ASHA's Health Care Economics Committee Answers Your Questions
The following questions have been gathered from a variety of sources, including the ASHA e-mail list, ASHA technical assistance, and revised and updated questions from "Ask the Expert" on Audiology Online. Answers are from the members of the Health Care Economics Committee (HCEC).
Is there any Current Procedural Terminology (CPT) code for the poor man (Foam and dome tests), computerized dynamic posturography (CDP), head thrust, and the vestibular autorotation test (VAT) tests? If yes, what other specifications need to be included in your reports? What about the sensory organization test (SOT)?
Answer: There is no CPT code that represents any of the procedures listed in this question except for CDP, which is coded 92548. For that reason, CPT code 92700 would be the code of choice for the other procedures. Code 92700 is the unspecified otolaryngology procedure that is intended to cover a variety of procedures that do not have their own codes. When this code is billed, a detailed report needs to accompany the invoice to the third party payer with the following pieces of information:
- An explanation of the presenting sign or symptom that caused one or more of these procedures to be performed for this patient
- A complete description of what was done and what was found
- A description of any equipment that was used in the evaluation process and a justification for its necessity
- A description of your clinical assessment and interpretation of the test outcomes
- The length of time required to complete the evaluation
Included in this report should be sufficient information to justify why these procedures were done in addition to or in place of other diagnostic procedures that have standard CPT codes.
What CPT codes should be used for subtests such as head shaking, hyperventilation induced nystagmus, or vibration induced nystagmus? What is the appropriate code for the canalith repositioning maneuver? Is it improper to bill for the vertical electrode component of the ENG test if you are performing the test with videonystagmography (VNG) equipment?
Answer: Procedures such as the head shaking test, hyperventilation induced nystagmus, or vibration induced nystagmus should be reported under CPT code 92700 (see discussion on CPT 92700 above). At the present time, the canalith repositioning maneuver is reported under a variety of codes depending on whom you ask. Some professional organizations and some insurers recommend use of CPT code 92700. Other organizations and insurers recommend the use of CPT codes 97110 (therapeutic procedure) or 97112 (neuromuscular reeducation of movement). Each clinician will need to do some homework to determine what each respective insurer recognizes. We do expect to see a dedicated code for canalith repositioning in the next year or two. Finally, the vertical electrode code (92547) is restricted only to the physical application of vertical electrodes and should not be used with VNG equipment.
I have gotten numerous answers to this question...can an independent audiologist bill insurance for the entire ABR and ENG? I do the test, I interpret the test, and then I send the results to the referring physician for review. I was told several times that I can bill for both the technical component and the interpretation component for each procedure (i.e., each ABR and each CPT procedure in the ENG battery).
Answer: Medicare allows audiologists to bill for both components. However, if the referring physician insists on billing for the interpretation (professional) component, the audiologist should not also bill for the same professional component. Many commercial third-party payers who recognize audiologists as providers will allow the audiologist to bill both the professional and the technical components (also known as the global fee).
We have children referred to us by their primary care physician for delayed speech, asking for a hearing test to be done to make sure they have normal hearing. Which diagnosis code do you use for these hearing tests if the results are normal? The V72.1 is not payable by most insurance companies, and if we use delayed speech they say we are using a speech diagnosis code with a hearing test procedure code and it is not payable. The insurance companies say to use a hearing diagnosis code.
Answer: The general rules for a diagnosis code are that it must match where you are, what you did, and what you found. Selection of the appropriate diagnosis code has been a major stumbling block across the entire realm of health care for many years. For that reason, Medicare published an authoritative document (Medicare bulletin AB-01-144) that gives guidance on appropriate selection of an ICD-9-CM code, especially when the outcome is normal. You can also find a "Coding Guidelines" section in the beginning of the ICD-9-CM code book. In general, the appropriate ICD-9-CM code is the sign or symptom of concern that brought the child to you for an evaluation. In the case of your example in this question, it is not so much delayed speech that brought the child to you as much as it is a question of whether that delayed speech is secondary to impaired hearing. Consequently, hearing loss is your primary concern that you are trying to rule out. As a result, the most common diagnosis code that is used in this instance is 389.9 (hearing loss, unspecified). Be aware that V72.1 is a group heading of less than five characters and invalid as a code. Codes in this group are V72.11 and V72.19, which are valid. Also be aware that "V" codes that accompany the ICD-9-CM system are not diagnosis codes but are a "supplementary classification of factors influencing health status and contact with health services." They are codes typically used with ancillary procedures that, in our case, are not necessarily related to the primary reason the patient is being seen. A "V" code should only be used if the third party payer requires its use. You may wish to visit ASHA's Coding Normal Results: Questions and Answers page for more information about this topic.
When we see children for universal newborn hearing screening (UNHS) follow-up testing, we frequently see normal evoked otoacoustic emissions (OAEs) at both ears after failing the initial screening from either ear in the hospital. There is some disagreement regarding the diagnosis code used there: Should it be conductive hearing loss, as that is what likely caused the initial failure, or V72.1 normal hearing? The V code would result in many rejected billings; while some audiologists argue that we should do that and submit them to our UNHS state system, we're still up in the air.
