Evaluation of Hearing Impairment Corporate Medical Policy

Transcription

1 Evaluation of Hing Impairment Corporate Medical Policy File Name: Evaluation of Hing Impairment File Code: UM.DIAG.01 Origination: 07/1997 Last Review: 04/2017 Next Review: 04/2018 Effective Date: 11/01/2017 Description Hing impairment or hing loss is a reduction in the ability to perceive sound. The loss may range from slight to complete deafness. Audiometric studies are diagnostic tests that evaluate sensorineural and conductive hing losses. Conductive hing loss is the result of disorders of the external or middle ; sensory hing loss is secondary to disturbance of the cochlea; neural hing loss results from disease of the auditory (eighth) nerve or central auditory channel connections. Sensory and neural hing losses are frequently included under the term sensorineural hing loss. Mixed or combined hing loss involves disturbances of both conductive and sensorineural mechanisms. Policy Coding Information Click the links below for attachments, coding tables & instructions. Attachment I- CPT coding table & instructions Attachment II- ICD-10 coding table When a service may be considered medically necessary The Plan covers a screening test for hing in conjunction with a preventive medicine evaluation and management service when done in accordance with current American Academy of Pediatrics, American Academy of Family Practice, and/or Bright Futures guidelines. Audiometric studies may be medically necessary in illnesses or injuries including, but not limited to, the following: Hing loss; Otitis media; Page 1 of 49

2 Meniere s disease; Labyrinthitis; Vertigo (dizziness); Tinnitus; Cochl otosclerosis; Neoplasms of the auditory or central nervous system; Congenital anomalies; Surgery involving the auditory and/or central nervous system, e.g., skull-based tumors such as acoustic neuroma and meningioma; Facial nerve paralysis (Bell s palsy); Bacterial meningitis; Exposure to intense noise; Ototoxic drugs; Fractures of the temporal bone or trauma affecting the central auditory pathways. Family history of childhood hing loss due to a genetically inheritable condition The grid that follows identifies standard and specialized audiology tests for adults, children, and infants. Tests identified as part of the standard battery may be considered medically necessary as part of the initial work-up of a patient with hing impairment in the corresponding age group. Tests identified as specialized would not be part of the initial work-up of patients presenting with hing impairment, but may be considered medically necessary when initial diagnostic tests are inconclusive. See Attachment I for procedure codes and Attachment II for diagnostic codes. Standard Battery Adult Child Infant Pure Tone Audiometry Air conduction Bone conduction Masking (if air bone gap is present) Pure Tone Audiometry (Same as adult, age dependent) Auditory Evoked Potentials (AEP) or Auditory Brainstem Response (ABR) Speech Audiometry Speech Recognition Thresholds (SRT) Word recognition ability(wr) Basic Immittance Test Battery Tympanometry Acoustic reflex Measurement Speech Audiometry (Same as adult, age dependent) Basic Immittance Test Battery (Same as adult, age dependent) Select Picture Audiometry Visual Reinforcement audiometry(vra) Evoked Otoacoustic Emissions(OAE) Acoustic Reflex Measurement Page 2 of 49

3 Specialized tests Auditory Evoked Potentials (AEP) or Auditory Brainstem Response (ABR) in: Difficult to test patients For neurologic assessment To diagnose retrocochl pathology (e.g. acoustic neuromas or other lesions) Echocochleography(ECochG) To diagnose endolymphatic hydrops Tone Decay Test For diagnosis of cochl vs. retrocochl (tone decay has been largely replaced by ABR but is still in use) Conditioning Play Audiometry Auditory Evoked Potentials (AEP) or Auditory Brainstem Response (ABR) (Same as adult, age dependent) Echocochleography(ECochG) (Same as adult, age dependent) Tone Decay Test (Same as adult, age dependent) Stenger Test, pure tone or speech For diagnosis of pseudohypacusis Stenger Test (Same as adult, age dependent) Sensorineural Acuity Level For diagnosis of pseudohypacusis Evoked Otoacoustic Emissions(OAE) When a service is considered not medically necessary Lombard test (replaced by the Stenger test and auditory evoked potential); Alternate binaural loudness balance test; Short increment sensitivity test (replaced by pure tone audiometry, auditory evoked potential); Bekesy audiometry. When a service is considered investigational* Staggered spondaic word test; Synthetic sentence identification test. *This policy no longer addresses tests of central auditory processing, since these tests do not evaluate hing impairment. See Rationale section for further general discussion of tests of central auditory processing. Page 3 of 49

4 When a service is considered non-covered because it is a contract exclusion Hing aids or examinations for the prescription or fitting of hing aids; tinnitus masking devices. Background A variety of tests have been designed to evaluate central auditory processing, which is a higher order cortical function that processes auditory information. Therefore, central auditory processing tests do not strictly evaluate hing impairment, and thus are not formally considered in this policy. The various audiometric tests can be subdivided into standard batteries that are typically used as part of the initial work-up of patients presenting with hing impairment, as well as specialized tests that are typically used in specific clinical situations. The standard batteries vary according to whether the patient is an adult, child, or infant. The tests are briefly defined as follows: Standard Battery of Tests for Adults and Children 1. Pure-tone audiometry, air and bone conduction This test is a standard audiometric study that uses tones of various frequencies and intensities as auditory stimuli to measure hing. As air conduction is the usual method of sound transmission, air audiometry uses the external and middle in the transmission of sound to the cochlea and beyond. Bone-conduction audiometry involves the vibration of the skull by direct contact with an oscillating device that is thought to set the cochl fluids into motion, bypassing the external and middle. When bone-conduction thresholds are better than air-conduction thresholds, the hing loss is conductive. When bone-conduction thresholds are the same as airconduction thresholds, the hing loss is sensorineural. When bone-conduction thresholds are reduced but are still better than air conductions, the loss is mixed or combined. 2. Speech audiometry This test is a standard audiometric study that measures overall performance in hing, understanding, and responding to speech for a general assessment of hing and an estimate of degree of practical handicap. It may include a speech recognition test, in which the patient repeats words back, and a speech reception threshold, which determines when the patient can first h speech. It may also be used to reaffirm the findings of the pure-tone audiometry and to diagnose pseudohypacusis (a non-existent or false hing loss). 3. Word recognition tests Page 4 of 49

