For Dates of Service Before January 1, 2014

Audiology Professional Services

The following table lists the CPT procedure codes for audiology services covered under the BadgerCare Plus Standard Plan and under the BadgerCare Plus Benchmark Plan for members 17 years of age and younger:

Procedure Code Description Copayment Prior Authorization Required Daily Service Limit Maximum Allowable Fee

69210

Removal impacted cerumen (separate procedure), one or both ears

Standard Plan: N/A. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit

No

1

$25.75

92504

Binocular microscopy (separate diagnostic procedure)

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$23.86

92506

Evaluation of speech, language, voice, communication, and/or auditory processing

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

PA after initial SOI

1

$57.19

92507

Treatment of speech, language, voice, communication, and/or auditory processing disorder

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

PA after initial SOI

1

$45.18

92508

Group, two or more individuals

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

PA after initial SOI

1

$26.68

92511

Nasopharyngoscopy with endoscope (separate procedure)

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$47.12

92512

Nasal function studies (eg, rhinomanometry)

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$36.38

92516

Facial nerve function studies (eg, electroneuronography)

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$26.07

92520

Laryngeal function studies (ie, aerodynamic testing and acoustic testing)

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$29.58

92526

Treatment of swallowing dysfunction and/or oral function for feeding

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$46.49

92531

Spontaneous nystagmus, including gaze

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$57.53

92532

Positional nystagmus test

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$37.12

92533

Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests)

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$24.22

92534

Optokinetic nystagmus test

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$42.06

92541

Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$34.67

92542

Positional nystagmus test, minimum of 4 positions, with recording

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$30.70

92543

Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests), with recording

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$39.29

92544

Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$23.77

92545

Oscillating tracking test, with recording

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$20.46

92546

Sinusoidal vertical axis rotational testing

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$26.42

92547

Use of vertical electrodes (List separately in addition to code for primary procedure)

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$18.16

92548

Computerized dynamic posturography

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$77.91

92550

Tympanometry and reflex threshold measurements

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$17.64

92551

Screening test, pure tone, air only

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$12.56

92552

Pure tone audiometry (threshold); air only

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$16.41

92553

air and bone

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$23.11

92555

Speech audiometry threshold;

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$14.51

92556

with speech recognition

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$21.34

92557

Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$38.18

92559

Audiometric testing of groups

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$21.98

92560

Bekesy audiometry; screening

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$17.78

92561

diagnostic

Standard Plan: $.50. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$7.18

92562

Loudness balance test, alternate binaural or monaural

Standard Plan: $.50. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$8.31

92563

Tone decay test

Standard Plan: $.50. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$9.17

92564

Short increment sensitivity index (SISI)

Standard Plan: $.50. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$8.33

92565

Stenger test, pure tone

Standard Plan: $.50. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$9.00

92567

Tympanometry (impedance testing)

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$17.03

92568

Acoustic reflex testing; threshold

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$12.94

92570

Acoustic immittance testing, includes tympanometry (impedance testing) acoustic reflex threshold testing, and acoustic reflex decay testing

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$26.87

92571

Filtered speech test

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$28.94

92572

Staggered spondaic word test

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$17.35

92575

Sensorineural acuity level test

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$17.35

92576

Synthetic sentence identification test

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$17.35

92577

Stenger test, speech

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$14.48

92579

Visual reinforcement audiometry (VRA)

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$25.29

92582

Conditioning play audiometry

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$15.07

92583

Select picture audiometry

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$15.29

92584

Electrocochleography

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$49.56

92585

Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$151.03

92586

limited

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$60.62

92587

Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$49.53

92588

Comprehensive or diagnostic evaluation (comparison of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies)

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$68.33

92590

Hearing aid examination and selection; monaural

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$22.93

92591

Binaural

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$25.41

92592

Hearing aid check; monaural

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$15.38

92593

Binaural

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$19.40

92594

Electroacoustic evaluation for hearing aid; monaural

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$11.39

92595

Binaural

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$14.36

92596

Ear protector attenuation measurements

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$10.36

92597

Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$72.33

92601

Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$112.20

92602

Subsequent reprogramming

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$76.90

92603

Diagnostic analysis of cochlear implant, age 7 years or older; with programming

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$69.32

92604

Subsequent reprogramming

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$49.43

92607

Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$60.57

92608

each additional 30 minutes (List separately in addition to code for primary procedure)

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$30.29

92609

Therapeutic services for the use of speech-generating device, including programming and modification

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$145.37

92610

Evaluation of oral and pharyngeal swallowing function

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$68.78

92611

Motion fluoroscopic evaluation of swallowing function by cine or video recording

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$111.35

92612

Flexible fiberoptic endoscopic evaluation of swallowing by cine or video recording

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$132.47

92614

Flexible fiberoptic endoscopic evaluation, laryngeal sensory testing by cine or video recording

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$124.41

92620

Evaluation of central auditory function, with report; initial 60 minutes

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$37.55

92621

Each additional 15 minutes

Standard Plan: $.50. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

2

$9.50

92625

Assessment of tinnitus (includes pitch, loudness matching, and masking)

Standard Plan: $2.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$36.92

92626

Evaluation of auditory rehabilitation status; first hour

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$65.40

92627

Each additional 15 minutes (List separately in addition to code for primary procedure)

Standard Plan: $1.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

2

$16.35

92630

Auditory rehabilitation; pre-lingual hearing loss

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$75.95

92633

Post-lingual hearing loss

Standard Plan: $3.00. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

No

1

$75.95

92700

Unlisted otorhinolaryngological service or procedure

Standard Plan: Based on pricing for procedure. Benchmark Plan: $15.00 per visit, regardless of number of procedures performed during the visit.

Yes

N/A

Manually Priced