Medicare Coverage of Audiological Diagnostic Testing
Private practice audiologists can bill Medicare directly for diagnostic services. The audiology coverage criteria are found in the Medicare Benefit Policy Manual at Chapter 15, Section 80.3 [PDF], which is highlighted here. The reader will find the audiologist qualifications required by Medicare in Section 80.3.1.
Medicare Benefit Policy Manual
Chapter 15-Covered Medical and Other Health Services
80 Requirements for Diagnostic X-ray, Diagnostic Laboratory, and Other Diagnostic Tests
80.3 Audiology Services
A. Benefit. Hearing and balance assessment services are generally covered as "other diagnostic tests" under section 1861(s)(3) of the Social Security Act. Hearing and balance assessment services furnished to an outpatient of a hospital are covered as "diagnostic services" under section 1861(s)(2)(C).
As defined in the Social Security Act, section 1861(ll)(3), the term "audiology services" specifically means such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise be covered if furnished by a physician.
Herein after in this section, hearing and balance assessment services are termed "audiology services," regardless of whether they are furnished by an audiologist, physician, nonphysician practitioner (NPP), or hospital.
Because audiology services are diagnostic tests, when furnished by a physician in an office or hospital outpatient department, they must be furnished under the appropriate level of supervision of a physician as established in 42 CFR 410.32(b)(1) and 410.28(e). However, as specified in 42 CFR 410.32(b)(2)(ii) or (v), respectively, they are excepted from physician supervision when they are personally furnished by a qualified audiologist or performed by a nurse practitioner or clinical nurse specialist authorized to perform the tests under applicable State laws.
Audiological diagnostic testing refers to tests of the audiological and vestibular systems, e.g., hearing, balance, auditory processing, tinnitus and diagnostic programming of certain prosthetic devices, performed by qualified audiologists.
Audiological diagnostic tests are not covered under the benefit for services incident to a physician's service (described in Pub. 100-02, chapter 15, section 60 [PDF, 1.6MB]), because they have their own benefit as "other diagnostic tests". See Pub. 100-04, chapter 13 [PDF] for general diagnostic test policies.
Audiology services, like all other services, should be reported under the most specific HCPCS code that describes the service that was furnished and in accordance with all CPT guidance and Medicare national and local contractor instructions.
B. Orders. Audiology tests are covered as "other diagnostic tests" under section 1861(s)(3)or1861(s)(2)(C) of the Act in the physician's office or hospital outpatient settings, respectively, when a physician (or an NPP, as applicable) orders such testing for the purpose of obtaining information necessary for the physician's diagnostic medical evaluation or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem. See section 80.6 of this chapter (Chapter 15 [PDF, 1.6MB]) for policies regarding the ordering of diagnostic tests.
If a beneficiary undergoes diagnostic testing performed by an audiologist without a physician order, the tests are not covered even if the audiologist discovers a pathologic condition.
When a qualified physician orders a qualified technician (see definition in subsection D of this section) to furnish an appropriate audiology service, that order must specify which test is to be furnished by the technician under the direct supervision of a physician. Only that test may be provided on that order by the technician.
When the qualified physician or NPP orders diagnostic audiology services furnished by an audiologist without naming specific tests, the audiologist may select the appropriate battery of tests.
C. Coverage and Payment for Audiology Services. Diagnostic services furnished by a qualified audiologist meeting the requirements in section 80.3.1 of this chapter or physicians and NPPs as described in section 80.6 are covered and payable under the MPFS as "other diagnostic tests."
Services furnished in a hospital outpatient department are covered and payable under the hospital Outpatient Prospective Payment System (OPPS) or other payment methodology applicable to the provider furnishing the services.
Coverage and, therefore, payment for audiological diagnostic tests is determined by the reason the tests were performed, rather than by the diagnosis or the patient's condition.
Under any Medicare payment system, payment for audiological diagnostic tests is not allowed by virtue of their exclusion from coverage in section 1862(a)(7) of the Social Security Act when:
- The type and severity of the current hearing, tinnitus or balance status needed to determine the appropriate medical or surgical treatment is known to the physician before the test; or
- The test was ordered for the specific purpose of fitting or modifying a hearing aid.
Payment of audiological diagnostic tests is allowed for other reasons and is not limited, for example, by:
- Any information resulting from the test, for example:
- Confirmation of a prior diagnosis;
- Post-evaluation diagnoses; or
- Treatment provided after diagnosis, including hearing aids, or
- The type of evaluation or treatment the physician anticipates before the diagnostic test; or
- Timing of reevaluation. Reevaluation is appropriate at a schedule dictated by the ordering physician when the information provided by the diagnostic test is required, for example, to determine changes in hearing, to evaluate the appropriate medical or surgical treatment or to evaluate the results of treatment. For example, reevaluation may be appropriate, even when the evaluation was recent, in cases where the hearing loss, balance, or tinnitus may be progressive or fluctuating, the patient or caregiver complains of new symptoms, or treatment (such as medication or surgery) may have changed the patient‟s audiological condition with or without awareness by the patient.
