Effective Date: October 14, 2019

Purpose:
This policy provides guidelines for reimbursement of tympanometry/impedance testing when billed by a provider at the time of a preventive medicine visit.

Scope:
Products included:

• NJ FamilyCare/Medicaid Plan
• Fully Integrated Dual Eligible Special Needs Plan (FIDE-SNP)

Definitions:

• CPT Code 92567: Tympanometry (impedance testing)
• Modifier -25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
• Modifier -59: Distinct Procedural Service
• Modifier XE: Separate encounter, a service that is distinct because it occurred during a separate encounter
• Preventative Medicine Visit: An evaluation and management visit on an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures

Policy:
Horizon NJ Health will only allow tympanometry/impedance testing (CPT code 92567) billed with a preventive medicine service (CPT codes 99381-99397) IF modifier -25 is appended to the Evaluation and Management (E/M) code. If modifier -25 is not appended, tympanometry/impedance testing will be considered part of the office visit and will be denied.

In addition, when distinct service modifier -59 or modifier -XE is not appended to the tympanometry/impedance testing code, the tympanometry/impedance testing will be denied.

Procedure:
Horizon NJ Health shall deny tympanometry/impedance testing (CPT code 92567) when billed by a provider at the time of a preventive medicine visit (CPT codes 99381-99397) if the correct modifiers are not applied.

Limitations and Exclusions:
While reimbursement is considered, payment determination is subject to, but not limited to:

• Benefit Limitations
• The terms of any applicable provider participation agreement;
• Routine claim editing logic, including but not limited to incidental or mutually exclusive logic;
• Medical necessity; and
• Applicable law, regulatory guidance, government mandates, and the terms of the Managed Care Contract between Horizon NJ Health and the New Jersey Department of Human Services, Division of Medical Assistance and Health Services.

References:

Medicare Claims Processing Manual, Chapter 18- Preventive and Screening Services cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c18.pdf

American Medical Association, Current Procedural Terminology (CPT®) Professional Edition and associated publications and services