5 This category includes filtered speech tests and synthetic sentence identification. These tests specifically assess the patient s ability to discriminate spoken words. 4. Acoustic reflex test and acoustic reflex decay These tests measure the changes in the s ability to conduct sound to the cochlea. Reflexes, called acoustic reflexes, exist and involve middle function. Absence of the acoustic reflex may be indicative, among other things, of lesions of the middle, acoustic tumor, otosclerosis, facial nerve involvement of the probe side, and surgical removal or congenital absence of the stapes. These tests may be used in assessing the hing of neonates and other children too young to cooperate in the audiometric testing of functional hing loss. 5. Tympanometry (impedance testing) This is a standard series of tests to measure the ability of the middle to conduct sound. It is particularly useful in the identification of fluid in the middle and in the anatomic localization of facial nerve paralysis. Additional Standard Battery of Tests for Children Only 1. Select picture audiometry This test is used to evaluate hing-impaired children. It involves the use of pictures on cards and the child s ability to correctly identify objects based on audiologic direction. 2. Conditioning play audiometry This is usually performed to test hing impairment in children 2 to 4 ys of age. The child is taught to put an object in a specific place, e.g., a marble in a box or a cow in the barnyard when a specific sound is hd. Standard Battery of Tests for Infants Only 1. Auditory evoked potential (also called auditory brainstem response [ABR]) This is an electrophysiological measure of auditory function that uses responses produced by the auditory nerve and the brainstem and helps differentiate sensory from neural hing loss. The response is the waveform averaged over many auditory clicks. It may be helpful in the diagnosis of cerebellopontine angle tumors and acoustic neuromas, is used as a monitor in posterior fossa surgery, and may help to establish a hing threshold for infants and difficult-to-test patients. 2. Visual reinforcement audiometry (VRA) Page 5 of 49

6 The VRA is part of a battery of tests used in the determination of infant hing loss. The premise of the test is that the rate of patient response is increased by the use of reinforcement. 3. Evoked otoacoustic emissions (OAE) Otoacoustic emissions are sounds measured in the external canal that are a reflection of the working of the cochlea. Probe and click stimuli are used in the performance of this test. OAE is used in the screening as well as the diagnosis of hing impairment in neonates and young children. 4. Acoustic reflex test See Standard Battery of Tests for Adults and Children, No. 4 Specialized Tests for Adults and Children 1. Auditory Evoked Potential See Standard Battery of Tests for Infants Only, No Electrocochleography (ECochG) This is a measure of the electrical potentials generated in the inner as a result of sound stimulation. This test may be used in the evaluation of endolymphatic hydrops or Meniere s disease. 3. Tone decay test This test involves the presentation of a continuous tone to determine whether the threshold for the tone has changed (becomes poorer) over time. The test helps differentiate sensory from neural hing loss, and is used in the diagnosis of cochl versus retrocochl lesions and eighth nerve tumors. While this test is still in use, the auditory evoked potential test is largely used in place of the tone decay test. 4. Stenger test, pure tone or speech This test uses a tone presented simultaneously to both s and is based on the principle that the tone is perceived only in the that receives the greater intensity. It is useful in the diagnosis of pseudohypacusis (hypacusis is a hing impairment of a conductive or a neurosensory nature, and pseudohypacusis is a non- existent [false] hing loss.) 5. Sensorineural acuity level (SAL) test This test measures the extent of sensorineural hing loss and is also used in the detection of pseudohypacusis among children. It is not a commonly performed test. There are several different tests in use, including one in which a bone-conduction vibrator is placed at the center of the forehead and the threshold shift for a normal versus an with sensorineural hing loss is analyzed. 6. Evoked otoacoustic emissions Page 6 of 49

7 While this test is considered part of the standard battery of tests in infants, it is considered a specialized test in adults and children. For a description, see Standard Battery of Tests for Infants Only, No. 3. The tests of hing impairment listed in the policy here are considered standard tests of hing impairment and thus the specific diagnostic parameters of each of these tests will not be considered further. In 2000, the American Academy of Pediatrics, as a participant in the Joint Committee on Infant Hing, published a position statement regarding ly hing detection. (1) This statement recommended that all infants have access to hing screening using a physiologic measure, with the goal that all infants who do not pass the birth admission screen and any subsequent rescreening begin appropriate audiologic and medical evaluations to confirm the presence of hing loss before 3 months of age. The position statement noted that otoacoustic emission (OAEs) or auditory brainstem response (ABR) are physiologic techniques that have been successfully used for newborn screening. For example, hospitals may screen with otoacoustic emissions technology or auditory brainstem response technology and retest infants who "refer" with the same or other technology. Central Auditory Processing When this policy was first issued in 1997, tests of central auditory processing (CAP) were considered investigational. These tests are no longer formally considered in the policy statement, since tests of central auditory processing are not tests of hing impairment, per se, but tests of how auditory information is processed by the brain. For example, central auditory processes are responsible for sound localization and lateralization, auditory discrimination, auditory pattern recognition, and temporal aspects of audition. Tests of CAP are commonly recommended for children with dyslexia, attention deficit disorder, or other lning or behavioral disabilities. (2) The results of the test may be used to tailor specific teaching or behavioral strategies, and thus depending on the contract or benefit design may be considered part of the mental health benefits, or contractually excluded as an evaluation of a lning disability. A literature sch based on the PubMed US national library of Medicine, National Institutes of Health database for the period of 2004 through June 2015 did not identify additional articles that would prompt reconsideration of the policy statement, which remains unchanged. Reference Resources 1. BCBSA Policy Archived June American Academy of Pediatrics. Y 2007 position statement: principles and guidelines for ly hing detection and intervention programs. Pediatrics 2007; 120(4): Bamiou DE, Musiek FE, Luxon LM. Aetiology and clinical presentations of auditory processing disorders a review. Arch Dis Child 2001; 85(5): Page 7 of 49

