American Speech-Language-Hearing Association

Medicare Frequently Asked Questions: Audiology

Where can audiologists obtain a complete listing of Medicare reimbursement rates for procedure codes?

A list of CPT codes with short descriptors and associated national rates for speech-language pathology and audiology can be found in the Medicare Fee Schedule . The Centers for Medicare & Medicaid Services (CMS) Web site provides precise payment rates based on locality .

  • Click on "List of HCPC codes" (i.e., CPT codes)
  • Choose "All modifiers"
  • Select specific LOCALITY (scroll through, in state order)

Your selected CPT codes will be displayed with the payment amount.

What is a CMS 1500 form?

Non-institutional providers and suppliers use the CMS 1500 form to bill Medicare Part B services, Medicaid, and private health plans. Diagnosis codes are inserted in Sections 21 and 24E. CPT codes are inserted in Section 24D. You may print sample black and white copies [PDF] through the CMS website or obtain copies from your local Medicare carrier, local printing companies, or the Government Printing Office (212-512-1800).

How do audiologists code "normal hearing" results when performing a hearing screening or an audiological evaluation?

Medicare's policy is that you should code for the sign(s) or symptom(s) that prompted the test to be ordered. For instance, a newborn fails an infant hearing screening and is referred for follow up testing which results in normal findings. In this situation, 389.9 (Unspecified hearing loss) would be appropriate.

Are audiology screenings covered under Medicare?

No. Medicare statute specifically excludes coverage for screening services except for mammography.

How do audiologists know which codes Medicare will and won't allow to be billed on the same day?

Go to National Correct Coding Initiative: Audiology Edits for a list of Correct Coding Initiative (CCI) edits for audiology codes.

CMS uses this automated edit system to control specific code pairs that can be reported on the same day. The National Correct Coding Initiative (NCCI or, more commonly, CCI) has been in place since January 1, 1996, and is updated quarterly. The goals of CCI are to eliminate "mutually exclusive" code pairings and codes considered to be components of more comprehensive services or otherwise inappropriate to be delivered to the same patient on the same day.

How should audiologists document their treatment?

Different facilities or agencies have different requirements for how services are to be documented (e.g., SOAP notes, narrative) and where notes are to be maintained (e.g., carbonless copies, writing notes directly in the patient's chart, electronic medical record).

Clinicians must consider the needs of the audience for which the documentation is intended. Oftentimes, a variety of related professionals and claims reviewers will read the assessment report, treatment plans, and discharge summaries, so the clinician needs to ensure that what they write can be understood by an audience of varying backgrounds and experience.

Payers may have documentation requirements of their own, including the information they want to see when reviewing a claim and the timelines in which documentation must be submitted. Typically, health plans are instructed by law to initially request only the minimum information necessary to pay a claim.

The following Medicare and ASHA documents provide excellent guidance on documentation requirements:

Overview of Documentation for Medicare Outpatient Therapy Services
Medical Review Guidelines: Speech-Language Pathology [PDF]
Medical Review Guidelines: Dysphagia [PDF]

Documentation Bottom Line Articles:

Documentation for Private Health Plans

Does Medicare cover bone-anchored hearing aids (BAHA)?

Yes. The Centers for Medicare and Medicaid Services (CMS) revised its hearing aid definition so that Auditory Osseointegrated and Auditory Brainstem Implant (ABI) devices and related services are clearly covered under Medicare as prosthetic devices. The revised policy, published on November 10, 2005, resulted from information provided by ASHA's Health Care Economics Committee and coordinated by Robert Fifer.

Change Request 4038, Pub 100-02, Transmittal 39 [PDF] of the CMS Manual System, can be found on the CMS Web site. Effective December 12, 2005, the updated Medicare policy states that prosthetic devices now include "osseointegrated implants to the mastoid process of the temporal bone and auditory brainstem devices."

A revised definition of hearing aids and auditory implants in the Medicare Benefit Policy Manual, Chapter 16, section 100, describes air conduction and bone conduction hearing aids. Now, it also describes specific devices that replace the function of the middle ear, cochlea, or auditory nerve as prosthetic devices that are payable by Medicare.

See also: Medlearn Matters Article: Auditory Osseointegrated and Auditory Brainstem Devices [PDF]

Is it appropriate to miss a treatment session that falls on a federal holiday?

The Medicare fiscal intermediary should be contacted to determine if a local policy exists regarding treatment during a holiday. There is a somewhat relevant instruction about breaks in rehabilitation service from the federal Medicare program. The Centers for Medicare and Medicaid Services (CMS) issued guidance ( Federal Register , 7/30/99, p. 41670) for maintaining coverage in a skilled nursing facility (SNF) that requires receipt of skilled services at least five days per week: ". . . the Medicare program does not specify in regulations or guidelines an official list of holidays or other specific occasions that a facility may observe as breaks in rehabilitation services . . .The facility itself must judge whether a brief, temporary pause in the delivery of therapy services would adversely affect the resident's condition." However, this guidance is not definitive because it was in response to situations where a SNF resident initiated a brief absence to attend an event with family or friends. It also does not respond to a specific Plan of Care that calls for 5 treatments per week.

Can I accept a payment from a health plan if the amount is higher than my usual and customary one?

A provider cannot charge Medicare a greater fee then their normal fee for a service, thus may not accept the higher fee. The Medicare payment will be the lower of the actual charge or the fee schedule allowance. If the reimbursement is from a private insurance company the speech-language pathologist or audiologist should refer to the contract between the provider and the health plan. If no such contract exists, the professional should contact the payer for clarification.

Share This Page

Print This Page