CCSD code 20230 – Impedance audiogram billing guide

Key takeaways

CCSD code 20230 covers the full impedance audiogram, which combines tympanometry with acoustic reflex threshold testing.

20230 sits in CCSD Chapter 1, among the investigations and simple procedures, not in the audiology diagnostic chapter.

Documentation must record tympanogram type, acoustic reflex results, laterality, the clinical indication, and the performing clinician.

Pre-authorization from the patient’s insurer is usually required before billing 20230, and submitting without it is the leading cause of rejection.

Practice management software like Pabau keeps CCSD documentation and claim submission on one patient record, so fewer claims come back rejected.

CCSD code 20230: Definition and clinical scope

CCSD code 20230 covers an impedance audiogram, the standard middle ear assessment in UK private practice. It is a five-digit numeric code, which places it in CCSD Chapter 1, covering investigations, simple procedures and consultation codes. The audiology diagnostic chapter is a separate part of the schedule and uses letter-prefixed codes.

The schedule is maintained by the Clinical Coding and Schedule Development Group, the body behind the procedure codes UK and Irish insurers use. One unit of 20230 covers the test whether one ear or both are assessed. Laterality still has to be documented in the clinical record.

Impedance audiometry assesses the mechanical properties of the middle ear rather than the patient’s subjective hearing ability. It is distinct from pure tone audiometry (CCSD code 20210), which tests hearing thresholds across frequencies. The two tests answer different clinical questions and are billed under separate codes. They may be performed in the same session when clinically indicated.

20230 is one entry in a schedule that runs to several thousand codes. Our overview of UK private billing codes explains how the chapters are organized and where to look up a code you do not recognize.

What does an impedance audiogram involve?

An impedance audiogram measures the acoustic immittance of the middle ear using a calibrated tympanometer. The procedure has two core subcomponents. They are performed in sequence and together make up the complete test billed under 20230.

Tympanometry: The core measurement

Tympanometry is the primary measurement within an impedance audiogram. A probe tip is placed in the ear canal to create an airtight seal. Air pressure is then varied systematically while a low-frequency tone is delivered. The instrument records how well the tympanic membrane moves at each pressure point, producing a tympanogram trace.

Tympanogram type indicates middle ear status:

• Type A: Normal middle ear pressure and mobility
• Type B: Flat trace; indicates middle ear effusion (glue ear), perforation, or cerumen occlusion
• Type C: Peak shifted to negative pressure; indicates eustachian tube dysfunction or early effusion

The tympanogram trace has to be retained in the patient record. Documenting the type and the peak pressure value supports the clinical indication and satisfies insurer documentation requirements for the claim.

Acoustic reflex testing and what it shows

Acoustic reflex testing measures contraction of the stapedius muscle in response to a loud sound stimulus. The probe delivers tones at varying intensities to find the acoustic reflex threshold, the lowest intensity that triggers the stapedial reflex. Acoustic reflex decay testing assesses whether the reflex is sustained over time.

Reflex results help differentiate conductive from sensorineural pathology. An absent reflex at expected levels alongside a Type A tympanogram may suggest ossicular discontinuity or a retrocochlear lesion.

A present reflex with a Type B tympanogram would be inconsistent and warrants clinical review. These findings form part of the result documented to support the 20230 claim.

Why is an impedance audiogram performed?

An impedance audiogram is performed to evaluate middle ear function when clinical signs suggest a conductive hearing problem, middle ear pathology, or eustachian tube disorder. It provides objective data that pure tone audiometry alone cannot supply. Referrals to private audiology practices for this test usually come from GPs and ENT surgeons.

• Suspected middle ear effusion (glue ear): particularly in children and adults with recurrent otitis media
• Eustachian tube dysfunction: pressure equalization problems causing intermittent hearing loss or otalgia
• Conductive hearing loss investigation: to distinguish ossicular chain pathology from sensorineural causes
• Pre- and post-surgical assessment: tympanoplasty, myringotomy, and ossiculoplasty monitoring
• Screening before hearing aid fitting: to confirm the middle ear is structurally suitable
• Pediatric hearing evaluation: children who cannot reliably participate in behavioral threshold testing

ENT surgeons may request the test as part of a full hearing workup alongside pure tone audiometry (CCSD 20210). Both codes are billed separately there, because each assesses a different aspect of auditory function.

