Medicare Coverage of Audiologic Diagnostic Testing
Medicare covers audiologic diagnostic testing provided by an audiologist when a physician or non-physician practitioner (nurse practitioner, clinical nurse specialist, or physician’s assistant) orders the evaluation for the purpose of informing the physician's diagnostic medical evaluation or determining appropriate medical or surgical treatment of a hearing deficit or related medical problem.
The Medicare Benefit Policy Manual at Chapter 15, Section 80.3 [PDF], defines the audiology benefit, qualifications, and other policy criteria necessary for audiologists providing services to Medicare beneficiaries.
Medicare Definition of Audiologist
The Social Security Act (Section 1861) defines a qualified audiologist as an individual who
- holds a master's or doctoral degree in audiology;
- in states that license audiologists, holds a valid license as an audiologist;
- in states that do not license audiologists, has
- successfully completed or is in the process of accumulating 350 clock hours of supervised clinical practicum,
- performed not less than 9 months of supervised full-time audiology services after obtaining a master's or doctoral degree in audiology,
- successfully completed a national examination in audiology approved by the Secretary.
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. Technicians, auxiliary personnel, hearing instrument specialists, and students of audiology performing audiologic assessments must have direct physician supervision. Direct supervision requires the physician to be on site and immediately available, but does not require the physician's presence in the room when the procedure is performed. According to Medicare rules, when a Medicare beneficiary is being evaluated by a student they must be 100% supervised by the licensed audiologist. For any services performed by a student, the audiologist must be in the room, guiding the student, fully engaged in the evaluation, and not performing any other tasks. The documentation must be signed by the audiologist, and the services are the full responsibility of the audiologist.
Audiology services are defined in section 1861 of the Social Security Act under "other diagnostic tests" as hearing and balance assessments furnished by a qualified audiologist, physician, nurse practitioner, or clinical nurse specialist performing services under applicable state laws. Coverage and payment for audiologic diagnostic tests are determined by the reason the tests were performed, rather than by the diagnosis or the patient's condition. Audiology services are limited to the diagnostic evaluation of hearing and balance: Treatment, rehabilitation, or other neurologic assessments (i.e., nerve conduction studies, somatosensory evoked potentials) are not recognized by Medicare when performed independently by an audiologist.
Audiology services that are recognized in the Medicare Benefit Policy Manual at Chapter 15, Section 80.3 [PDF], include
- evaluation of the cause of disorders of hearing, tinnitus, or balance;
- evaluation of suspected change in hearing, tinnitus, or balance;
- determination of the effect of medication, surgery, or other treatment;
- reevaluation to follow up regarding 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;
- audiologic diagnostic tests before and periodically after implantation of auditory prosthetic devices.
Any services provided for the purpose of hearing-aid evaluation and fitting are not covered, regardless of how they are billed. However, 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.
A physician order is required prior to the provision of audiology services. 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.
The order for a test performed by an audiologist does not require specific tests; the audiologist may select the appropriate battery of tests. When texts are performed by a technician or other qualified medical personnel, the order must specify which tests are to be performed under direct supervision of a physician. The reason for the test should be documented either on the order, on the audiologic evaluation report, or in the patient's medical record.
The National Provider Identifier (NPI) and name of the physician ordering the audiology evaluation must be included on the claim form.
Audiologists who provide diagnostic testing for the hearing and vestibular systems to Medicare beneficiaries must bill Medicare directly for their services. These services cannot be billed "incident to" a physician, because they are a defined benefit for audiologists. The NPI of the audiologist must be listed on the claim as the rendering provider of the services.
Audiologists do not have an "opt-out" provision in their definition that allows private contracts with Medicare beneficiaries. If the service is covered by Medicare, there is a mandatory claim submission as defined in law (Social Security Act, Section 1848). Unless the patient agrees of his or her own free will to privately pay for the services or specifically refuses claim submission to Medicare, the audiologist must enroll as a Medicare provider and submit the claim. If a Medicare beneficiary requests at any time for the claim to be submitted, the audiologist must comply. Violations of the mandatory submission rule may result in a civil penalty of up to $2,000 for each violation.
Audiologists providing treatment services or other diagnostic services outside of the hearing and balance definition cannot directly bill Medicare for those services. Aural rehabilitation is a Medicare benefit when provided by a speech-language pathologist. Vestibular rehabilitation may be covered when provided by physical or occupational therapists. Even though Medicare does not recognize audiologists as treatment providers, the labor for the technical component (TC) of other diagnostic tests or treatment services may qualify to be billed when furnished by audiologists under physician supervision. Audiologists should be cautioned to ensure they are performing services 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.
Introduction to Medicare
Medicare Reimbursement of Audiology Services
Medicare Coverage Policies: Audiology
Medicare Frequently Asked Questions: Audiology
Medicare Coverage of Students & Clinical Fellows: Audiology
Medicare Audits and Program Integrity