March 17, 2023
In response to our requests for a resolution to Medicare claim denials, the Centers for Medicare & Medicaid Services (CMS) issued an update with limited guidance for addressing audiology claim denials when using the AB modifier. Specifically, CMS stated when using the AB modifier, audiologists can leave boxes 17 A and B (name and national provider identifier (NPI) of the referring provider) on the CMS-1500 claim form “blank or incomplete.” ASHA is seeking clarification from CMS about how this information has been communicated to the Medicare Administrative Contractors (MAC) to avoid additional denials. Unfortunately, CMS did not clarify how denials received in the early months of implementing this new policy will be addressed.
CMS also provided in its guidance a “tip” for billing audiology services with the AB modifier. The “tip” was to maintain “documentation [that] good faith efforts were made to provide services for non-acute hearing conditions without the order of a treating physician or NPP so that the claim won’t deny if you unexpectedly discover an acute condition.” CMS does not provide examples of what is considered a “good faith effort” when providing services without a physician order only for non-acute hearing services.
ASHA recognizes the outstanding questions this Medicare guidance creates for our members including:
As a result, audiologists may find it necessary to continue to provide services with a physician order until these issues are resolved.
ASHA will seek clarification from CMS on what constitutes a “good faith effort,” but, in the interim, ASHA advises audiologists to inquire before scheduling a patient who does not have a referral if the symptoms (e.g., hearing loss) were sudden in onset, to determine if a referral is needed prior to testing. If, upon evaluation, it is determined the issue is acute, document in the assessment report that the results of the evaluation, history, and physical did not align with what the patient reported during the “screening” process.
Last month, ASHA informed members that audiologists in at least four states were reporting denials from their MAC when using the AB modifier to indicate Medicare Part B services were provided without a physician order. It is likely that these denials were occurring nationwide.
ASHA raised this issue with CMS staff and requested an expedited resolution. CMS partially addressed these denials and provided new implementation guidance in its March 16 update. However, this guidance does not address how documentation for services provided in January, February, or early March should be modified for compliance purposes.
In addition, CMS did not clearly address a longstanding concern of the newly implemented audiology access policy. Under the new policy, audiology evaluation services can only be provided without a physician order for a specific subset of Current Procedural Terminology (CPT®) codes once per 12 calendar months per Medicare beneficiary for non-acute hearing loss. ASHA consistently raised concerns that the concept of “non-acute” was not easily distinguished without evaluating the patient and, as a result, posed significant financial risks for both the patient and audiologist if it was ultimately determined the hearing loss would be considered acute per Medicare guidelines.
ASHA continues to engage CMS looking for clear and concise information to share with members during this transition. More information on the Medicare audiology access policy is available on ASHA’s website and will be updated when CMS provides new or revised guidance.
Access to and knowledge about hearing health care continues to present a challenge for many Americans; when patients have direct access to audiologic services, audiologists can play a key role in streamlining health care for beneficiaries. The successful broadening of patient access to audiological care is dependent on clarifying language, procedures, and expectations from CMS.