Choosing between 20230 and related audiology codes

Selecting the correct CCSD code means distinguishing 20230 from the audiology codes next to it. Using the wrong one is among the most common causes of claim rejection in private audiology billing.

Never substitute 20230 for 20210 when only a pure tone audiogram was performed, or the other way round. Insurers cross-reference the code against the clinical notes.

A claim whose documented procedure does not match the submitted code is rejected. For Bupa-specific audiology rules, see our reference on Bupa CCSD codes.

Billing CCSD code 20230: Step-by-step

A structured billing workflow reduces rejections and speeds up reimbursement. Follow these steps each time 20230 goes to a private medical insurer. Practices running private practice claims software can automate several of them.

1. Confirm insurer pre-authorization before the appointment. Most UK private medical insurers want an authorization number before audiology investigations are performed. Contact the patient’s insurer with the planned code and the referring clinician’s details to get the authorization reference. Note that number in the patient’s file before the test takes place.
2. Verify the referral letter is in place. Bupa and AXA Health typically require a GP or specialist referral letter before approving audiology investigations. Confirm the referral is on file and matches the intended test before proceeding.
3. Perform the impedance audiogram and document in real time. Record the tympanogram trace and type, acoustic reflex threshold values, any reflex decay findings, and laterality. Add the equipment make and model, the performing clinician’s name and credentials, and the date of service.
4. Select CCSD code 20230 on the invoice. Confirm that only procedures actually performed are coded. If a pure tone audiogram was also performed, add 20210 as a separate line item. Never use 20230 as a catch-all for a hearing test.
5. Attach supporting clinical notes to the claim. Submit the audiometry report, including the tympanogram trace, alongside the invoice. Many insurers want documentation at the point of claim submission for diagnostic procedures.
6. Submit the claim within the insurer’s billing window. Most UK private medical insurers require claims within 90 days of the date of service. Late submission is an avoidable rejection reason.

What to document for every impedance audiogram

Complete documentation does two jobs. It supports the clinical record, and it satisfies insurer audit requirements. Thin notes are the second most common cause of rejection for this code, after a missing pre-authorization.

The minimum documentation set for each impedance audiogram includes:

• Tympanogram trace: the printed or digitally stored curve, including peak pressure (in daPa) and peak compliance values
• Tympanogram classification: Type A, B, or C recorded for each tested ear
• Acoustic reflex results: threshold levels for ipsilateral and contralateral reflexes at each tested frequency, plus reflex decay findings where performed
• Laterality: clearly state which ear or ears were tested (left, right, or bilateral)
• Clinical indication: the reason for referral, such as conductive hearing loss, suspected effusion, or pre-surgical assessment
• Performing clinician: full name, professional registration number (RCCP or HCPC), and insurer recognition number
• Equipment: make, model, and calibration status of the tympanometer used
• Date of service

Adult clinical records should be kept for a minimum of eight years after the last entry. That figure comes from the NHS Records Management Code of Practice and professional retention guidance, not from UK GDPR.

UK GDPR sets no fixed retention period of its own. It asks you to justify how long you hold a record and why. Records for minors are held longer, so check your own policy against current guidance before you rely on it.

Can you bill 20230 for both ears?

Bilateral billing rules for 20230 are not standardized across insurers, so confirm the position with each one before you submit. Some UK private medical insurers treat bilateral impedance audiometry as a single billable unit. Others accept bilateral testing at a higher fee, or ask for two line items with left and right specified.

Because these rules are payer-specific and change with each annual schedule update, check the provider manual or call provider relations. Laterality must be documented clearly in the notes whatever the insurer’s position.

Which UK insurers accept the code?