Answer: Just as stated above, the universal guidance for diagnosis code selection is that the code must match where you are, what you did, and most importantly, what you found on that date of service. Unless there are special arrangements with a particular third-party payer, the typical code that is used when the hearing evaluation did not show hearing loss is 389.9 (unspecified hearing loss). Code V72.1 is an encounter/visit code, not diagnosis code. And, as a code with only four characters, it is not valid. V72.11 (Encounter for hearing exam following failed hearing screening) and V72.19 (Other exam of ears and hearing) fall under the section of the ICD-9-CM manual that implies extra services that were done unrelated to the primary reason that the patient was being seen on that date. Florida Medicaid, for example, requires use of V72.19 for Medicaid eligible children under the universal newborn hearing screening program. That is an example of a special arrangement. The rationale for use in that code for Florida Medicaid is that V72.19 will not be used under any other circumstance if the provider wants to be paid. But for all non-Medicaid children, even in Florida, we use ICD-9-CM code 389.9 when the outcome is normal.
What CPT code do you use for Real Ear Measurements?
Answer: From the CPT listings, CPT codes 92594 (Electroacoustic evaluation for hearing aid; monaural) or 92595 (Electroacoustic evaluation for hearing aid; binaural). These are rather ill-defined codes, they are part of the original set that came in with the Harvard survey in the late 1980s and conceivably could represent 2-cc coupler measurements or real ear measurements. From the Healthcare Common Procedure Coding System (HCPCS) level II roster, code V5011 (Fitting/orientation/checking of hearing aid) could be a possibility. The parenthetical note states that this code is for the fitting and checking of a hearing aid. Which one you select would depend on your purpose in using the code. If you want to account for productivity or procedure counts, you would use any of the codes. If you are working with a third party payer, you will need to check with the payer to find out what code they are programmed to receive.
Can Audiologists bill Medicare for cerumen removal? What is the code?
Answer: Medicare includes cerumen removal as part of the audiometric tests. If the cerumen is impacted and the audiologist believes it must be removed by a physician, the physician may bill a special Medicare HCOCS level II code G0268. On a day in which no testing has occurred, the physician may bill 69210 (impacted cerumen removal).
What CPT code should you use when a diagnostic OAE evaluation could not be performed due to high internal noise and/or infant was very active?
Answer: If you begin to do the diagnostic OAE procedure and don't get far enough to have any interpretable data, I would not bill anything. This is on the assumption that if you start the procedure and the child is continuously very noisy or active, there will be a limit after about 5-10 minutes when you give it up. The reason I would not charge in that case is because you don't really have anything to show for your efforts. Having said that, if you begin the procedure and obtain some information and then lose the child due to noise or activity, I would report the 92588 with a -52 modifier (indicating reduced services). In that scenario, you do have something to show for your efforts, albeit incomplete.
What is the correct way to bill for binaural hearing aids? Our claims have been processed as 1 unit when we use a binaural code such as HCPCS level II V5261, even when we bill as 2 units. Can we bill a V5257 with a LT/RT modifier? We usually receive the maximum amount the insurance will pay; however, the wording on the Explanation of Benefits is confusing regarding how much the patient owes.
Answer: Unfortunately, you have just discovered one of the major issues associated with insurance companies and coverage for hearing aids. The first suggestion I would offer is to contact the provider relations office for that insurance company and try to determine what HCPCS codes they will accept. Secondly, if you do not have the contract language that your center has with the insurance company, I would request a copy of that section of the contract to learn what stipulations and limitations exist. The insurance coverage of hearing aids is all over the map and sometimes is limited to one unit or, they say, two units even though they reimburse you for only one. It is also not uncommon for the insurance company or managed care organization to put a severe restriction on what you can collect from the patient in addition to what the health plan paid. In other words, the ability to balance bill is very limited in some cases. Thirdly, you need to learn from the contract or through the provider relations office what restrictions there may be on the type of hearing aid that you are authorized to provide to the patient. In theory, HCPCS code V5261 should be twice the value of V5257 because it covers binaural hearing aids. However, the possibility may also exist that you will need to report V5257 with a LT/RT modifier. No two health plans are the same when it comes to hearing aid coverage. It depends in large part on the company and also in large part on the specific language of the contract with the employer.
When testing an infant (with visual reinforcement audiometry [VRA] - 92579) or a child (with conditioning play audiometry [CPA] - 92582), is it appropriate to use separate codes for speech awareness/threshold testing (92555) and tonal testing (92582 and 92579)? Do VRA and CPA codes include speech testing or tone testing only?
Answer: The speech awareness threshold is included as part of the description and evaluation for CPT code 92579. In contrast, CPT code 92582 represents only the audiogram obtained via conditioned play audiometry techniques and does not include any speech testing. As such, it would be permissible to report CPT code 92555 with CPT code 92582. It would not be permissible to report CPT code 92555 with CPT code 92579.
What is the appropriate code for a baby who fails an OAE screening in the nursery? Our coders want us to use V72.1. The problem is that when we see them for a further testing, if we have used this code, the insurance company won't pay for further testing. In the past we had been using 389.9 unspecified and there were no problems. Please advise.
