Vestibular evaluations are used to diagnose the origin of symptoms such as dizziness and vertigo, and specifically to determine if something is wrong with the vestibular portion of the inner ear. If dizziness is not caused by the inner ear, it might be caused by brain disorders, another medical condition (e.g., low blood pressure), or even psychological issues (e.g., anxiety).
A basic vestibular evaluation includes four components:
a spontaneous nystagmus test
a positional nystagmus test
an optokinetic nystagmus test
an oscillating tracking test
CPT® includes codes to report each of these component tests individually; however, if all components are performed together, you would report them using a single code, 92540 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.
In past years there was confusion about how to report the individual components of the vestibular evaluation if a complete evaluation was not performed. Parenthetic instructions within CPT® now clarify that if three or fewer of the above component tests are performed, in any combination, you may report each test separately, as follows:
92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording
92542 Positional nystagmus test, minimum of 4 positions, with recording
92544 Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording
92545 Oscillating tracking test, with recording
For instance, for spontaneous nystagmus test and optokinetic nystagmus test, report 92541 and 92544. If these tests occurred along with positional nystagmus and oscillating tracking tests, report 92540 to describe all four components. Don’t report any single component (92541, 92542, 92544, or 92545) in addition to 92540.
Note, however, that codes describing caloric vestibular test (92543 Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests), with recording), vertical axis rotational testing (92546 Sinusoidal vertical axis rotational testing) and use of vertical electrodes (+92547 Use of vertical electrodes (List separately in addition to code for primary procedure) may be separately reported with 92540 or any legitimate combination (three or fewer) of 92541, 92542, 92544, and 92545.