Basics of Otorhinolaryngologic Services Coding

In otorhinolaryngology, auditory processing disorders are characterized by inefficient communication between the ears and the brain resulting in an inability to process the information heard. Special otorhinolaryngologic service codes 92521-92524 are used to report diagnostic services that are not included in an evaluation and management service and that are predominantly performed by speech-language pathologists (SLPs). Because most of the population with auditory processing disorders are children, proper diagnosis is extremely important and allows physicians or other qualified health care professionals (such as an SLP) to distinguish between an auditory processing disorder and learning disabilities.

Although codes 92521-92524 have remained unchanged since 2014, they still cause some confusion for clinicians when evaluating patients for aphasia, cognitive-communication issues, and other disorders, especially when it comes to reporting code 92523 vs code 96125. This article provides an overview of the intent and use of code 92523 vs code 96125 and clarifies the similarities and differences between the reporting of these two codes for cognitive performance testing.

Coding description of Otorhinolaryngologic Services

 92521 Evaluation of speech fluency (eg, stuttering, cluttering)

 92522 Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthia);

 92523 with evaluation of language comprehension and expression (eg, receptive and expressive language)

 92524 Behavioral and qualitative analysis of voice and resonance

Assessment of Aphasia and Cognitive Performance Testing

 96125  Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per hour of a qualified health care professional’s time, both face-to-face time administering tests to the patient and time interpreting these test results and preparing the report

Reporting CPT Code 92523

Code 92523 describes an evaluation of speech sound production performed with language evaluation using standardized or non-standardized tools. Code 92523 may also be reported if an SLP is assessing cognitive-communication skills using only non-standardized tools with a full speech and language evaluation. However, according to the American Speech-Language-Hearing Association, speech and language abilities should be the dominant focus when reporting code 92523.

When both speech and language were evaluated, and it is documented that speech-sound production was assessed and the results of that assessment are available, it would be appropriate to report code 92523. Documentation should contain further details regarding sentence- and conversation-level intelligibility with the results of an orofacial examination of the structure and function of articulators.

For an evaluation of language only, ie, without documentation of an assessment of speech, code 92523 should be reported with modifier 52, Reduced Services, appended to indicate that the services provided were less than the full service described by the code descriptor.

Reporting CPT Code 96125

Code 96125 describes an evaluation of cognitive performance using a standardized assessment instrument (eg, Ross Information Processing Assessment-Second Edition, Arizona Battery for Cognitive-Communication Disorders of Dementia, Functional Assessment of Verbal Reasoning and Executive Strategies). Code 96125 is reported per hour and includes both face-to-face time and non-face-to-face time for the interpretation of results and preparation of the report.

Code 96125 should not be used to report tests that are identified as screening tools, such as the Montreal Cognitive Assessment and the Saint Louis University Mental Status examinations. The use of multiple instruments for brief assessment does not replace psychological testing and is not intended for diagnostic purposes. Code 96125 may be reported only when any subsets of the standardized tests performed are themselves standardized.

As a time-based code, code 96125 follows the standard CPT time-based reporting conventions: to report the first hour, at least 31 minutes must be spent on conducting the evaluation, interpreting the results, and writing the evaluation report; 91 minutes is required to report the second hour, etc. Thus, an SLP would report code 96125 if a standardized cognitive test were performed and it took at least 31 minutes to conduct the evaluation, interpret the results, and write the report. If it took less than 31 minutes to conduct the evaluation, interpret the results, and write the evaluation report, it would not be appropriate to report code 96125. In addition, because code 96125 is a time-based code, it would not be appropriate to append modifier 52, Reduced Services.

There is no existing code for a cognitive-only evaluation without the performance of standardized testing. Codes 92523 and 96125 may be reported together if both a full cognitive evaluation and a full speech sound production and language evaluation were performed on the same day of service.

The following clinical examples and procedural descriptions reflect typical clinical scenarios for which these codes would be appropriately reported.

Clinical Example (CPT 92523)

A 5-year-old male presents with significant deficits of receptive, expressive, and social language and highly unintelligible speech sound production that limit his abilities to understand and communicate effectively in daily social and educational activities with family and peers.

Description of Procedure (CPT 92523)

Parent or caregiver is interviewed to review and clarify the information provided by the intake materials. A complete case history is obtained including the impact of deficits on daily function. Parent or caregiver concerns and expectations are determined. A standardized evaluation of speech sound production (eg, using a standardized test) is administered and scored. Capability to approximate correct production of deficit sounds is evaluated to determine potential for improved speech sound production. Intelligibility and consistency of speech sound production in conversation is evaluated. Precision of rapid articulatory movements is evaluated. Signs of abnormal oral function and craniofacial abnormalities are identified. The ability to detect and discriminate speech sound components (eg, using a standardized test) is evaluated.

Standardized language test measures (eg, using standardized instruments, evaluations, and/or tests) are administered and scored, as are criterion-referenced assessments. A spontaneous language sample (eg, mean length of utterance, complexity of sentence structure, pragmatics) is obtained via audio or video recording, for example, and analyzed. Other deficits are identified, including fluency, voice, swallowing, and hearing. Pre-service and intraservice information is analyzed and integrated to formulate findings and recommendations. Results are documented.

Clinical Example (CPT 96125)

A patient with diagnosed brain damage is referred for standardized cognitive performance testing.

Description of Procedure (CPT 96125)

The qualified health care professional reviews the patient’s case history and conducts an interview with the patient (if able to participate) and family/caregiver(s) to assess the cognitive demands on relevant social, academic, and/or vocational tasks, and the support competencies of the family/caregiver(s) or others in the patient’s daily environment. The patient is advised about what testing will entail. The qualified health care professional completes a face-to-face administration of the appropriate standardized test(s) (eg, Ross Information Processing Assessment) to assess the patient’s ability to complete specific functional tasks applicable to the patient’s environment in order to identify or quantify specific cognitive deficits in areas such as attention, memory, reasoning, executive function, problem solving, and/or pragmatic functioning.

The patient’s potential for effective compensatory behaviors and associated motivational barriers and facilitators are also examined. Raw and standardized scores are derived, analyzed, and interpreted. A comprehensive report of findings and recommendations for plan of care is written, incorporating the dimensions of cognitive and related impairments, activity limitations, and the patient’s participation in society.

References: CPT assistant April 2024