Answer: Unless the third party payer has clearly specified to use a "V" code from the ICD-9-CM , it would not be appropriate to use V72.1, V72.11, or V72.19. These are "Supplemental Classification of Factors Influencing Health Status and Contact with Health Services" codes and not diagnosis codes. ASHA has been advised that V codes should follow the diagnosis, condition, problem, or other reason for encounter/visit. With the potential caveat of third party payer arrangements, 389.9 is a code that should be used to signify possible hearing loss of unknown type or degree. If or when hearing loss is confirmed, then the 389.9 code could be changed to, for example, 389.10, 389.11, or 389.03. The reason I place the caveat into this answer is because there are a few third-party payers who wish to have universal newborn hearing screening babies identified as such for special reimbursement arrangements. Florida Medicaid is one example of this exception whereby facilities are requested to use V72.19 for the in-hospital screenings and the initial outpatient re-screen. This code was selected because it is typically not used as a diagnostic code and easily identifies the baby as coming under different rules for reimbursement from Florida Medicaid. However, in this example, the audiologist must revert to the numeric ICD-9 codes after the first outpatient evaluation if the infant shows signs of hearing loss and requires additional follow-up.
I have had difficulty with the code 92507, which I thought was to be used when hearing treatment/feedback/counseling was done. Is there a different code I should be using in lieu of this? Some insurance companies will not cover this CPT code?
Answer: Medicare will not reimburse audiologists for using CPT code 92507. This is considered a speech, language, voice, nonaudiology catch-all therapy code. However, for non-Medicare patients, it is advised that an audiologist seek written confirmation in advance regarding acceptability of 92507. The newer auditory rehabilitation codes 92630 and 92633 should be considered as well. Some insurance companies allow the use of certain office visit CPT codes (known as Evaluation & Management codes). For new patients, see CPT 99201-99205, which are identified as approximately 10, 20, 30, 45, and 60 minute visits. These should also be approved in writing by the payer so as to eliminate retrospective denials.
Are TOS (Type of Service) codes required when billing Medicare for audiological function tests?
Answer: Yes. The TOS code is K - Hearing Items and Services.
Our physicians employ an audiologist within our practice. We would like to be able to do auditory evoked potentials for evoked response audiometry (ABR) procedure at an Ambulatory Surgery Center (ASC) on a child under 1. Are we able to bill for this? Our ASC is stating that they will not be reimbursed as it is not an approved procedure at an ASC according to Medicare. Is our only option a hospital setting?
Answer: The ABR code 92585 is not included on the list of approved procedures for an Ambulatory Surgery Center. If anesthesia is the issue, then it would appear that the hospital setting would be the likely alternative.
I am an audiologist working for a private audiology clinic and hearing aid dispensing center. Our facility wants to contract our audiology services to physicians. If we draw up a contract for an hourly rate of fair market value and provide audiologic services that the physician will bill for himself for Medicare reimbursement, is he violating the Stark Law? The contract would stipulate the number of hours per week we would be in his office, the rate per hour he is paying us, and the amount of time the contract would last. We would in return like to be one of the top two to three places the physician would refer to.
Answer: The contract you describe means that the audiologists are contractors to the physician. In the eyes of Medicare, this is the same status as an employee. Your last sentence states that you would want preference in referrals from the physician. Technically, this is the physician referring to himself because you are his contractor/employee. Such "self-referral" is allowed by Medicare. What is not allowed is the physician's referral for services to a separate entity (i.e., separate from the physician's office) in which the physician has a financial interest or from which the physician receives a financial benefit because of the referral (or, in other words, a kickback).
We are considering performing vestibular evoked myogenic potentials (VEMPs) in our otology office but are unsure how to bill for it. Do you know if there is a CPT code that can be used and if this is normally covered by insurance plans?
Answer: At the present time there is not a CPT code for VEMP. On the premise that this evoked potential is elicited by an acoustic stimulus, we are recommending the use of the diagnostic ABR code 92585. Its coverage by insurance plans may vary from one company to the next. Because the procedure would be using a familiar code, I would speculate that it is probably covered. Having said that, your documentation will need to ensure the clarity of medical necessity as the basis for performing the procedure and will need to mention the acoustic stimulus because you are using an auditory evoked potential procedure code. The VEMP now qualifies for its own CPT code. We are beginning the process of preparing the application to the American Medical Association CPT Editorial Panel for this procedure.
What is the diagnostic code for auditory neuropathy (AN)? I was not able to find a code specific for AN.
Answer: There is not a specific diagnostic code for auditory neuropathy in the ICD-9-CM system. ICD-9-CM code 389.13 (neural hearing loss, unilateral) or 389.12 (neural hearing loss, bilateral) would be the most appropriate diagnostic codes if you have indication of normal cochlear function. If you have indications of cochlear compromise in addition to neuropathy, then 389.15 (sensorineural hearing loss, unilateral) or 389.18 (sensorineural hearing loss, bilateral) would be appropriate codes.
I have a question about billing for an ABR. I currently use multiple stimuli (clicks and frequency-specific tone bursts) and perform threshold testing in each ear when I evaluate infants. I know that 92585 is the code for ABR but how should I use it when I am testing threshold at multiple frequencies?
