June 8, 2010 Audiology

Navigating the Coding and Reimbursement Maze

Webinar Offers Audiologists Guidance on Medicare, Private Insurance Billing

In February ASHA hosted a webinar, "2010 Audiology Coding and Reimbursement Update." Audiologists had many questions that were answered during the event; answers to additional questions are presented here. (For information about on-demand replay of the webinar, search "audiology coding seminar" at ASHA's Web site).

Q: Patients often come to us with a referral from a physician for hearing testing. Under which of the following conditions can we bill Medicare?

  • The patient has a referral from a primary care physician for hearing testing; we diagnose a sensorineural hearing loss and the patient needs a hearing aid. Can we bill Medicare for the test?
  • A patient visits a physician for a non-hearing related issue, but during the visit tells the physician about difficulty hearing. The physician gives the patient a prescription with a diagnosis of decreased hearing. Can we bill Medicare using the diagnosis of decreased hearing?

Medicare recognizes audiological testing as a covered diagnostic service when a physician orders such testing for the purpose of obtaining information necessary (1) for a diagnostic medical evaluation or (2) to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem. If the referral is consistent with one of these two reasons, the service is covered and you can bill Medicare.

Q: We have a patient who wears hearing aids. Will Medicare pay for annual hearing testing?

Routine testing is not covered. The purpose of the evaluation must be to obtain information necessary (1) for the physician's diagnostic medical evaluation or (2) to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem. If the patient is not complaining of a change in hearing, the test is not covered by Medicare.

Q: Can an audiologist ever bill evaluation and management CPT (Current Procedural Terminology, ©American Medical Association) codes such as 99244, 99201, or 99215?

Audiologists cannot bill Medicare for evaluation and management services (i.e., office visits). Some private health plans allow audiologists to use these codes. You should check with the private health plan before submitting a bill.

Q: For patients in assisted living, we often have to call family members to discuss matters such as the patient's diagnosis, recommendations, and hearing aids. Is there a code for billing Medicare?

No. Audiology is considered a diagnostic test benefit under Medicare and is limited to the test codes.

Q: Which code should be billed and is most likely to be reimbursed for the Epley maneuver?

 CPT code 95992 is used to report canalith repositioning procedures. However, Medicare scope of coverage does not recognize audiologists as providers of treatment or therapy services. Coverage for this service by private health plans and Medicaid needs to be checked individually. Interestingly, Medicare will not reimburse physicians for 95992 because the Centers for Medicare and Medicaid Services (CMS) states that it is part of an evaluation and management service. Physical therapists must use a physical medicine and rehabilitation code (97112 neuromuscular reeducation) to be reimbursed for the service by Medicare.

Q: Can an audiologist request a referral from a doctor on behalf of the patient?

There is no Medicare regulation that bars an audiologist from contacting a patient's physician, discussing the symptoms, and requesting a referral for testing. As a precaution, the audiologist should ask the physician to acknowledge that the testing will be used to make, confirm, or rule out a diagnosis or otherwise manage the patient's medical care as the basis for Medicare coverage. Diagnostic testing will not be covered if performed before a referral is received.

Q: What prompts Medicare to audit a clinician? What red flags should we try to avoid?

Any aberrant billing behavior could trigger an audit. For example, Medicare might be concerned about the following: a large number of tests performed on each of many patients; the same tests being performed on many patients; most patients (especially a large number) being referred from the same physician; or a large number of patients with the same diagnosis.

Q: Some of our claims are being denied because of ICD-9-CM diagnosis code errors. Are there codes (one or a combination) that should be used or are more successful?

The ICD-9-CM codes should be accurate and consistent with your findings. Private health plans may be looking for diagnoses that indicate an accident or illness before covering the service. Some Medicare contractors list specific diagnostic codes applicable to specific diagnostic tests.

Q: Can we use the -52 modifier (i.e., reduced service) for procedure code 92557 if we do not test both ears?

Using the modifier -52 is appropriate for indicating that you have tested one ear.

Q: Is it correct to bill two units of V5140 for hearing aids?

 V5140 is a Healthcare Common Procedure Coding System (HCPCS) code for devices and supplies, not a CPT code. This particular code indicates binaural, behind-the-ear hearing aids. Binaural hearing aids are already included in the code and should therefore be considered one unit.

Q: If an insurance company does not fully reimburse for the cost of a hearing aid, can you bill the patient for the remainder if the patient has signed an Advance Beneficiary Notice (ABN)?

Some insurance companies require that an enrolled provider (i.e., a preferred provider) accept their reimbursement as payment in full for certain devices. Otherwise, a form similar to the ABN [PDF] should be given to the patient in advance to inform the patient that he/she is clearly responsible for the portion of the purchase price not covered by the insurance plan. Note that the ABN is a Medicare document and Medicare does not cover hearing aids.

Q: We have a clinical NPI number and have applied for Medicare number. I understand we have to wait to get a Medicare number to bill. What date goes on the claim form: the date we received Medicare approval for billing or the date the test was performed?

The date of service on the claim form should reflect the actual date the services were rendered. Billing privileges commence on the date you filed your enrollment application. However, do not submit the claim until you have received acknowledgement of acceptance as a Medicare supplier. This privilege is granted by 42 CFR 424.520(d):

"The effective date for billing privileges for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations is the later of the date of filing of a Medicare enrollment application that was subsequently approved by a Medicare contractor or the date an enrolled physician or nonphysician practitioner first began furnishing services at a new practice location."

Q: We have two AuD-level and two master's level audiologists. Can I bill under one audiology supplier number and NPI for all services?

All four audiologists are individually qualified to bill for services if licensed. A single group practice can bill for all staff audiologists by using its group NPI in the "Billing Provider" item #33 of the 1500 claim form. The audiologist(s) should enter his/her NPI for each CPT procedure performed (Item#24.J).

Steven White, PhD, CCC-A, director of health care economics and advocacy, can be reached at white@asha.org.

Mark Kander, director of health care regulatory analysis, can be reached at mkander@asha.org.

Robert Fifer, PhD, CCC-A, is a member of the Health Care Economics Committee and ASHA advisor to the Health Care Professionals Advisory Committee of the American Medical Association/Specialty Society Relative Value Scale Update Committee. He can be reached at rfifer@med.miami.edu.

cite as: White, S. , Kander, M.  & Fifer, R. (2010, June 08). Navigating the Coding and Reimbursement Maze : Webinar Offers Audiologists Guidance on Medicare, Private Insurance Billing. The ASHA Leader.


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