Audiology Medicare Claims with “AB” Modifier are Being Denied

See update (3/17/2023): CMS Issues Guidance on Audiology Medicare Claims with “AB” Modifier

ASHA has learned that audiologists in at least four states—Iowa, New York, Texas, and Florida—are receiving denials from their Medicare Administrative Contractor (MAC) when using the new “AB” modifier to indicate Medicare Part B services were provided without a physician order. It is likely that these denials are occurring in additional states. ASHA has raised these issues with Centers for Medicare & Medicaid Services (CMS) staff and is committed to preventing additional denials and ensuring denied claims are paid as quickly as possible.

To date, the denial pattern appears consistent, and the remittance advice codes include:

• CO16 (claim/service lacks information or has billing submission errors);
• N286 (missing /incomplete/invalid referring provider primary identifier); and
• MA130 (your claim contains incomplete and/or invalid information and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/corrected information)

Audiologists reported that they did not believe it was necessary or appropriate to include a referring physician National Provider Identifier (NPI) number in Box 17 of the CMS 1500 claim form when submitting the claim for payment because they did not have an order on file and intended to use the “AB” modifier, as allowed under Medicare coverage rules. 

ASHA has requested CMS to implement policy guidance and claims processing edits to prevent denied claims that are submitted with the “AB” modifier and without the referring physician NPI. In addition, CMS must identify how audiologists who have been denied to date will be paid through resubmission of claims or another mechanism. 

Audiologists have options to consider until additional guidance is provided by CMS. For example, audiologists could:

• Continue to utilize the “AB” modifier but hold claims until these issues are resolved;
• Submit claims and, if denied, hold these claims until a resolution is identified; or
• Continue to require a physician order and implement the audiology access policy (with the use of the “AB” modifier) only after CMS issues the requisite guidance and claims processing edits.

Background

The audiology access policy and “AB” modifier are new in 2023. In finalizing the policy for implementation on January 1, 2023, CMS noted that it will take until mid-2023 to issue all the necessary guidance and claims processing updates. In addition to ensuring the process as currently structured is implemented as seamlessly as possible, ASHA is also committed to securing improvements in the policy in future years. 

Questions?

More information on the new Medicare audiology access policy is available on ASHA’s website. If you have received a denial associated with the new audiology access policy or the “AB” modifier that does not align with the remittance advice above, please contact Sarah Warren, ASHA’s director of health care policy for Medicare, at swarren@asha.org.