Answer: Your primary option to obtain increased reimbursement would focus on the -22 modifier. The basis of using a -22 is the increased time and complexity associated with completion of the procedure. Your report should detail the various components of your evaluation, with emphasis on using clicks and frequency-specific tone bursts for each ear. There should also be notation of the start time and stop time or, at minimum, simply the duration of the evaluation to further emphasize the complexity and the length of time. Do not attempt to bill CPT code 92585 in units. You may be reimbursed for multiple units of the code, but I can pretty well assure you that it will raise a red flag and open the door to an audit and possible sanctions. Code 92585 is intended to be billed once per date of service, which makes the -22 modifier your best option. Along with the modifier, you will need to establish what price you are requesting from the third-party payer and justify the price based on the extra complexity and time required to complete the procedure.
If I bill 92557, is there a specification for "traditional" audiometry? When I bill 92557, I have typically tested at 9 frequencies (.125, .25, .5, 1, 2, 3, 4, 6, and 8 kHz). I have also seen persons who bill 92557 and only test 6 frequencies (.250, .5, 1, 2, 4, and 8 kHz). How is 92557 defined?
Answer: There is no strict prescription on how many frequencies must be employed for air conduction testing under CPT codes 92557. Typically, the octave frequencies from 250 Hz through 8000 Hz constitute the minimum. Depending on the configuration of the hearing loss, 3000 Hz, 6000 Hz, and 1500 Hz could be added without a problem. The goal of 92557 is to provide sufficient results that can be considered a "comprehensive" audiogram for air conduction testing, bone conduction testing, speech reception threshold, and speech discrimination.
I have heard from many insurance companies that the typical code for hearing aids—V5060 for monaural and V5140 for binaural—are no longer valid. However, they will not give me the new codes, and I cannot find them anywhere. Do you know what they are? I would appreciate any help you have to offer.
Answer: V5060 and V5140 are valid HCPCS codes. They are both for behind the ear hearing aids. For the complete list of speech and hearing related HCPCS codes, go to ASHA's Web site. The HCPCS spreadsheet can also be found on the Centers for Medicare and Medicaid Services Web site. If the insurance companies are telling you that the codes are no longer valid, then the codes are no longer valid only for those companies. They are still very much alive and well in the HCPCS level II code book. It would be up to each company to determine what codes they want to use in place of V5060 and V5140. I suggest that if you have the authority to do so, contact the provider relations office of the insurance company (also known as provider education) to determine which codes they are using at this time.
If physical therapy (PT) wanted to refer a patient to audiology for vestibular testing and the patient was originally referred to PT by a primary care physician for another concern and issue, can the audiology services be billed to Medicare under the primary care physician's name? We are all housed inside same building at a hospital.
Answer: For Medicare and Medicaid and for most, if not all, private health plans, a direct physician referral is required for the vestibular testing. Physical therapists cannot refer a patient to an audiologist, and an audiologist cannot bill Medicare through the primary care physician's name unless the primary care physician has personally initiated the referral to the audiologist.
In a patient suspected of having benign paroxysmal positional vertigo (BPPV), I do a video assisted Dix-Hallpike to confirm BPPV and to document the findings. The patient is scheduled to return for repositioning on another day. Can I charge for the video recorded Dix-Hallpike using the positional codes from the VNG battery?
Answer: At this time, you could use CPT code 92542 to report the video assisted Dix-Hallpike procedure to diagnose and/or document the BPPV findings. It would not be appropriate to report this code for canalith repositioning. CPT code 92542 is a diagnostic procedure and not an intervention code. The appropriate code for canalith repositioning at the time of this writing would be 92700, 97110, or 97112, depending on the directive of the third-party payer.
How many tests are allowed for vestibular testing procedures that are performed multiple times on the same day. Also, are we expected to use a repeat procedure modifier?
Answer: Under Medicare, there may be a local coverage determination (LCD) by the carrier or intermediary that addresses vestibular testing and a daily restriction might be stated. It would be prudent to include the repeat procedure modifier (-76) if the procedure is completely repeated for all aspects of the protocol. However, that modifier does not indicate reasons for the repeat. One should submit with the claim specific reasons for the repeated testing. Keep in mind that CPT codes 92542, 92544, 92545, and 92546, under normal circumstances, are not reported more than once per day and they must not be reported in units unless the audiologist has a directive from a particular third-party payer to do so. CPT code 92543 may be reported up to four times on the same date of service. And 92547 is an add-on code to be reported in conjunction with the other balance evaluation codes for which the audiologist employs vertical electrodes (not goggles). If you do one of the above procedures and for whatever reason you have occasion on that same date of service to redo the entire procedure, it would be appropriate to use the modifier -76 and be prepared to submit a report to justify the repeated procedure.
Our hospital audit committee has received a statement from the AMA stating that the vertical electrode code 92547 may not be used for vertical recordings when VNG (goggles) are used instead of electrodes. We have been instructed to use CPT code 92700 (Unlisted otorhinololaryngological procedure). Is this true?