8 4. Amos NE, Humes LE. SCAN test-retest reliability for first and third grade children. J Speech Lang H Res 1998; 41(4): Domitz DM, Schow RL. A new CAPD battery multiple processing assessment: factor analysis and comparisons with SCAN. Am J Audiol 2000; 9(2): Task Force on Central Auditory Processing Consensus Development. American Speech-Language-Hing Association. Central auditory processing: Current status of resch and implications for clinical practice. Am J Audiol 1996; 5: Jerger J, Musiek F. Report of the Consensus Conference on the Diagnosis of Auditory Processing Disorders in School-Aged Children. J Am Acad Audiol 2000; 11(9): Document Precedence Blue Cross and Blue Shield of Vermont (BCBSVT) Medical Policies are developed to provide clinical guidance and are based on resch of current medical literature and review of common medical practices in the treatment and diagnosis of disease. The applicable group/individual contract and member certificate language, or employer s benefit plan if an ASO group, determines benefits that are in effect at the time of service. Since medical practices and knowledge are constantly evolving, BCBSVT reserves the right to review and revise its medical policies periodically. To the extent that there may be any conflict between medical policy and contract/employer benefit plan language, the member s contract/employer benefit plan language takes precedence. Audit Information BCBSVT reserves the right to conduct audits on any provider and/or facility to ensure compliance with the guidelines stated in the medical policy. If an audit identifies instances of non-compliance with this medical policy, BCBSVT reserves the right to recoup all non-compliant payments. Benefit Determination Guidance Administrative and Contractual Guidance Federal Employee Program (FEP): Members may have different benefits that apply. For further information please contact FEP customer service or refer to the FEP Service Benefit Plan Brochure. It is important to verify the member s benefits prior to providing the service to determine if benefits are available or if there is a specific exclusion in the member s benefit. Coverage varies according to the member s group or individual contract. Not all groups are required to follow the Vermont legislative mandates. Member Contract language takes precedence over medical policy when there is a conflict. If the member receives benefits through an Administrative Services Only (ASO) group, benefits may vary or not apply. To verify benefit information, please refer to the Page 8 of 49

9 member s employer benefit plan documents or contact the customer service department. Language in the employer benefit plan documents takes precedence over medical policy when there is a conflict. Individual employer groups may have benefits for hing aids and/or examinations that are subject to the terms, limitations and conditions of the subscriber contract or employer benefit plan documents. Cochl implants are not considered to be hing aids and are not addressed under this policy. Policy Implementation/Update information 12/2005 Reviewed replacement battery codes added to attachment. Clarified benefit, corrected and added new CPT codes 06/2007 Added CPT codes 07/2007 Reviewed by CAC 06/2008 Annual review. No clinical changes made. Minor changes to attachment page. 07/2008 Reviewed by CAC 11/2009 Name changed to match BCBSA Medical Policy and incorporated language and criteria; audiologists and speechlanguage pathologists added as providers; and when services are not covered was clarified. Cerumen removal was removed from policy as not applicable 01/2010 Reviewed by CAC 08/2011 Policy converted to new format 09/2011 Policy adopted Coding is appropriate per Medical/Clinical Coder SAR 02/2014 ICD-10 remediation only. SAR 06/2015 Vestibular CPTs added. S0618 added to non-covered section. Providers encouraged to use more appropriate CPT code. Reviewed and approved by MPC on 06/08/15. 01/2016 CPT code updates to reflect AMA CPT changes. 04/2017 Reviewed, corrected and added new CPT Codes. ICD 10 Codes reviewed and updated. CPT Code deleted 01/01/2017, CPT codes deleted 01/01/2017 replaced with 92521, 92522, 92523, 92524, CPT Codes deleted 01/01/2010, CPT cods deleted 01/01/2015, (Unlisted) changed from not medically necessary to suspend for review. HCPCS Code S0618 changed from non-covered to not medically necessary. Eligible providers Qualified healthcare professionals practicing within the scope of their license(s). Page 9 of 49

10 Approved by BCBSVT Medical Directors Date Approved Gabrielle Bercy-Roberson, MD, MPH, MBA Senior Medical Director Chair, Health Policy Committee Joshua Plavin, MD, MPH, MBA Chief Medical Officer Attachment I CPT coding table & instructions Code Type Number Description Policy Instructions The following codes will be considered as medically necessary when applicable criteria have CPT CPT CPT CPT CPT Treatment of speech, language voice, communication, and/or auditory processing disorder (includes aural rehabilitation); individual Evaluation of speech fluency (eg, stuttering, cluttering) Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language Behavioral and qualitative analysis of voice and resonance Page 10 of 49

11 CPT CPT Caloric vestibular test with recording, ; bithermal (ie, one warm and one cool irrigation in each for a total of four irrigations) Caloric vestibular test with recording, ; monothermal (ie, one irrigation in each for a total of two irrigations) CPT CPT CPT CPT CPT CPT CPT CPT Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording Positional nystagmus test, minimum of 4 positions, with recording Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording Oscillating tracking test, with recording Sinusoidal vertical axis rotational testing Use of vertical electrodes (List separately in addition to code for primary procedure) Tympanometry and reflex threshold measurements CPT Screening test, pure tone, air only Page 11 of 49

12 CPT Pure tone audiometry (threshold);air only CPT Pure air and bone audiometry CPT Speech audiometry threshold CPT CPT CPT Tone decay test Speech audiometry threshold; with speech recognition Comprehensive audiometry threshold evaluation and speech recognition ( and combined) CPT Stenger test, pure tone CPT Tympanometry (impedance testing) CPT Acoustic reflex testing CPT Acoustic Inmittance testing CPT Filtered speech test CPT Sensorineural acuity level test CPT Stenger test, speech CPT Visual reinforcement audiometry (VRA) CPT Conditioning play audiometry Page 12 of 49

13 CPT Select picture audiometry CPT Electrocochleography CPT CPT CPT CPT Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products) Evoked otoacoustic emissions: comprehensive or diagnostic evaluation (comparisons of transient and/or distortion product otoacoustic emissions at multiple levels and frequencies) Evaluation of central auditory function, with report; initial 60 minutes CPT Each additional 15 minutes CPT Assessment of tinnitus (includes pitch, loudness, matching and masking.) The following codes will be denied as Not Medically Necessary, Non-Covered, Contract Exclusions or Investigational CPT Computerized Dynamic Posturography Investigational CPT Audiometric testing of groups Not Medically Necessary CPT Bekesy audiometry; screening Not Medically Necessary CPT Bekesy diagnostic Not Medically Necessary CPT Loudness balance test, alternate binaural or monaural Not Medically Necessary Page 13 of 49

14 CPT Short Increment Sensitivity index SISI Not Medically Necessary CPT Staggered spondaic word test Investigational CPT Synthetic sentence identification test Investigational CPT Hing aid examination and selection; monaural Contract Exclusion CPT Hing aid examination and selection; binaural Contract Exclusion CPT Hing aid check; monaural Contract Exclusion CPT Hing aid check; binaural Contract Exclusion CPT Electroacoustic evaluation for hing aid; monaural Contract Exclusion CPT CPT CPT HCPCS S0618 Electroacoustic evaluation for hing aid; binaural Ear protector attenuation measurements Unlisted otorhinolaryngological service or procedure Audiometry for hing aid evaluation to determine the level and degree of hing loss Contract Exclusion Not Medically Necessary Suspend for Medical Review Not Medically Necessary. Please use CPT Level I Codes that more accurately describes the service. Attachment II ICD-10 coding table The following diagnoses are considered medically necessary when applicable criteria in this policy is met. ICD-10 Description ICD-10 Description B45.1 Cerebral cryptococcosis H75.82 Other specified disorders of left middle and mastoid in diseases classified elsewhere Page 14 of 49

15 C70.1 Malignant neoplasm of spinal meninges H75.83 Other specified disorders of middle and mastoid in diseases classified elsewhere, C71.6 Malignant neoplasm of cerebellum H80.00 Otosclerosis involving oval window, nonobliterative, C79.31 Secondary malignant neoplasm of brain H80.01 Otosclerosis involving oval window, nonobliterative, right C79.32 Secondary malignant neoplasm of cerebral meninges H80.02 Otosclerosis involving oval window, nonobliterative, left C79.40 C79.49 D32.0 Secondary malignant neoplasm of unspecified part of nervous system Secondary malignant neoplasm of other parts of nervous system Benign neoplasm of cerebral meninges H80.03 H80.10 H80.11 Otosclerosis involving oval window, nonobliterative, Otosclerosis involving oval window, obliterative, Otosclerosis involving oval window, obliterative, right D32.1 Benign neoplasm of spinal meninges H80.12 Otosclerosis involving oval window, obliterative, left D32.9 Benign neoplasm of meninges, unspecified H80.13 Otosclerosis involving oval window, obliterative, D33.0 Benign neoplasm of brain, supratentorial H80.20 Cochl otosclerosis, D33.1 Benign neoplasm of brain, infratentorial H80.21 Cochl otosclerosis, right D33.2 Benign neoplasm of brain, unspecified H80.22 Cochl otosclerosis, left D33.3 Benign neoplasm of cranial nerves H80.23 Cochl otosclerosis, Page 15 of 49

16 D42.0 D42.1 Neoplasm of uncertain behavior of cerebral meninges Neoplasm of uncertain behavior of spinal meninges H80.80 H80.81 Other otosclerosis, Other otosclerosis, right D42.9 Neoplasm of uncertain behavior of meninges, unspecified H80.82 Other otosclerosis, left D43.0 Neoplasm of uncertain behavior of brain, supratentorial H80.83 Other otosclerosis, D43.1 Neoplasm of uncertain behavior of brain, infratentorial H80.90 otosclerosis, D43.2 D43.3 D43.4 D43.8 D43.9 D49.6 D49.7 Neoplasm of uncertain behavior of brain, unspecified Neoplasm of uncertain behavior of cranial nerves Neoplasm of uncertain behavior of spinal cord Neoplasm of uncertain behavior of other specified parts of central nervous system Neoplasm of uncertain behavior of central nervous system, unspecified Neoplasm of unspecified behavior of brain Neoplasm of unspecified behavior of endocrine glands and other parts of nervous system H80.91 H80.92 H80.93 H81.01 otosclerosis, right otosclerosis, left otosclerosis, Ménière's disease, right H81.02 Ménière's disease, left H81.03 H81.09 Ménière's disease, Ménière's disease, Page 16 of 49

