The most common procedures have fairly straightforward coding; however, once in a while, a procedure comes along for which there does not seem to be a good CPT code. The Canalith Repostioning Procedure is such a procedure.

BPPV is caused by minute, almost microscopic, liths or stones composed mostly of calcium carbonate that have wended their way from the utricle of the vestibule of the inner ear, where these liths occur naturally, into the semicircular canals. Of course, the semicircular canals are responsible for a persons sense of balance, and the presence of these tiny particles in the canals, where they become known as canaliths, plays havoc with a persons ability to remain balanced by stimulating the balance nerve inappropriately. These canaliths can cause vertigo when the head is moved into certain positions. There is often a severe spinning sensation usually lasting about 20 seconds, which can produce unsteadiness and nausea, sometimes lasting several hours.

BPPV is often diagnosed using the Dix-Hallpike Maneuver (also called Nylen's Maneuver or Barany's Maneuver). The Dix-Hallpike Maneuver involves quickly laying a patient on his back with his neck extended, and turning the patients head to the left. The patient then sits up again and the procedure is repeated this time turning the patients head to the right. In both instances, the patient is evaluated for symptoms of vertigo or for nystagmus, or involuntary cyclical movement of the eyeballs.

Once BPPV has been diagnosed, a treatment for the condition is the Canalith Repositioning Procedure (CRP) also called the Epley Maneuver. There is a similar maneuver called the Semont or Parnes Maneuver that is not generally favored in the United States. In the CRP, the physician maneuvers the patient's head through a series of positions in a particular order in an effort to reposition the small canaliths that have wended their way into the patient's semicircular canals. The series of positions is as follows: after first having the patient sit up for a few moments, the physician will have the patient lie on his back for 30 to 60 seconds with the patients head turned to the affected side by about 45 degrees. The patients head will then be rotated slightly to the unaffected side for another 30 to 60 seconds. Next, the patients entire body will be rolled to the unaffected side so that the patients nose is pointing down by about 45 degrees. The patient will remain in this position for another 30 seconds. Finally, the patient will be returned to an upright position with the nose pointing slightly down. This entire series of maneuvers is then repeated two more times.

Blindly repositioning the canaliths from the posterior ear canal into the utricle in this manner can be a successful treatment for benign paroxysmal positional vertigo (BPPV). A typical CRP lasts about 10 minutes; most recently, many physicians have begun using a small vibrator or oscillator applied to the patients forehead during the entire procedure to help the canaliths "wiggle" back to where they belong.

After undergoing the Epley Maneuver treatment, the Dix-Hallpike Maneuver will likely be repeated, generally about a week later, to determine if the CRP was successful. So, strictly speaking, the Dix-Hallpike Maneuver (which is diagnostic) and the CRP (which is therapeutic) are two separate things.

Different CPT codes to report CRP have been suggested over the years by coders. These include 98925, 97110, 97112, and 92599. However, recently the AMA has clarified that CPT code 92599 Unlisted otorhinolaryngological service or procedure should be used to report a Canalith Repositioning Procedure.

Note that the CPT code 92599 was deleted from the CPT code set, effective Jan. 1, 2003, after publication of this article. The CPT book now instructs coders to report 92700 unlisted otorhinolaryngological service or procedure instead of 92599. 

Of course, it bears repeating that when reporting an unlisted procedure code to describe a procedure or service, it will be necessary to submit supporting documentation (e.g., a procedure report) along with the claim to provide an adequate description of the nature, extent, and need for the procedure, as well as the time, effort, and equipment necessary to provide the service.

Reimbursement for this service will vary depending upon the payers policies. For example, HGS Administrators (the Medicare Carrier for Pennsylvania) issued a Local Medicare Review Policy regarding CRP back in September of 1998. It can be obtained at the following Web address:

http://www.hgsa.com/professionals/med-reports/mr0998.shtml

In conformance with CPT coding guidelines, HGS Administrators' policy instructs providers to use CPT code 92599 Unlisted otorhinolaryngological service or procedure. It also indicates that they will only reimburse for this procedure if the ICD-9-CM code associated with this procedure is 386.11 (BPPV).

On the other hand, TrailBlazer Health Enterprises (the Medicare Carrier for Texas, Maryland, D.C., Delaware and Virginia) also has a policy regarding CRP. Their policy is to not pay for them at all for any condition. Their policy is at:

• http://www.the-medicare.com/lmrp/tx/canalrpo.asp

On yet another hand, First Coast Service Options, Inc. (the Medicare Carrier for Florida), like TrailBlazer Health Enterprises, will not pay for CRP. However, First Coast Service Options, Inc. wants providers of CRP to use HCPCS code A9270 Noncovered item or service to report CRP services. Their policy can be found by searching for "canalith" at http://www.floridamedicare.com/.

So, as always, it would be best to check with the payer to see how they would like CRP services reported. In the absence of any such payer-specific policy, however, standard CPT coding guidelines would seem to apply.

The Web is a good source of information on BPPV and CRP. Excellent information on these two subjects can be found at the following Web sites:

• http://www.fpnotebook.com/ENT45.htm
• http://www.galter.nwu.edu/geriatrics/chapters/dizziness.cfm]
• http://users.aol.com/inventmd/bppv.html
• http://www.neurosci-online.com/benign_positional_vertigo.html

Greg Schnitzer, CodeRyte, Inc.

The above article was originally published in the November/December 2001 issue of The Coding Edge published by The American Academy of Professional Coders.

CPT codes, descriptions, and other data only are copyright 2006 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply.