CPT code 92626
CPT code 92626 is important for audiologists and SLPs who work with clients with hearing loss to know. In general, therapists should be familiar with the most relevant CPT codes to use with the populations they serve. This can ensure more accurate documentation and billing.
The official description of the 92626 CPT Code is:
Evaluation of Auditory Function for Surgically Implanted Device(s) Candidacy or Postoperative Status of a Surgically Implanted Device(s); first hour.
Before we get into the details of CPT code 92626, let’s review what a CPT code is and when therapists need to use one.
CPT stands for Current Procedural Terminology. CPT codes contribute to a standardized system of coding that’s managed by the American Medical Association (AMA).
CPT codes help ensure consistency among documentation by SLPs and other medical professionals. CPT codes consist of five specific digits, which refer to a certain diagnosis.
Attaching the appropriate CPT code to documentation such as evaluation reports and treatment notes is required by Medicare and Medicaid for billing purposes. Many private insurance companies also require the use of CPT codes on therapists’ documentation.
SLPs should stay in-the-know about commonly used CPT codes in their field, including 92626 that can help improve the efficiency and accuracy of their documentation and billing.
A current list of CPT codes is available to view on the Centers for Medicare & Medicaid Services (CMS) website.
Now, if you’re an Audiologist or Speech-Language Pathologist who works with clients with hearing loss including those with hearing aids or cochlear implants, let’s dive into the what, how, when, where, and why for using the CPT Code 92626.
What is the 92626 CPT Code?
The 92626 CPT code description is: Evaluation of Auditory Function for Surgically Implanted Device(s) Candidacy or Postoperative Status of a Surgically Implanted Device(s); first hour.
It can be used pre-op or post-op of surgically implemented devices for hearing loss.
Pre-op, this code would be used to determine a client’s candidacy for surgically implanted devices and an assessment of their proficiency in understanding speech, given their hearing loss.
When used post-op, the CPT code 92626 includes an assessment of the client’s auditory function to determine their progress with previously implanted devices.
According to the American Speech-Language Hearing Association’s (ASHA) reference of the American Medical Association:
“This code is to be used “for the purpose of defining candidacy for auditory osseointegrated implant(s), middle-ear implant(s), and/or cochlear implant(s) or to monitor the progress of the intervention.”
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The CPT code 92626 may only be billed by an Audiologist or a Speech Language Pathologist.
The evaluation should include the following components:
- A comprehensive client history
- This includes details regarding the client’s history of hearing loss and their use of amplification.
- Review of results from a questionnaire that may have been given to the client before the evaluation.
- Adult clients: (e.g., the Abbreviated Profile of Hearing Aid Benefit or the Hearing Handicap Inventory)
- Pediatric Clients: (e.g., the Little EARS Auditory Questionnaire or Infant-Toddler Meaningful Auditory Integration Scale (IT-MAIS)).
- Confirmation of the integrity and performance of the client’s device.
- Not required to bill CPT code 92626, and can be performed on a separate day or with a different provider.
- If this is completed during the evaluation, the time should be counted as a component of the appointment (and shouldn’t be billed separately).
- Aided and/or Unaided Behavioral Tests of Auditory Function
- For adult clients, this might include sound or sentence repetition tasks with varying levels of background noise (i.e., Quick Speech in Noise test).
- In pediatric clients, this depends on the child’s age and developmental skills. It may include perceptual tasks such as the Ling Six Sound Test or the Early Speech Perception Test.
- Patient/family counseling, including a review of the result and recommendations of the assessment.
According to ASHA, clinicians should strive to identify and use the “best” code to describe the services they provide.
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Here are some examples of procedures in which the provider can attach the 92626 CPT code within documentation and billing:
- A 4 year old with sensorineural hearing loss, who is evaluated for candidacy and is determined a candidate for using a head-worn soft band with a bone-anchored processor.
- An assessment with a 5 year old post-op of a cochlear implant due to the presence of sensorineural hearing loss.