17 G00.0 Hemophilus meningitis H81.10 Benign paroxysmal vertigo, G00.1 Pneumococcal meningitis H81.11 Benign paroxysmal vertigo, right G00.2 Streptococcal meningitis H81.12 Benign paroxysmal vertigo, left G00.3 Staphylococcal meningitis H81.13 Benign paroxysmal vertigo, G00.8 Other bacterial meningitis H81.20 Vestibular neuronitis, G00.9 G01 G02 G03.0 Bacterial meningitis, unspecified Meningitis in bacterial diseases classified elsewhere Meningitis in other infectious and parasitic diseases classified elsewhere Nonpyogenic meningitis H81.21 H81.22 H81.23 Vestibular neuronitis, right Vestibular neuronitis, left Vestibular neuronitis, H Aural vertigo, right G03.1 Chronic meningitis H Aural vertigo, left G03.8 Meningitis due to other specified causes H Aural vertigo, G03.9 Meningitis, unspecified H Aural vertigo, unspecified G04.2 G09 Bacterial meningoencephalitis and meningomyelitis, not elsewhere classified Sequelae of inflammatory diseases of central nervous system H H Other peripheral vertigo, right Other peripheral vertigo, left G35 Multiple Sclerosis BLANK BLANK G51.0 Bell's palsy H Other peripheral vertigo, Page 17 of 49

18 G96.0 Cerebrospinal fluid leak H Other peripheral vertigo, H65.00 Acute serous otitis media, unspecified H81.41 Vertigo of central origin, right H65.01 Acute serous otitis media, right H81.42 Vertigo of central origin, left H65.02 Acute serous otitis media, left H81.43 Vertigo of central origin, H65.03 Acute serous otitis media, H81.49 Vertigo of central origin, H65.04 Acute serous otitis media, recurrent, right H81.8X1 Other disorders of vestibular function, right H65.05 H65.06 Acute serous otitis media, recurrent, left Acute serous otitis media, recurrent, H81.8X2 H81.8X3 Other disorders of vestibular function, left Other disorders of vestibular function, H65.07 Acute serous otitis media, recurrent, H81.8X9 Other disorders of vestibular function, H Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), right H81.90 disorder of vestibular function, H Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), left H81.91 disorder of vestibular function, right H Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), H81.92 disorder of vestibular function, left Page 18 of 49

19 H H H H H H H H H H Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, right Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, left Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), recurrent, Acute and subacute allergic otitis media (mucoid) (sanguinous) (serous), unspecified Other acute nonsuppurative otitis media, right Other acute nonsuppurative otitis media, left Other acute nonsuppurative otitis media, Other acute nonsuppurative otitis media, recurrent, right Other acute nonsuppurative otitis media, recurrent, left H81.93 H82.1 H82.2 H82.3 H82.9 disorder of vestibular function, Vertiginous syndromes in diseases classified elsewhere, right Vertiginous syndromes in diseases classified elsewhere, left Vertiginous syndromes in diseases classified elsewhere, Vertiginous syndromes in diseases classified elsewhere, unspecified H83.01 Labyrinthitis, right H83.02 Labyrinthitis, left H83.03 Labyrinthitis, H83.09 H83.11 Labyrinthitis, unspecified Labyrinthine fistula, right Page 19 of 49

20 H H H H65.20 Other acute nonsuppurative otitis media, recurrent, Other acute nonsuppurative otitis media recurrent, Other acute nonsuppurative otitis media, unspecified Chronic serous otitis media, unspecified H83.12 H83.13 H83.19 H83.2X1 Labyrinthine fistula, left Labyrinthine fistula, Labyrinthine fistula, Labyrinthine dysfunction, right H65.21 Chronic serous otitis media, right H83.2X2 Labyrinthine dysfunction, left H65.22 Chronic serous otitis media, left H83.2X3 Labyrinthine dysfunction, H65.23 Chronic serous otitis media, H83.2X9 Labyrinthine dysfunction, H65.30 Chronic mucoid otitis media, unspecified H83.3X1 Noise effects on right inner H65.31 Chronic mucoid otitis media, right H83.3X2 Noise effects on left inner H65.32 Chronic mucoid otitis media, left H83.3X3 Noise effects on inner, H65.33 Chronic mucoid otitis media, H83.3X9 Noise effects on inner, H Chronic allergic otitis media, right H83.8X1 Other specified diseases of right inner H Chronic allergic otitis media, left H83.8X2 Other specified diseases of left inner H Chronic allergic otitis media, H83.8X3 Other specified diseases of inner, H Chronic allergic otitis media, unspecified H83.8X9 Other specified diseases of inner, Page 20 of 49

21 H Other chronic nonsuppurative otitis media, right H83.90 disease of inner, H Other chronic nonsuppurative otitis media, left H83.91 disease of right inner H Other chronic nonsuppurative otitis media, H83.92 disease of left inner H H65.90 Other chronic nonsuppurative otitis media, unspecified nonsuppurative otitis media, unspecified H83.93 H90.0 disease of inner, Conductive hing loss, H65.91 nonsuppurative otitis media, right H90.11 Conductive hing loss, unilateral, right, with unrestricted hing on the contralateral side H65.92 nonsuppurative otitis media, left H90.12 Conductive hing loss, unilateral, left, with unrestricted hing on the contralateral side H65.93 nonsuppurative otitis media, H90.2 Conductive hing loss, unspecified H Acute suppurative otitis media without spontaneous rupture of drum, right H90.3 Sensorineural hing loss, H Acute suppurative otitis media without spontaneous rupture of drum, left H90.41 Sensorineural hing loss, unilateral, right, with unrestricted hing on the contralateral side Page 21 of 49

