional components of the service, which evaluates the patient’s motor, sensory, and integrative processes used to maintain balance and stability.

2. Official Description

The official description of CPT code 92549 is: ‘Computerized dynamic posturography sensory organization test (CDP-SOT), 6 conditions (ie, eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform and visual sway), including interpretation and report; with motor control test (MCT) and adaptation test (ADT).’ This code represents both the technical and professional components of the service.

3. Procedure

1. The provider performs computerized dynamic posturography sensory organization testing to evaluate the patient’s motor, sensory, and integrative processes used to maintain balance and stability.
2. The test is carried out using 6 conditions specified in the descriptor, including eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, and platform and visual sway.
3. The procedure includes a motor control test (MCT) to assess the patient’s automatic motor responses to restore balance after forward and backward movements of the platform.
4. An adaptation test (ADT) is also conducted to assess the patient’s ability to adapt to unexpected platform rotation when standing in a toes-up and toes-down position.
5. The provider collects data by asking the patient to stand on a platform with force plates surrounded by a visual field, while wearing a harness for safety.
6. The provider initiates the automated test, which alters the angle of the platform and shifts the visual field to assess the patient’s balance and postural control.
7. The provider monitors visual and vestibular information using various techniques, such as electronystagmography, vestibular evoked myogenic potentials, and vestibular ocular reflex (VOR) testing.
8. Each stage of the test is conducted for 30 seconds, and the provider records any abnormal findings using electromyography.
9. The provider interprets the findings and prepares a report for further evaluation and treatment planning.

4. Qualifying circumstances

CPT 92549 is performed on patients who require evaluation of their posture and balance under various conditions. The test assesses elements such as the sense of touch in the lower extremities, vision, and the vestibular system of the inner ear and brain. Patients within the normal range for posture and balance can maintain their balance sufficiently during the tests, while patients unable to maintain balance may show abnormal results.

5. When to use CPT code 92549

CPT code 92549 should be used when a provider performs the computerized dynamic posturography sensory organization test (CDP-SOT) with motor control test (MCT) and adaptation test (ADT). This code represents both the technical and professional components of the service and should be reported when all components of the test are performed.

6. Documentation requirements

To support a claim for CPT 92549, the provider must document the following information:

• Patient’s medical history and reason for the test
• Specific conditions tested, including eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, and platform and visual sway
• Date and duration of the test
• Results of the motor control test (MCT) and adaptation test (ADT)
• Interpretation of the findings
• Preparation of a report for further evaluation and treatment planning

7. Billing guidelines

When billing for CPT 92549, ensure that all components of the test, including the computerized dynamic posturography sensory organization test (CDP-SOT), motor control test (MCT), and adaptation test (ADT), are performed. Append modifier 26 to the code when reporting only the professional component, and append modifier TC when reporting only the technical component. Do not append modifiers when reporting a global service in which one provider renders both the professional and technical components. It is important to check with the payer to ascertain coverage, as some payers may consider CDP-SOT experimental or unproven for certain conditions.

8. Historical information

CPT 92549 was added to the Current Procedural Terminology system on January 1, 2020. There have been no updates to the code since its addition.

9. Examples

1. A patient undergoes the computerized dynamic posturography sensory organization test (CDP-SOT) with motor control test (MCT) and adaptation test (ADT) to evaluate their balance and stability after experiencing frequent falls.
2. A provider performs CPT 92549 on a patient with a history of vestibular dysfunction to assess their motor, sensory, and integrative processes used for maintaining balance.
3. A patient with a suspected vestibular disorder undergoes the computerized dynamic posturography sensory organization test (CDP-SOT) with motor control test (MCT) and adaptation test (ADT) to determine the underlying cause of their balance problems.
4. A provider uses CPT 92549 to evaluate a patient’s postural control and balance after a head injury.
5. A patient with a history of dizziness and vertigo undergoes the computerized dynamic posturography sensory organization test (CDP-SOT) with motor control test (MCT) and adaptation test (ADT) to assess their vestibular function.