- An evaluation of auditory function after an adult client has received bilateral hearing aids.
How to use the 92626 CPT code
CPT codes are categorized as either being timed or service-based procedures.
The 92626 CPT code is time-based. It should be used for the first 60 minutes of the assessment. The assessment must take at least 31 minutes in order to bill this code.
For each additional 15-minutes spent completing the evaluation, the CPT code 92627 should be used (there must be a minimum of 8 minutes beyond the initial 60 minutes to use this code).
Follow these steps to correctly bill for the 92626 CPT code
- Refer to the AMA CPT manual to ensure that the 92626 CPT code is the most appropriate code for you to use for the service you provided.
- Complete documentation for the evaluation (such as a Speech Therapy Evaluation for a client with hearing loss)
- Document the start and end time of the evaluation.
- Attach the 92626 CPT code to your documentation.
- SLPs have the option of completing a superbill. This may be submitted directly to the payor (ex: Medicaid, Medicare, or private insurance) or can be given to the client.
- Automated billing is another option. This easy and efficient way of billing with the 92626 CPT code is offered by TheraPlatform.
The SLP’s documentation for the evaluation should reflect that the client has a treatment diagnosis related to the description of the 92626 CPT code.
There are several ICD-10 codes that may be associated with the need for an assessment of speech sound production.
These may include:
- F80.4: Speech and language development delay due to hearing loss
- H90.A31: Mixed conductive and sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side
- H90.A12: Conductive hearing loss, unilateral, left ear, with restricted hearing on the contralateral side
The assessment procedures targeted within the session should also relate to the areas outlined in the description for CPT code 92626.
Do’s and Don’ts
Here are some key points to remember, and errors to avoid, when billing the 92626 CPT code. This can help reduce the likeliness of a reimbursement denial.
- Do use the code for evaluation, not treatment.
- Do use this code even if the client will not receive a device implant immediately or possibly ever.
- Clearly differentiate this evaluation from post-op CI programming and mapping (CPT codes 92601-92604) when they are completed on the same day.
- Do not bill using the 92626 CPT code more than one time in a day.
- Do not bill CPT 92626 if the evaluation takes less than 31 minutes.
- (If less than 31 minutes, do not use the reduced service modifier -52
- Do not bill the following CPT codes in conjunction with CPT code 92626: 92590, 92591, 92592, 92593, 92594, or 92595.
- Do not use CPT code 92626 when assessing the client’s phonological skills (instead, use CPT code 9253: Evaluation of Speech Sound Production and Receptive and Expressive Language Skills).
Speech therapists can view which CPT codes to use for various services by referring to ASHA’s Medicare Fee Schedule for Speech-Language Pathologists. This source also lists current reimbursement rates for Speech Therapy Services.
The 2023 national fee for the 92626 CPT code is $85.63.
Reimbursement rates of private insurance payers vary according to specific plans. Determining whether the client’s insurance plan covers Speech Therapy (including an evaluation with the 92626 CPT code) for their specific diagnosis is important.
It’s recommended that you and your client verify this prior to initiating services. That can help maximize reimbursement for this code.
Some private providers choose to set their prices for services to be similar to Medicare or Medicaid reimbursement rates.
Clinicians should stay current on updates to CPT codes, which are performed periodically. Changes may affect the way the clinician bills for services.
On January 1, 2020, the current definition of CPT code 92626 was implemented. Prior to this, the code was used for an evaluation of auditory rehabilitation status.
The changes were made to improve specificity of when to use the code, due to prior insurance denials and inappropriate billing of this code.
SLPs can remain up to date with changes to the 92626 CPT code by checking the AMA’s CPT codebook when updates are made. CPT codes are updated by the AMA annually and are effective for use on January 1st of each year.
Speech Language Pathologists who work with clients with hearing loss should be familiar with the 92626 CPT code.
By staying current on what types of treatment the code includes and when to use it, providers can have more assurance that they’re following AMA guidelines and will receive reimbursement for services.
Resources through TheraPlatform
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