Examples of appropriate reasons for ordering audiological diagnostic tests that could be covered include, but are not limited to:
- Evaluation of suspected change in hearing, tinnitus, or balance;
- Evaluation of the cause of disorders of hearing, tinnitus, or balance;
- Determination of the effect of medication, surgery, or other treatment;
- Reevaluation to follow-up changes in hearing, tinnitus, or balance that may be caused by established diagnoses that place the patient at probable risk for a change in status including, but not limited to: otosclerosis, atelectatic tympanic membrane, tympanosclerosis, cholesteatoma, resolving middle ear infection, Meniére's disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, acoustic neuroma, demyelinating diseases, ototoxicity secondary to medications, or genetic vascular and viral conditions;
- Failure of a screening test (although the screening test is not covered);
- Diagnostic analysis of cochlear or brainstem implant and programming; and
- Audiology diagnostic tests before and periodically after implantation of auditory prosthetic devices.
If a physician refers a beneficiary to an audiologist for testing related to signs or symptoms associated with hearing loss, balance disorder, tinnitus, ear disease, or ear injury, the audiologist's diagnostic testing services should be covered even if the only outcome is the prescription of a hearing aid.
D. Individuals Who Furnish Audiological Tests.
- Qualified Professionals. See section 80.3.1 of this chapter for the qualifications of audiologists. See section 80.6 of this chapter (Chapter 15 [PDF, 1.6MB]) for the qualifications of physicians and NPPs who may furnish diagnostic tests.
- Qualified Technicians or Other Qualified Staff. References to technicians in this section include other qualified clinical staff. The qualifications for technicians vary locally and may also depend on the type of test, the patient, and the level of participation of the physician who is directly supervising the test. Therefore, an individual must meet qualifications appropriate to the service furnished as determined by the contractor to whom the claim is billed. If it is necessary to determine whether the individual who furnished the labor for appropriate audiology services is qualified, contractors may request verification of any relevant education and training that has been completed by the technician, which shall be available in the records of the clinic or facility.
Depending on the qualifications determined by the contractor, individuals who are also hearing instrument specialists, students of audiology, or other health care professionals may furnish the labor for appropriate audiology services under direct physician supervision when these services are billed by physicians or hospital outpatient departments.
E. Documentation for Audiology Services.
- Documentation for Orders (Reasons for Tests). The reason for the test should be documented either on the order, on the audiological evaluation report, or in the patient's medical record. (See subsection C. of this section concerning reasons for tests.)
- Documenting skilled services.
When the medical record is subject to medical review, it is necessary that the record contains sufficient information so that the contractor may determine that the service qualifies for payment. For example, documentation should indicate that the test was ordered, that the reason for the test results in coverage, and that the test was furnished to the patient by a qualified individual.
Records that support the appropriate provision of an audiological diagnostic test shall be made available to the contractor on request.
F. Audiological Treatment. There is no provision in the law for Medicare to pay audiologists for therapeutic services. For example, vestibular treatment, auditory rehabilitation treatment, auditory processing treatment, and canalith repositioning, while they are generally within the scope of practice of audiologists, are not those hearing and balance assessment services that are defined as audiology services in 1861(ll)(3) of the Social Security Act and, therefore, shall not be billed by audiologists to Medicare. Services for the purpose of hearing aid evaluation and fitting are not covered regardless of how they are billed. Services identified as "always" therapy in Pub. 100-04, chapter 5, section 20 [PDF] may not be billed by hospitals, physicians, NPPs, or audiologists when provided by audiologists. (See also Pub. 100-04, chapter 12, section 30.3 [PDF])
Treatment related to hearing may be covered under the speech-language pathology benefit when the services are provided by speech-language pathologists. Treatment related to balance (e.g., services described by "always therapy" codes 97001-97004, 97110, 97112, 97116, and 97750) may be covered under the physical therapy or occupational therapy benefit when the services are provided by therapists or their assistants, where appropriate. Covered therapy services incident to a physician's service must conform to policies in sections 60, 220, and 230 of this chapter (Chapter 15 [PDF, 1.6MB]). Audiological treatment provided under the benefits for physical therapy and speech-language pathology services may also be personally provided and billed by physicians and NPPs when the services are within their scope of practice and consistent with State and local laws.