Answer: This is the actual advice issued by the AMA coding section. The AMA did not issue guidance on which CPT code to use instead of 92547 when goggles are used. Typically, additional billing for the vertical channel is not appropriate when goggles are used.
I work in an ENT practice in North Carolina and I have had some claims rejected by Medicare. For example, an established patient came in for an annual hearing evaluation and to discuss hearing aid options. She has sensorineural hearing loss and I recommended hearing aids. Our office submitted a claim and Medicare denied the claim. In reading the article by Dr. Fifer, I was under the impression that ''regardless of the outcome of any visit, Medicare would pay for the audiologist's services." The patient has been seen by our physician and has been diagnosed with sensorineural hearing loss and hearing aids were recommended at every visit. She waited initially and returned some time later and wanted to have her hearing reevaluated and to discuss hearing aid options. Can Medicare deny a claim for those reasons?
Answer: If the physician does not need audiometric or vestibular test results for assisting in the determination of a medical or surgical diagnosis, then the tests are not within the Medicare scope of coverage. Medicare will cover audiological diagnostic tests, regardless of the outcome, only if the diagnosis is not yet known. If the diagnosis is already known or if the purpose of the evaluation is solely to discuss hearing aid options, then Medicare can and will deny claims. The operational term in this case is medical necessity. If the diagnosis is already known and the patient has no new complaints or change in symptoms, then Medicare has determined that a repeat evaluation (such as an annual audiogram) does not fall under the heading of medical necessity and, therefore, is not covered as a Medicare benefit.
I understand Medicare does not reimburse for an audiogram unless it is part of a medical evaluation referred by a physician. However, what if during a hearing aid check it is apparent there is a decrease in hearing that requires further testing and medical intervention. If we advise the patient to contact her physician for follow-up and to request a referral for a hearing evaluation, does this violate any Medicare guidelines? Or, in another case, a hearing aid user drops in with a reported sudden hearing loss and we perform the necessary tests and then have her follow up with her physician. Would Medicare reimburse if the audiologist is the first professional contacted?
Answer: In the first scenario, the patient should be referred to the primary care physician as soon as the audiologist observes that there has been a decrease in hearing. It will then be up to the primary care physician to determine what additional diagnostic testing will be necessary and to make the appropriate referrals. In the case of the reported sudden hearing loss, to adhere to Medicare coverage rules the audiologist should refer the patient immediately to the primary care physician without complete diagnostic testing. Upon physical examination of the patient and a history, the physician can determine the totality of the diagnostic tests that will be necessary and, once again, make appropriate referrals. Even though it defies logic for being "patient-friendly," the reason why the referral must be to the physician before diagnostic testing is done is by virtue of the premise upon which audiologists are paid. If the diagnosis is already determined, additional diagnostic testing to redetermine that diagnosis is not justifiable. All diagnostic testing must be performed after physician referral has been obtained and for the purpose of determining the magnitude and characteristics of a previously undiagnosed problem. The concern would be that if the audiologist performed diagnostic testing and referred the patient to the physician for referral for repeated testing, everything would be disqualified because the key diagnostics were performed before the referral was made. The audiologist cannot perform diagnostic testing and have it covered by Medicare without a physician referral beforehand even if the audiologist is the first person that the patient contacts.
I am currently employed as an audiologist at a balance clinic in Indiana. My question relates to our profession and the use of technicians to perform balance testing. I know that at the hospital where I used to work they had technicians performing their balance testing. When coding for services in a private practice, is it possible to bill and be reimbursed for this testing using a technician? An audiologist would be supervising the technician. I am also curious about using technicians in a hearing screening capacity with the same question about reimbursement. If you could give me some insight or refer me to an article or other reference to find best practices in audiology information, I would appreciate it.
Answer: Under Medicare, audiology technicians cannot be supervised by audiologists. In this instance, the service must be personally delivered by an audiologist. Use of technicians and billing non-Medicare third-party payers may vary by specific private insurers and also by the license law governing technicians in your state. If the balance clinic is in a hospital or part of a physician practice, then use of the technician is covered. Surprisingly, Medicare does not require a physician to be on the premises when nonaudiologists perform tests or other technical services. In a prior life, I employed a technician who did outstanding work in the performance on balance evaluation procedures. However, notwithstanding the quality of the technician, Medicare patients must receive the personal, professional services provided directly by an audiologist.
I am an employee of an otolaryngologist who recently went to a ''coding'' course and was told that audiologists should not be using the ''global'' code of 92585 for billing ABRs. It was stated that audiologists are not allowed to bill for the professional component of this code (only the technical component) and should therefore be billing it with the TC modifier. I have always done the testing and the interpretation and received reimbursement for both, from Medicare, by using the 92585 code.
Answer: Medicare does allow the global code to be billed. Also, a Medicare carrier (AdminaStar) confirmed in 2004 that the Chicago CMS Regional Office instructed the carrier to reimburse global charges from independent audiologists. In addition, the Medicare Claims Processing Manual (chapter 5, section 10) states that audiologists may bill globally in skilled nursing facility settings. The only caveat to this answer rests in the audiologist-physician relationship. If the treating/referring physician insists on the interpretation and billing of the professional component, then the audiologist must bill only the technical component. But that should be the only exception to the global billing guideline for audiologists.