22 H Acute suppurative otitis media without spontaneous rupture of drum, H90.42 Sensorineural hing loss, unilateral, left, with unrestricted hing on the contralateral side H Acute suppurative otitis media without spontaneous rupture of drum, recurrent, right H90.5 sensorineural hing loss H Acute suppurative otitis media without spontaneous rupture of drum, recurrent, left H90.6 Mixed conductive and sensorineural hing loss, H Acute suppurative otitis media without spontaneous rupture of drum, recurrent, H90.71 Mixed conductive and sensorineural hing loss, unilateral, right, with unrestricted hing on the contralateral side H Acute suppurative otitis media without spontaneous rupture of drum, recurrent, unspecified H90.72 Mixed conductive and sensorineural hing loss, unilateral, left, with unrestricted hing on the contralateral side H Acute suppurative otitis media without spontaneous rupture of drum, H90.8 Mixed conductive and sensorineural hing loss, unspecified BLANK BLANK H90.A11 Conductive hing loss, unilateral, right with restricted hing on the contralateral side BLANK BLANK H90.A12 Conductive hing loss, unilateral, left with restricted hing on the contralateral side Page 22 of 49

23 BLANK BLANK H90.A21 Sensorineural hing loss, unilateral, right, with restricted hing on the contralateral side BLANK BLANK H90.A22 BLANK BLANK H90.A31 BLANK BLANK H90.A32 Sensorineural hing loss, unilateral, left, with restricted hing on the contralateral side Mixed conductive and sensorineural hing loss, unilateral, right with restricted hing on the contralateral side Mixed conductive and sensorineural hing loss, unilateral, left with restricted hing on the contralateral side H Acute suppurative otitis media with spontaneous rupture of drum, right H91.01 Ototoxic hing loss, right H Acute suppurative otitis media with spontaneous rupture of drum, left H91.02 Ototoxic hing loss, left H Acute suppurative otitis media with spontaneous rupture of drum, H91.03 Ototoxic hing loss, H Acute suppurative otitis media with spontaneous rupture of drum, recurrent, right H91.09 Ototoxic hing loss, Page 23 of 49

24 H H H H Acute suppurative otitis media with spontaneous rupture of drum, recurrent, left Acute suppurative otitis media with spontaneous rupture of drum, recurrent, Acute suppurative otitis media with spontaneous rupture of drum, recurrent, unspecified Acute suppurative otitis media with spontaneous rupture of drum, H91.10 Presbycusis, unspecified H91.11 Presbycusis, right H91.12 Presbycusis, left H91.13 Presbycusis, H66.10 Chronic tubotympanic suppurative otitis media, unspecified H91.20 Sudden idiopathic hing loss, H66.11 Chronic tubotympanic suppurative otitis media, right H91.21 Sudden idiopathic hing loss, right H66.12 Chronic tubotympanic suppurative otitis media, left H91.22 Sudden idiopathic hing loss, left H66.13 Chronic tubotympanic suppurative otitis media, H91.23 Sudden idiopathic hing loss, H66.20 Chronic atticoantral suppurative otitis media, unspecified H91.3 Deaf nonspeaking, not elsewhere classified Page 24 of 49

25 H66.21 Chronic atticoantral suppurative otitis media, right H91.8X1 Other specified hing loss, right H66.22 Chronic atticoantral suppurative otitis media, left H91.8X2 Other specified hing loss, left H66.23 Chronic atticoantral suppurative otitis media, H91.8X3 Other specified hing loss, H66.3X1 Other chronic suppurative otitis media, right H91.8X9 Other specified hing loss, H66.3X2 Other chronic suppurative otitis media, left H91.90 hing loss, H66.3X3 H66.3X9 H66.40 H66.41 H66.42 H66.43 H66.90 Other chronic suppurative otitis media, Other chronic suppurative otitis media, unspecified Suppurative otitis media, unspecified, Suppurative otitis media, unspecified, right Suppurative otitis media, unspecified, left Suppurative otitis media, unspecified, Otitis media, unspecified, H91.91 H91.92 H91.93 hing loss, right hing loss, left hing loss, H92.01 Otalgia, right H92.02 Otalgia, left H92.03 Otalgia, H92.09 Otalgia, Page 25 of 49

26 H66.91 H66.92 H66.93 H67.1 H67.2 H67.3 H67.9 H Otitis media, unspecified, right Otitis media, unspecified, left Otitis media, unspecified, Otitis media in diseases classified elsewhere, right Otitis media in diseases classified elsewhere, left Otitis media in diseases classified elsewhere, Otitis media in diseases classified elsewhere, Eustachian salpingitis, right H92.10 Otorrhea, H92.11 Otorrhea, right H92.12 Otorrhea, left H92.13 Otorrhea, H92.20 Otorrhagia, unspecified H92.21 Otorrhagia, right H92.22 Otorrhagia, left H92.23 Otorrhagia, H Eustachian salpingitis, left H Transient ischemic deafness, right H Eustachian salpingitis, H Transient ischemic deafness, left H Eustachian salpingitis, H Transient ischemic deafness, H Acute Eustachian salpingitis, right H Transient ischemic deafness, H H Acute Eustachian salpingitis, left Acute Eustachian salpingitis, H H degenerative and vascular disorders of right degenerative and vascular disorders of left Page 26 of 49

27 H H H H Acute Eustachian salpingitis, Chronic Eustachian salpingitis, right Chronic Eustachian salpingitis, left Chronic Eustachian salpingitis, H H degenerative and vascular disorders of, degenerative and vascular disorders of H93.11 Tinnitus, right H93.12 Tinnitus, left H H Chronic Eustachian salpingitis, obstruction of Eustachian tube, right BLANK BLANK H93.A1 H93.13 Tinnitus, H93.19 Tinnitus, Pulsatile tinnitus, right BLANK BLANK H93.A2 Pulsatile tinnitus, left BLANK BLANK H93.A3 Pulsatile tinnitus, BLANK BLANK H93.A9 H H H H obstruction of Eustachian tube, left obstruction of Eustachian tube, obstruction of Eustachian tube, Osseous obstruction of Eustachian tube, right H H H H Pulsatile tinnitus, Auditory recruitment, right Auditory recruitment, left Auditory recruitment, Auditory recruitment, Page 27 of 49

