​

​Coding Fact Sheet for Primary Care Pediatricians

While coding for hearing screening is relatively straightforward, ensuring that appropriate payment is received for such services is a more complicated matter. This Coding Fact Sheet will provide you with a guide to coding for pediatric hearing screening. While we have provided you with some suggested codes, it should be noted that payer recognition of codes might vary. Most plans are now required to cover hearing screen services under the Affordable Care Act, however, that may still vary.

Diagnosis Codes

International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) Codes (Prior to October 1, 2015)

International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Codes (On or after October 1, 2015)​

Commonly Reported Diagnosis Codes Related To Primary Care Pediatricians & Hearing Loss

Other Diagnosis Codes Related To Hearing Loss

Nervous System and Sense Organs

Congenital Anomalies

Injury and Poisoning

Symptoms, Signs, and Ill-Defined Conditions

Other

NOTE: The ICD-9-CM codes below are used to deal with occasions when circumstances other than a disease or injury are recorded as "diagnoses" or "problems." Some carriers may request supporting documentation for the reporting of V codes.

- Indicates an additional character is required

 

Procedure Codes

Current Procedural Terminology (CPT®) Codes

Commonly Reported Procedure Codes Related To Primary Care Pediatricians & Hearing Loss

​Health and Behavior Assessment/Intervention Codes

These codes cannot be reported by a physician.

The focus of the assessment is not on mental health but on the biopsychosocial factors important to physical health problems and treatments.

The focus of the intervention is to improve the patient's health and well-being utilizing cognitive, behavioral, social, and/or psychophysiological procedures designed to ameliorate the specific hearing-related problems.

Healthcare Common Procedural Coding System (HCPCS) Level II Procedure and Supply Codes

CPT codes are also known as Healthcare Common Procedure Coding System (HCPCS) Level I codes. The Healthcare Common Procedure Coding System also contains Level II codes. These Level II codes (commonly referred to as HCPCS "hick-picks" codes) are national codes that are included as part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) standard procedural transaction coding set along with CPT codes.

HCPCS Level II codes were developed to fill in the gaps in the CPT nomenclature. While they are reported in the same way as a CPT code, they consist of one alphabetic character (A-V) followed by four digits. In the past, insurance carriers did not uniformly recognize HCPCS Level II codes. However, with the advent of HIPAA, carrier software systems must now be able to recognize all HCPCS Level I (CPT^®) and Level II codes.

HCPCS Hearing Services Codes

Vignettes

Vignette #1

5-year-old male established patient presenting for pre-kindergarten health assessment, fails to pass the hearing screen, using a pure tone audiometer at the 30 decibels (dB) level from 500 to 4000 Hertz (Hz) in the left ear. He has a history of three ear infections in his second year. Tympanometry is normal for both ears, indicating no evidence of middle ear effusion. Parents deny any behaviors that would suggest hearing loss (does not turn up the TV, appears to hear voice commands, and does not speak loudly).

How is this service reported?

CPT Coding:

ICD-9-CM and ICD-10-CM Coding:

Note: Contrary to CPT^® guidelines, some payers may inappropriately bundle the screening audiometry service(s) with the preventive medicine evaluation and management (E/M) code. Appending modifier 25 to the preventive medicine service may unbundle the services.

Health assessment should include information pertinent to hearing loss such as prenatal or perinatal risk factors, family history of hearing loss under 30 years of age, physical stigmata related to hearing loss.

The patient is then referred to an audiologist proficient in hearing testing of children for diagnostic testing. Audiologist report for pure tone audiometry (air and bone) and sound booth testing indicates he has sensorineural hearing loss at 50dB in the left ear and normal hearing at 20 dB in the right ear; his left ear speech threshold is 40 dB and right ear speech threshold is 15 dB.

How is this service reported?

CPT Coding:

ICD-9-CM and ICD-10-CM Coding:

Pediatrician counsels parents for 15 minutes on the audiological diagnostic testing results, reviews possible etiologies for unilateral hearing loss, provides information on the effects of unilateral hearing loss on classroom learning, and refers the patient to an otolaryngologist.

How is this service reported?

CPT Coding:

ICD-9-CM and ICD-10-CM Coding:

Note: Otolaryngologist may request CT of left ear or BAER (ABR) testing. Patient should be considered for unilateral amplification in the classroom setting to reduce possible learning barrier.

Vignette #2

An infant is born to parents who both have hearing loss greater than 90 dB. The newborn hearing screen is normal, with no indication of hearing loss. There is a significant family history of congenital hearing loss in both families. Patient is recommended by the hospital hearing screener for repeat hearing testing at 6 months.

How is this service reported?

CPT Coding:

ICD-9-CM and ICD-10-CM Coding:

Note: Payers may inappropriately bundle this procedure into the hospital care E/M code.

Six months later, patient sees hospital screener for repeat hearing testing. Options might include automated brain response (auditory evoked potentials) versus sound booth testing as OAE testing not possible in the active child. Because of the family history, parents are offered a referral to a geneticist for testing for the Connexin 26 gene and subsequent genetic counseling. Referral to an early intervention agency is provided so communication issues can be addressed as parents sign only and have no oral speech.

How is this service reported?

CPT Coding:

ICD-9-CM and ICD-10-CM Coding:

Physician sees patient to confirm audiological screening results. Recommends genetic assessment for Connexin gene for future pregnancy planning. Recommends family seek early intervention services to address communication issues for deaf parents who sign only and a hearing child.

How is this service reported?

CPT Coding:

ICD-9-CMand ICD-10-CM Coding:

Vignette #3

An infant who was referred following an abnormal otoacoustic emission hearing test also fails diagnostic testing at age 5 weeks for both OAE and ABR. ABR indicates a pure tone threshold at about 80dB in both ears; hearing aids may improve auditory acuity. The parents have normal hearing.

How is this service reported?

CPT Coding:

ICD-9-CM and ICD-10-CM Coding:

Patient requires a medical workup for congenital hearing loss. History should assess prenatal or perinatal causes, family history of hearing loss, examination for stigmata associated with hearing loss, genetic testing, EKG (CPT code 93000), and ENT and ophthalmological exams.

How is this service reported?

CPT Coding:

ICD-9-CM and ICD-10-CM Coding:

At the 8-week well exam the parents inquire about the next steps to eventually obtaining a cochlear device so the patient can have oral communication. They want to know what is done during the waiting period for the cochlear implant to communicate effectively with their infant and whether there are any additional referrals to other physicians or studies needed.

How is this service reported?

CPT Coding:

ICD-9-CM and ICD-10-CM Coding:

Patient needs referral to area cochlear implant service, early intervention agency to facilitate nonverbal communication pending cochlear implant by 3 months, and CT scan of ears to assess inner ear anatomy. Otolaryngologist and audiologist should refer patient for auditory amplification by age 6 months.

CPT Coding:

ICD-9-CM and ICD-10-CM Coding:

Modifiers

25  Significant and separately identifiable evaluation and management service

50  Bilateral procedure

52  Reduced procedural service (can be used when a code indicates a bilateral hearing screen/test, but only one ear is tested)

59  Distinct procedural service