Medicare stipulates that a physician's referral is required for audiologic testing for payment to be made to audiologist. What does that 'referral need to say? Can the request simply be "hearing evaluation" or "for the evaluation of hearing loss"? Does the physician need to be more specific?
Answer: Ideally, the referral should state that the physician needs the test results to help determine or refine a medical diagnosis. A referral for a "hearing evaluation not related to a hearing aid evaluation" would also usually be acceptable. It is wise to contact your Medicare carrier for their specific advice on this. As a practical matter, however, the physician, in an ideal world, would state in writing that the patient needs a diagnostic audiological evaluation and then would offer a list of the presenting symptoms. However, in the real world, the written referral typically only says "hearing evaluation." In that instance, the audiologist must take a history to list the presenting symptoms and their severity and other pertinent aspects of the patient's history to justify the medical necessity of the evaluation.
What is a CPT modifier? When should I use a modifier?
Answer: A CPT modifier provides additional information about the service rendered. This information may help to get the procedure covered by insurance or it may result in a specific payment increase or decrease. Always submit with the bill a detailed reason why the modifier was used. Common modifiers are listed in Appendix A of the CPT Manual. Examples are as follows:
- 22 Unusually long or intense procedure (may result in a 20% to 50% increase in payment)
- 26 Professional component
- 52 Reduced services (i.e., unusually short or simple)-may result in a decrease in payment of approximately 50%
- 59 Distinct procedural service (commonly used to bypass claims review edits that disallow certain pairs of procedures on the same day)
- 76 Repeat procedure by same physician-subsequent to the original procedure
- 77 Repeat procedure by another physician
Which audiology codes should I use for the Otogram™?
Answer: An article recently appeared in the AMA CPT Assistant providing guidance that the Otogram procedures should be reported under CPT code 92700 (otolaryngologic procedure, unspecified). As always when using 92700, the professional reporting the code must include a report to stating why this procedure was done, why currently recognized procedures with their own CPT codes could not be used, a complete description of what was done and what was found, a description of the equipment that was used, the length of time required for the evaluation, and the benefit to the patient for having done this procedure.
I just discovered that some of the OAEs I've billed for haven't been reimbursed by a few insurance companies. I'm wondering if using a specific diagnostic code (i.e., 388.40) would get certain procedures denied. I try to do OAEs on all new patients for a baseline, and also will perform them on children who have tubes. I am billing 92588 (diagnostic OAEs).
Answer: It is quite possible that some insurance companies are scrutinizing your billing on the basis that 92588 is being reported much more often than the norm. All third-party payers now operate under the heading of medical necessity, which means that each procedure must be clinically justified in order to answer a diagnostic question and determine patient status. It generally is not acceptable under typical circumstances to do a procedure simply to establish a baseline. (One of those exceptions could be a baseline procedure prior to initiation of chemotherapy.) All procedures must serve the purpose of deriving a diagnosis based on specific complaints, signs and symptoms, or risk factors of associated diagnoses. Also be aware that 92588 is a very comprehensive OAE procedure that is intended to obtain much more detailed information about cochlear function than either a screening OAE or what an audiogram can provide. Another potential problem could be the choice of diagnostic codes. Generally, third-party payers want to see an ICD-9 code that comes from the 389 family for hearing loss diagnoses. A substantial number of third-party payers do not recognize codes from the 388 family in relation to audiology diagnostic CPT codes. Consequently, the moral of the story is to think carefully about what procedures you will include as part of your diagnostic battery relative to a specific diagnostic question focused on an individual patient. In addition, be careful how you combine the CPT codes and ICD-9 codes. Their respective combinations must make sense to third-party payers.
If I bill 92553 and 92556 instead of 92557, I get more reimbursement. Why can't I do this routinely?
Answer: CPT code 92557, by definition, is a combination of 92553 and 92556. If you reported 92553 and 92556 in place of 92557, that would be called "unbundling." Federal regulations prohibit unbundling for the sake of increasing reimbursement. Consequently, to abide by the Federal regulations, only the bundled code 92557 can be reported if all the elements of pure tone air conduction and bone conduction thresholds, speech reception thresholds, and speech discrimination were completed.
Has anyone successfully used a 26 modifier when billing for 92557. We have a different fee for an initial evaluation than for routine evaluations so our cost is higher for the initial diagnostic evaluation. I have been told that a 26 modifier cannot be used since "since this is a technical service code."
Answer: It sounds like your question refers primarily to Medicare. There was no professional component for 92557 until 2008; consequently, the code was not eligible for the 26 modifier as of the time of this writing. Also, Medicare and other payers will not pay more for the initial test. A procedure is considered the same whether it is initial or follow-up, and each procedure must have a uniform charge for all occasions to all payers. Incidentally, "physician work" (or the professional component) relative value units have been established for 92557 for 2008 under Medicare.
Why can't I bill for auditory rehabilitation and a speech-language pathologist can? Also, why can a speech-language pathologist bill for auditory processing disorder testing?
