Provider Alert! Benefit Criteria for Evoked Response Tests and Neuromuscular Procedures UpdateTexas Children's Health Plan
Date: April 7, 2022
Effective date: March 1, 2022
Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated with the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
TCHP will apply updates and reprocess impacted claims as soon as possible. However, please allow up to sixty (60) business days for reprocessing. Providers are not required to appeal claims unless denied for other reasons.
Providers should direct questions to their Provider Relations Liaison or send an email inquiry to the Provider Relations Department at firstname.lastname@example.org.
Call to action: Texas Children’s Health Plan (TCHP) would like to inform providers that effective for dates of service on or after March 1, 2022, benefit criteria will be added for vestibular evoked myogenic potentials (VEMP) procedure codes 92517, 92518, and 92519.
How this impacts providers: Some conditions under which VEMP testing (procedure codes 92517, 92518, and 92519) may be appropriate include:
- Evaluation of chronic symptoms of pressure, tinnitus, disorientation, or chronic vertigo after all other recommended vestibular tests has been completed and a definitive diagnosis is lacking.
- Evaluation is required after a positive computed tomography (CT) scan for superior semicircular canal dehiscence syndrome (SCDS).
Documentation must include the following:
- The other differential diagnoses under consideration
- The additional diagnoses considered
- The clinical signs, symptoms, or electro-diagnostic findings that necessitated the inclusion
VEMP testing procedure codes 92517, 92518, and 92519 must be medically indicated and may be reimbursed when submitted with one of the following diagnosis codes:
VEMP testing is not medically necessary for any other indications.
All the following criteria are documentation requirements for VEMP testing:
- For each VEMP test performed, the referral reason must include a clear diagnostic impression documented in the client’s medical record.
- Medical necessity for the VEMP test must be clearly documented in the client’s medical record and reflect the actual results of specific tests (which could include latency and amplitude).
- Medical necessity of client reevaluation after the initial consultation and testing must be clearly documented. Supporting documentation must include the following:
- New symptoms unrelated to previously evaluated symptoms, which may result in a new diagnosis
- Rapidly changing client condition documentation, supported by the following:
- Current clinical signs and symptoms
- Prior clinical condition
- Expected clinical disease course
- Clinical benefit of additional studies
The client’s medical records are subject to retrospective review.
Next steps for providers: Providers should share this communication with their staff.
If you have any questions, please email Provider Network Management at: email@example.com.
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