All major UK private medical insurers use the CCSD schedule for audiology billing. Each applies its own pre-authorization rules, referral requirements, and documentation standards. The table below summarizes publicly available guidance. Always verify current requirements on the insurer’s provider portal before you submit, because policies change.

Irish private insurers, including VHI, also use the CCSD schedule. Pre-authorization and referral requirements follow similar principles to the UK. Verify them on the relevant Irish provider portal before submitting claims for Irish-based patients.

Why impedance audiogram claims get rejected

Claim rejections for impedance audiometry follow predictable patterns. Practices that review rejected claims by category, then fix the workflow step behind each one, see denial rates fall over time.

• Missing pre-authorization: the single most common reason. The claim goes out without a valid authorization number, or the authorization was obtained for a different code or clinician.
• Insufficient clinical documentation: no tympanogram trace on file, missing acoustic reflex results, or notes that never record the indication for testing.
• Wrong code selected: billing 20210 when an impedance audiogram was performed, or the other way round. Each test has its own descriptor and must be coded accurately.
• Laterality not stated: the insurer cannot verify whether the test was unilateral or bilateral without explicit documentation. Claims missing laterality are frequently queried or rejected.
• Unrecognized clinician: the performing audiologist does not hold current recognition with the insurer. Recognition must be renewed annually with most UK insurers.
• Late submission: claims beyond the insurer’s billing window, typically 90 days from the date of service, are rejected on administrative grounds.
• Bundling error: submitting 20230 and 20210 as a single combined code rather than two separate line items when both tests were performed.

Each of these reasons has one check attached to it, and the check almost always sits earlier in the workflow than the rejection does.

A pre-submission checklist that prevents rejections

A pre-submission checklist applied to every impedance audiogram appointment removes most avoidable rejections. The steps below address each of the denial reasons above.

• Obtain and record the insurer pre-authorization number before the patient attends. Never perform a billable investigation without confirmed authorization for diagnostic procedures.
• Confirm the referring clinician’s details match those submitted for pre-authorization. A mismatch between the referral letter and the authorization record triggers queries.
• Complete the clinical record during the appointment, not afterwards. Tympanogram type, acoustic reflex threshold values, and laterality must be written down as they are measured.
• Attach the tympanogram trace and the full audiometry report to the claim, even where the portal does not ask for them upfront. Supplying documentation early reduces the chance of a retrospective audit query.
• Verify the performing audiologist’s insurer recognition is current before the appointment. Many private practices run recognition audits at the start of each contract year.

How Pabau keeps CCSD documentation and claims in one place

Most private audiology practices run 20230 billing across three places. The tympanometer prints the trace, the clinical notes sit in one system, and the invoice is raised in another. Every handover between them is a chance to lose the authorization number or the laterality line.

Practice management software like Pabau keeps those steps on one patient record. The clinician records tympanogram type, reflex thresholds and laterality on a structured form during the appointment. The pre-authorization reference sits on the same record, so it is there when the invoice is raised.

Pabau then builds the claim against the code you selected, with the audiometry report attached. Reporting shows which claims came back rejected and why, so you can repair the step that caused it instead of re-checking every file by hand.

Reduce CCSD billing errors across your audiology practice

Pabau helps private audiology and ENT practices manage CCSD code documentation, patient records, and claim submissions in one place, so fewer claims come back rejected.

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Conclusion

Billing 20230 accurately is mostly a sequencing problem. The authorization has to exist before the test. The trace and reflex results have to be written during it. The claim then has to go out inside the insurer’s window.

A practice that keeps missing on one of those three steps rarely has a coding problem. It has a workflow that lets a step happen late. Sorting a month of rejections by reason will tell you which step that is, usually in an afternoon.

Fix the sequence and the code looks after itself. Book a demo to see how Pabau keeps CCSD documentation, pre-authorization records and claim submission on one patient file.

Continue your research

Billing an impedance audiogram performed alongside another procedure? CCSD code 20240 covers the companion code and when it applies instead of 20230.

Want fewer claims coming back from UK insurers? Medical billing compliance sets out the record-keeping and submission standards that keep private claims clean.

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