28 H H H H H H H H H H H H69.00 Osseous obstruction of Eustachian tube, left Osseous obstruction of Eustachian tube, Osseous obstruction of Eustachian tube, Intrinsic cartilagenous obstruction of Eustachian tube, right Intrinsic cartilagenous obstruction of Eustachian tube, left Intrinsic cartilagenous obstruction of Eustachian tube, Intrinsic cartilagenous obstruction of Eustachian tube, Extrinsic cartilagenous obstruction of Eustachian tube, right Extrinsic cartilagenous obstruction of Eustachian tube, left Extrinsic cartilagenous obstruction of Eustachian tube, Extrinsic cartilagenous obstruction of Eustachian tube, Patulous Eustachian tube, H Diplacusis, right H Diplacusis, left H Diplacusis, H Diplacusis, H Hyperacusis, right H Hyperacusis, left H Hyperacusis, H H H H H Hyperacusis, unspecified Temporary auditory threshold shift, right Temporary auditory threshold shift, left Temporary auditory threshold shift, Temporary auditory threshold shift, Page 28 of 49

29 H69.01 Patulous Eustachian tube, right H Other abnormal auditory perceptions, right H69.02 Patulous Eustachian tube, left H Other abnormal auditory perceptions, left H69.03 Patulous Eustachian tube, H Other abnormal auditory perceptions, H69.80 H69.81 H69.82 H69.83 H69.90 H69.91 H69.92 H69.93 H Other specified disorders of Eustachian tube, Other specified disorders of Eustachian tube, right Other specified disorders of Eustachian tube, left Other specified disorders of Eustachian tube, Eustachian tube disorder, unspecified Eustachian tube disorder, right Eustachian tube disorder, left Eustachian tube disorder, Acute mastoiditis without complications, right H H93.3X1 H93.3X2 H93.3X3 H93.3x9 H93.8X1 H93.8X2 H93.8X3 H93.8X9 Other abnormal auditory perceptions, unspecified Disorders of right acoustic nerve Disorders of left acoustic nerve Disorders of acoustic nerves Disorders of unspecified acoustic nerve Other specified disorders of right Other specified disorders of left Other specified disorders of, Other specified disorders of, Page 29 of 49

30 H H H Acute mastoiditis without complications, left Acute mastoiditis without complications, Acute mastoiditis without complications, H93.90 H93.91 H93.92 disorder of, disorder of right disorder of left H Subperiosteal abscess of mastoid, right H93.93 disorder of, H H H H H Subperiosteal abscess of mastoid, left Subperiosteal abscess of mastoid, Subperiosteal abscess of mastoid, Acute mastoiditis with other complications, right Acute mastoiditis with other complications, left H94.00 H94.01 H94.02 H94.03 H94.80 Acoustic neuritis in infectious and parasitic diseases classified elsewhere, unspecified Acoustic neuritis in infectious and parasitic diseases classified elsewhere, right Acoustic neuritis in infectious and parasitic diseases classified elsewhere, left Acoustic neuritis in infectious and parasitic diseases classified elsewhere, Other specified disorders of in diseases classified elsewhere, H Acute mastoiditis with other complications, H94.81 Other specified disorders of right in diseases classified elsewhere H Acute mastoiditis with other complications, H94.82 Other specified disorders of left in diseases classified elsewhere Page 30 of 49

31 H70.10 Chronic mastoiditis, H94.83 Other specified disorders of in diseases classified elsewhere, H70.11 Chronic mastoiditis, right H95.00 Recurrent cholesteatoma of postmastoidectomy cavity, H70.12 Chronic mastoiditis, left H95.01 Recurrent cholesteatoma of postmastoidectomy cavity, right H70.13 Chronic mastoiditis, H95.02 Recurrent cholesteatoma of postmastoidectomy cavity, left H petrositis, right H95.03 Recurrent cholesteatoma of postmastoidectomy cavity, s H petrositis, left H Chronic inflammation of postmastoidectomy cavity, right H petrositis, H Chronic inflammation of postmastoidectomy cavity, left H petrositis, H Chronic inflammation of postmastoidectomy cavity, s H Acute petrositis, right H Chronic inflammation of postmastoidectomy cavity, H Acute petrositis, left H Granulation of postmastoidectomy cavity, right H Acute petrositis, H Granulation of postmastoidectomy cavity, left Page 31 of 49

32 H Acute petrositis, H Granulation of postmastoidectomy cavity, s H Chronic petrositis, right H Granulation of postmastoidectomy cavity, H Chronic petrositis, left H Mucosal cyst of postmastoidectomy cavity, right H Chronic petrositis, H Mucosal cyst of postmastoidectomy cavity, left H Chronic petrositis, H Mucosal cyst of postmastoidectomy cavity, s H Postauricular fistula, right H Mucosal cyst of postmastoidectomy cavity, H Postauricular fistula, left H Other disorders following mastoidectomy, right H Postauricular fistula, H Other disorders following mastoidectomy, left H Postauricular fistula, H Other disorders following mastoidectomy, s H Other mastoiditis and related conditions, right H Other disorders following mastoidectomy, H Other mastoiditis and related conditions, left H95.21 Intraoperative hemorrhage and hematoma of and mastoid process complicating a procedure on the and mastoid process Page 32 of 49