Answer: Under Medicare, audiology services are limited by law to diagnostic testing. Since the inception of Medicare, audiology has been a diagnostic-only service. The Medicare statute was silent on audiology itself but included a diagnostic testing section. The Medicare regulators (first the Health Care Financing Administration that was to become the Centers for Medicare and Medicaid Services) covered audiology services as a benefit under the diagnostic testing section. It wasn't until ASHA had the statute amended that audiology and audiologist were defined but the language had to be limited to then current Medicare policies. The APD question requires a little bit of history. As stated in another answer, auditory processing began as an audiology proposed code in 1995. To conserve the number of CPT code descriptors, the AMA rolled the auditory processing procedure into CPT code 92506 to make it a multidisciplinary multi-access code. In the meantime, some of the newer speech and language test batteries now include subtests for what they call auditory processing. In general, this brand of auditory processing is not what audiologists perform. Rather, it is a group of subtests focused on elements of receptive language. Speech-language pathologists should not be billing just for an auditory processing evaluation. There are a number of scope-of-practice and ethical issues involved with this. However, they are within their scope of practice to include elements of what they call auditory processing as part of their global language evaluation. I am also aware of speech-language pathologists who perform the SCAN battery as a stand-alone screener or as part of their language evaluation. Even for this, it would not be appropriate for a speech-language pathologist to bill for an auditory processing evaluation (i.e., 92620/92621).
I would like some information on when to use codes 389.11 and 389.12 and on how the determination is made to use one or the other or the unspecified code 389.1.
Answer: First, ICD-9 code 389.1 should never be used. The guide found in Medicare regulations requires that the diagnosis code should be reported to the highest level of specificity. CPT 389.1 is not the highest level of specificity for that family of codes. Now, with regard to 389.11 or 389.12, your choice of codes will depend on the evidence that you have gleaned from your diagnostic results. If the evidence suggests that you have a cochlear hearing loss only, then the diagnosis code of choice would be 389.11. If, however, the evidence suggests that you have VIIIth nerve involvement and the cochleae are normal (i.e., auditory neuropathy), then the code of choice would be 389.12.
Do I need physician referrals for every patient that I see?
Answer: Medicare requires a physician referral for diagnostic testing. Such referrals may also ensure that your services are covered when billed to other payers. However, there may be some commercial third-party payers that do not require a physician referral. It may be that a managed care organization would have open access by which a patient can make an appointment directly with an audiologist. In that instance, the weight of evidence for medical necessity falls directly on the shoulders of the audiologist and should be reflected in the documentation that supports the CPT and ICD-9-CM codes. It behooves you to check with the health plans in your area to determine if a physician referral is required.
How should the professional component of the electronystagmography (ENG) be billed?
Answer: As stated above in the question related to "global" billing, Medicare allows independent audiologists to bill for the professional and technical components. If the referring physician insists on billing for the professional component, you would bill only for the technical component by adding a modifier, -TC, to the CPT code.
It is becoming more common in bilateral cochlear implantation to have both implant devices activated on the same date for the initial stimulation and for each follow-up visit. There is no CPT code that represents bilateral cochlear implant programming. How can I bill this?
Answer: You are correct in saying that there is no CPT code that allows programming for two independent cochlear implant systems on the same date of service. However, there is a suffix (i.e., modifier) that can be used to accomplish the same purpose. The suffix is -76 and it means that the procedure was repeated in its entirety by the same provider on the same date of service. In this instance, you would report, for example, CPT code 92601 for the first device and 92601-76 for the second device. Your report of the programming session would need to indicate all that you did for the first device and that the session essentially ended with regard to the programming, and then you turn your attention to program the second device. It could be a good idea to include the start and stop times for programming each device to further highlight that there were two independent procedures for two different cochlear implant devices.
Is it true that no physician referral is needed for Medicare or Medicaid when the audiologist is in the same office as the physician, or when leasing an office space from the physician?
Answer: For Medicare, a physician referral is always required for audiometric or vestibular testing if the billing is in the name of the audiologist. This is true even if the audiologist shares office space with the physician under a lease or other arrangement. Where, however, the physician employs the audiologist and bills for the audiologist services, in our judgment, no formal referral is required. Although we have not identified an official policy rule in this situation, we think a referral can be presumed from the nature of the employment relationship. Finally, for Medicaid purposes, a physician referral is generally not required if the state defines an audiologist as a "licensed practitioner of the healing arts." However, given the multiplicity of state laws, we would urge audiologists to confirm this view with their state association or with the state Medicaid agency.
What are the reimbursement options for hospital audiology program administrators?
Answer: Medicare payments are determined by the Hospital Outpatient Prospective Payment System (HOPPS). Under this system, the CPT codes marked on the encounter form are translated in the billing office to Ambulatory Payment Classifications (APCs). APCs are categorical listings of procedures for which reimbursement is a flat fee for each CPT procedure in the APC. Private third-party payers can often be billed by CPT code without conversion to the APC listing, depending on the specific contract with the respective payers. In this case, the hospital administration and billing office typically sets the fees by CPT code and based on some type of survey (usually by an outside accounting or consulting firm) or a calculation of the cost of service delivery. More information on HOPPS, including 2008 rates, is found in an ASHA document that also includes the Medicare Fee Schedule.