For example, aural rehabilitation and signed communication training may be payable according to the benefit for speech-language pathology services or as speech-language pathology services incident to a physician's or NPP's service. Treatment for balance disorders may be payable according to the benefit for physical therapy services or as a physical therapy service incident to the services of a physician or NPP. See the policies in this chapter (Chapter 15 [PDF, 1.6MB]), sections 220 and 230, for details.
G. Assignment. Nonhospital entities billing for the audiologist's services may accept assignment under the usual procedure or, if not accepting assignment, may charge the patient and submit a nonassigned claim on their behalf.
H. Opt Out and Mandatory Claims Submissions. The opt out law does not define "physician" or "practitioner" to include audiologists; therefore, they may not opt out of Medicare and provide services under private contracts. See section 40.4 of this chapter (Chapter 15 [PDF, 1.6MB]) for details.
When a physician or supplier furnishes a service that is covered by Medicare, then it is subject to the mandatory claim submission provisions of section 1848(g)(4) of the Social Security Act. Therefore, if an audiologist charges or attempts to charge a beneficiary any remuneration for a service that is covered by Medicare, then the audiologist must submit a claim to Medicare.
L. Non-Audiology Services Furnished by Audiologists. Audiologists may be qualified to furnish all or part of some diagnostic tests or treatments that are not defined as audiology services under the MPFS, such as non-auditory evoked potentials or cerumen removal. Audiologists may not bill Medicare for services that are not audiology services according to Medicare's definition. However, the labor for the Technical Component (TC) of certain other diagnostic tests or treatment services may qualify to be billed when furnished by audiologists under physician supervision when all the appropriate policies are followed.
When furnishing services that are not on the Medicare list of audiology services, the audiologist may or may not be working within the scope of practice of an audiologist according to State law. The audiologist furnishing the service must have the qualifications that are ordinarily required of any person providing that service. Consult the following policies for details:
- Policies for physical therapy, occupational therapy, and speech-language pathology services are in sections 220 and 230 of this chapter (Chapter 15 [PDF, 1.6MB]) and in Pub. 100-04, chapter 5, sections 10 and 20 [PDF].
- Policies for services furnished incident to physicians' services in the physician's office are in section 60 of this chapter (Chapter 15 [PDF, 1.6MB]).
- Policies for therapeutic services furnished incident to physicians' services in the hospital outpatient setting are in chapter 6, section 20.5 [PDF], of this manual.
- Policies for diagnostic tests in the physician's office are in section 80 of this chapter (Chapter 15 [PDF, 1.6MB]).
- Policies for diagnostic tests furnished in the hospital outpatient setting are in chapter 6, section 20.4, of this manual.
Therapeutic or treatment services that are not audiology services and are not "always" therapy (according to the policy in Pub.100-04, chapter 5, section 20 [PDF]) and are furnished by audiologists may be billed incident to the services of a physician when all other appropriate requirements are met.
In addition, the TC or facility services for diagnostic tests that are not audiology services may be billed by physicians or hospital outpatient departments when provided by qualified personnel (who may be audiologists), and physicians and hospital outpatient departments may bill for these diagnostic tests when provided by those qualified personnel under the specified level of physician supervision for the diagnostic test.
80.3.1 Definition of Qualified Audiologist
Audiological tests require the skills of an audiologist and shall be furnished by qualified audiologists, or, in States where it is allowed by State and local laws, by a physician or non-physician practitioner. Medicare is not authorized to pay for these services when performed by audiological aides, assistants, technicians, or others who do not meet the qualifications below. In cases where it is not clear, the Medicare contractor shall determine whether a service is an audiological service that requires the skills of an audiologist and whether the qualifications for an audiologist have been met.
Section 1861(ll)(3) of the Act, provides that a qualified audiologist is an individual with a master's or doctoral degree in audiology. Therefore, a Doctor of Audiology (AuD) 4th year student with a provisional license from a State does not qualify unless he or she also holds a master's or doctoral degree in audiology. In addition, a qualified audiologist is an individual who:
- Is licensed as an audiologist by the State in which the individual furnishes such services, or
- In the case of an individual who furnishes services in a State which does not license audiologists has:
- Successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience), and
- Performed not less than 9 months of supervised full-time audiology services after obtaining a master's or doctoral degree in audiology or a related field, and
- Successfully completed a national examination in audiology approved by the Secretary.
If it is necessary to determine whether a particular audiologist is qualified under the above definition, the carrier should check references. Carriers in States that have statutory licensure or certification should secure from the appropriate State agency a current listing of audiologists holding the required credentials. Additional references for determining an audiologist's professional qualifications are the national directory published annually by the American Speech-Language-Hearing Association and records and directories, which may be available from the State Licensing Authority.