33 H H H70.90 H70.91 Other mastoiditis and related conditions, Other mastoiditis and related conditions, mastoiditis, mastoiditis, right H95.22 H95.31 H95.32 H95.41 Intraoperative hemorrhage and hematoma of and mastoid process complicating other procedure Accidental puncture and laceration of the and mastoid process during a procedure on the and mastoid process Accidental puncture and laceration of the and mastoid process during other procedure Postprocedural hemorrhage of and mastoid process following a procedure on the and mastoid process H70.92 mastoiditis, left H95.42 Postprocedural hemorrhage and hematoma of and mastoid process following other procedure Postprocedural hemorrhage of and mastoid process following other procedure BLANK BLANK H95.51 BLANK BLANK H95.52 BLANK BLANK H95.53 Postprocedural hematoma of and mastoid process following a procedure on the and mastoid process Postprocedural hematoma of and mastoid process following other procedure Postprocedural seroma of and mastoid process following a procedure on the and mastoid process Page 33 of 49

34 BLANK BLANK H95.54 Postprocedural seroma of and mastoid process following other procedure H70.93 mastoiditis, H95.88 Other intraoperative complications and disorders of the and mastoid process, not elsewhere classified H71.00 Cholesteatoma of attic, H95.89 Other postprocedural complications and disorders of the and mastoid process, not elsewhere classified H71.01 Cholesteatoma of attic, right P11.3 Birth injury to facial nerve H71.02 Cholesteatoma of attic, left Q16.9 Congenital malformation of causing impairment of hing, unspecified H71.03 Cholesteatoma of attic, Q85.02 Neurofibromatosis, type 2 H71.10 Cholesteatoma of tympanum, Q85.09 Other neurofibromatosis H71.11 Cholesteatoma of tympanum, right R42 Dizziness and giddiness H71.12 Cholesteatoma of tympanum, left H71.13 Cholesteatoma of tympanum, H71.20 H71.21 Cholesteatoma of mastoid, unspecified Cholesteatoma of mastoid, right S02.110A S02.110B Type I occipital condyle fracture, initial for closed fracture Type I occipital condyle fracture, initial for open fracture Page 34 of 49

35 H71.22 Cholesteatoma of mastoid, left S02.111A Type II occipital condyle fracture, initial for closed fracture H71.23 Cholesteatoma of mastoid, S02.111B Type II occipital condyle fracture, initial for open fracture H71.30 Diffuse cholesteatosis, S02.112A Type III occipital condyle fracture, initial for closed fracture H71.31 Diffuse cholesteatosis, right S02.112B Type III occipital condyle fracture, initial for open fracture H71.32 H71.33 Diffuse cholesteatosis, left Diffuse cholesteatosis, S02.113A S02.113B occipital condyle fracture, initial for closed fracture occipital condyle fracture, initial for open fracture H71.90 cholesteatoma, S02.118A Other fracture of occiput, initial for closed fracture H71.91 cholesteatoma, right S02.118B Other fracture of occiput, initial for open fracture H71.92 cholesteatoma, left S02.119A fracture of occiput, initial for closed fracture H71.93 cholesteatoma, S02.119B fracture of occiput, initial for open fracture H72.00 Central perforation of S02.19XA Other fracture of base of skull, initial for closed fracture Page 35 of 49

36 H72.01 Central perforation of right S02.19XB Other fracture of base of skull, initial for open fracture H72.02 Central perforation of left S02.91XA fracture of skull, initial for closed fracture H72.03 Central perforation of S02.91XB fracture of skull, initial for open fracture H72.10 Attic perforation of S04.60XA Injury of acoustic nerve, unspecified side, initial H72.11 Attic perforation of right S04.60XD Injury of acoustic nerve, unspecified side, subsequent H72.12 Attic perforation of left S04.60XS Injury of acoustic nerve, unspecified side, sequela H72.13 Attic perforation of S04.61XA Injury of acoustic nerve, right side, initial H72.2X1 H72.2X2 H72.2X3 H72.2X9 Other marginal perforations of right Other marginal perforations of left Other marginal perforations of Other marginal perforations of S04.61XD S04.61XS S04.62XA S04.62XD Injury of acoustic nerve, right side, subsequent Injury of acoustic nerve, right side, sequela Injury of acoustic nerve, left side, initial Injury of acoustic nerve, left side, subsequent Page 36 of 49

37 H Multiple perforations of tympanic membrane, right S04.62XS Injury of acoustic nerve, left side, sequela H H H H H H H Multiple perforations of tympanic membrane, left Multiple perforations of tympanic membrane, Multiple perforations of tympanic membrane, Total perforations of right Total perforations of left Total perforations of Total perforations of S06.330A S06.331A S06.332A S06.333A S06.334A S06.335A S06.336A Contusion and laceration of cerebrum, unspecified, without loss of consciousness, initial Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, initial Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 1 hour to 5 hours 59 minutes, initial Contusion and laceration of cerebrum, unspecified, with loss of consciousness of 6 hours to 24 hours, initial Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial Contusion and laceration of cerebrum, unspecified, with loss of consciousness greater than 24 hours without return to preexisting conscious level with patient surviving, initial Page 37 of 49

38 H72.90 H72.91 perforation of perforation of right S06.337A S06.338A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to brain injury prior to regaining consciousness, initial Contusion and laceration of cerebrum, unspecified, with loss of consciousness of any duration with death due to other cause prior to regaining consciousness, initial H72.92 perforation of left S06.339A Contusion and laceration of cerebrum, unspecified, with loss of consciousness of unspecified duration, initial H72.93 perforation of S06.360A Traumatic hemorrhage of cerebrum, unspecified, without loss of consciousness, initial H Acute myringitis, right S06.361A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 30 minutes or less, initial H Acute myringitis, left S06.362A Traumatic hemorrhage of cerebrum, unspecified, with loss of consciousness of 31 minutes to 59 minutes, initial Page 38 of 49