How are flat-fee outpatient clinic rates, often incorporating an array of specialty services for Medicaid recipients, billed?
Answer: Flat fee rates are controlled by third party payer rules and by state regulations, including Medicaid regulations. Medicaid requirements vary from state to state. This would require detailed knowledge of the reading of each specific contract and familiarity with Medicaid payment policies of your state. In a situation where the billing is outsourced to a commercial third-party entity, it will be extremely important to maintain ongoing communications with that company to obtain the EOBs (explanations of benefits). In that manner, if denials for payment are rendered by the insurance company or HMO, the department administrator can be aware to make a decision of whether to write it off, seek collection from the family (depending on the terms of the contract with a third party payer), or correct an error and resubmit the invoice for payment.
What are typical rates? What are the best ways to raise an outpatient department flat-rate fee schedule? When would a Medicaid PIN number become necessary for an audiologist who is providing outpatient services at a Medicaid hospital clinic?
Answer: I am afraid that there is no such thing as a typical rate. Only Medicare Part B and hospital outpatient rates are uniform across the country, subject to geographic adjustments. To set the rate for non-Medicare patients, many facilities will calculate the cost of service delivery and establish a flat rate based on that analysis. Medicaid regulations will vary considerably from one state to the next with regard to CPT code billing, flat-rate provisions, or other billing paradigms. There is no such thing as a Medicaid PIN number, per se. The identification number intended for all health care providers comes under the National Provider Identification system. Each health care provider should have his or her NPI number identification when that is necessary. In a hospital setting, the hospital will often have the option of billing under the hospital's NPI number, the provider's NPI number, or a combination of the two. Regardless of the arrangement, it is very worthwhile and very important for each health care provider to have an individual NPI number. Information on the NPI is found on the ASHA Web site.
Is it necessary to have a written referral for a hearing test to be covered under Medicare?
Answer: Each Medicare carrier determines if a written referral is required. A transcription of the physician's phone referral is acceptable to some carriers. In general, it is preferable to have a written referral on the physician's letterhead, the physician's prescription pad, or other type of document unique to the referring physician. If you do obtain a written referral, it must not be on a pad prepared by your office and sent to the referring physician's office. This could be construed as a solicitation of patient referral, which would be a violation of Medicare regulations. In any case, Medicare coverage is denied if the referral is obtained after tests have been performed.
In an otolaryngology practice, what are the procedures that if billed with an audiology procedure with the same date of service result in only one or the other being paid, that is, only the medical procedure or only the audiologic?
Answer: Under Medicare, impacted cerumen removal (69210) is not covered if performed on the same day as audiology testing unless a special Medicare code G0268 is used (see further discussion below regarding Medicare cerumen management). ASHA has a listing of correct coding initiative (CCI) edits that Medicare and other payers use to determine which codes cannot be billed on the same day as others.
How do you determine an audiologist's productivity? Should you use time-based units and how much time should be assigned to each task?
Answer: There is no single method by which productivity can be measured. Several techniques have been used in various settings and each one by itself comes up short. One method is to count the total relative value units (RVUs) produced by each audiologist in the course of a clinic day. If this method is used, it is important to use total RVUs and not simply the "work" RVUs. I'm aware of some settings that use the RVU methodology to determine productivity and the need for additional personnel, but they only use the work RVUs and not the total RVUs. The downfall in this methodology is that many of our procedures do not have work RVUs assigned at this time. Consequently, an audiologist may do a number of different procedures and receive no credit for having done them. Additionally, other procedure codes have a very small work RVU and a very large practice expense RVU (relatively speaking). So if the RVU method is used to determine productivity, it needs to take into consideration the total RVU for each procedure and not any single component.
Another method by which productivity is measured is the income generated. This is a popular method used in many hospital settings because the bottom line regarding continued financial support of a service area is whether that service area earns sufficient support for salaries, overhead, equipment, and supplies. This method is judged in two different ways. One is the amount of money that is billed. The other is the amount of money received. Usually there is a summary report that combines the two values for productivity and measured income.
The third method with which I am familiar is the hourly count of patient contact time. Basically, this method examines how much of the work day is actually spent in patient contact versus other administrative or clinical activities. It also takes into consideration the patient "show" rate reflecting how much down time each audiologist has during the course of the day.
Under the heading of "Fifer's humble, highly biased opinion," I would offer the recommendation for a combination of the three methods. Each one has its own strengths and reflects different perspectives and productivity. For example, an audiologist may see 20 patients in the course of a morning, but if those 20 patients are primarily for tympanometry reflexes, it is possible that that could be counted equivalent to seeing one patient for an auditory evoked potential evaluation in terms of charges and collections, especially if that one patient is an infant. In this example, it would be necessary to take into account the actual patient contact time in addition to the number of patients, the outgoing charges, the collectibles received, and the total RVUs per unit of time. Each of these factors contributes significantly to the analysis of meaningful productivity when used together. Each method of examination in isolation falls far short of conveying a global picture of true productivity for each professional.
These questions first appeared in the Vol. 7, No. 1, January/February 2008 issue of Access Audiology.
Related article: Why the Need for the HCEC?