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Coding and Payment for Aural Rehabilitation Services

Considerations for Audiologists and Speech-Language Pathologists

Payment and coverage of audiology and speech-language pathology services related to aural rehabilitation (AR) varies widely based on factors such as the patient’s medical history, the payer, and the patient’s specific health insurance plan. It is critical for clinicians to understand coverage policies for the payers they commonly bill, to verify coverage for each patient prior to initiating services, and to be familiar with appropriate diagnosis and procedure coding for accurate claims submission.

Note: Aural rehabilitation is also referred to as audiologic rehabilitation, auditory rehabilitation, hearing rehabilitation, and rehabilitative audiology. 

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Payer Policies

It is important for audiologists and speech-language pathologists (SLPs) to understand that there is significant variability in the coverage of services for patients who may require aural rehabilitation. Policies may be limited to services for patients who require surgically implanted hearing devices, such as a cochlear implant or an auditory osseointegrated implant, or who meet other specific criteria (e.g., degree of hearing loss or standardized test scores). Some policies may require an audiologic evaluation before initiating treatment and may also limit what type of provider can bill for treatment.

Always verify payer coverage policies before providing evaluation and treatment services. In general, clinicians can find payer coverage guidelines in medical policy documents related to audiology or speech-language pathology services, or specific to aural rehabilitation services. Clinicians should seek guidance in the following areas:

  • ensure AR services are covered;
  • clarify the provider types who are eligible to bill for AR services;
  • identify other factors contributing to the level of coverage (e.g., setting where services are provided);
  • clarify if there are requirements for prior authorization or specific visit limits; and
  • determine which Current Procedural Terminology (CPT®; American Medical Association) and International Classification of Diseases (ICD) codes are eligible for AR services.

It's also critical for clinicians to establish medical necessity for AR services and provide clear documentation to support the need for the skilled audiology or speech-language pathology services.

Medicare

Under Medicare, both audiologists and SLPs may evaluate the impact of hearing loss on a patient's functional communication abilities. Treatment provided by an SLP may also be a Medicare-covered benefit if a) the services are medically reasonable and necessary to improve patient function and b) the treating physician approves the plan of care. However, the Social Security Act defines audiology services as "hearing and balance assessment services," limiting the ability for audiologists to bill the Medicare program for treatment services. The law only applies to the ability to bill, not to the scope of practice of an audiologist. An audiologist may provide AR services to a Medicare beneficiary, but the beneficiary must understand that treatment services provided by an audiologist are not covered by the Medicare program. It may also be possible for an audiologist to perform the services "incident to" a physician, meaning that the treatment services provided by the audiologist are billed to Medicare under a physician’s National Provider Identifier (NPI) number.

Some local Medicare Administrative Contractors (MACs) may publish detailed coverage guidelines in local coverage determinations (LCDs). Clinicians can also refer to Chapter 15 of the Medicare Benefit Policy Manual [PDF], which describes AR services provided by audiologists and SLPs under the Medicare benefit, as quoted below:

Evaluation and treatment for disorders of the auditory system may be covered and medically necessary, for example, when it has been determined by a speech language pathologist in collaboration with an audiologist that the hearing impaired beneficiary’s current amplification options (hearing aid, other amplification device or cochlear implant) will not sufficiently meet the patient’s functional communication needs. Audiologists and speech-language pathologists both evaluate beneficiaries for disorders of the auditory system using different skills and techniques, but only speech-language pathologists may provide treatment.

Assessment for the need for rehabilitation of the auditory system (but not the vestibular system) may be done by a speech language pathologist. Examples include but are not limited to: evaluation of comprehension and production of language in oral, signed or written modalities, speech and voice production, listening skills, speech reading, communications strategies, and the impact of the hearing loss on the patient/client and family.

Examples of rehabilitation include but are not limited to treatment that focuses on comprehension, and production of language in oral, signed or written modalities; speech and voice production, auditory training, speech reading, multimodal (e.g., visual, auditory-visual, and tactile) training, communication strategies, education and counseling. In determining the necessity for treatment, the beneficiary’s performance in both clinical and natural environment should be considered.

See also: Medicare Payment for Outpatient Audiology and Speech-Language Pathology Services

Medicaid

Medicaid coverage of AR services varies widely, as each state has the authority to determine its own guidelines. Coverage within a state may further vary depending on the patient’s age (e.g., pediatric vs. adult). Services for children under 21 may be covered because audiology and speech-language pathology are considered mandatory services for children as a result of the federal Early and Periodic Screening, Diagnostic and Treatment (EPSDT) mandate. Audiology and speech-language pathology services for adults are considered optional services at the discretion of the state. There is also variation depending on the setting where services are provided (e.g., school, health care, early intervention). Unlike Medicare, Medicaid may allow evaluation and treatment services by both audiologists and SLPs. Clinicians should verify coverage through state-specific guidelines, which can be found in Medicaid guidance documents, such as the state provider handbook, or by contacting the state Medicaid agency.

See also: ASHA’s Medicaid Toolkit

Commerical or Private Insurance

Like Medicaid, each commercial insurance plan can decide whether they will reimburse for AR services and who can provide those services. Clinicians should verify coverage for each patient through health plan medical policies and the patient’s specific health insurance plan (e.g., employer-funded plan).

Coding Considerations

Clinicians should include both International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes to report the patient’s diagnosis and Current Procedural Terminology (CPT®) codes to report the services provided by the clinician on each claim submitted to a payer for reimbursement of AR services

The following information is based on generally accepted coding principles. Clinicians should consult the payer if clarification of coding or coverage is needed regarding a specific case.

ICD-10-CM Diagnosis Codes

Selection of the correct ICD-10-CM code(s) for patients who require AR services will be based on the patient's relevant underlying medical condition(s), type of hearing loss, and any associated speech, language, or other communication disorders.

ICD-10-CM codes related to hearing disorders are captured in the H60-H95 series (diseases of the ear and mastoid process). For example, the H80- series of codes describes otosclerosis, the H90- series describes conductive and sensorineural hearing loss, and the H93- series describes other disorders of the ear, including abnormal auditory perceptions.

Speech and language delays due to hearing loss can be reported with F80.4.

Detailed lists of ICD-10-CM codes for audiologists and SLPs are available on ASHA’s ICD-10 webpage.

CPT Procedure Codes

Audiologists and SLPs code for evaluation and treatment using the same CPT codes, regardless of the patient’s medical diagnosis or age. Clinicians typically use the following CPT codes to report aural rehabilitation services.

92626 Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour

92627 each additional 15 minutes (list separately in addition to code for primary procedure)

(Use 92627 in conjunction with 92626)

(When reporting 92626, 92627, use the face-to-face time with the patient or family)

(Do not report 92626, 92627 in conjunction with 92590, 92591, 92592, 92593, 92594, 92595 for hearing aid evaluation, fitting, follow-up, or selection)

92630 Auditory rehabilitation; pre-lingual hearing loss

92633 Auditory rehabilitation; post-lingual hearing loss

Evaluation

Prior to January 1, 2020, CPT code 92626 was defined as "Evaluation of auditory rehabilitation status; first hour" with 92627 as the add-on code for each additional 15 minutes of evaluation. However, 92626 and 92627 are now revised and more clearly defined to report an evaluation of auditory function to determine candidacy for a surgically implanted hearing device (e.g., cochlear implant, auditory osseointegrated implant) or for a post-surgical evaluation to document progress in speech understanding. Evaluation results can be used as a diagnostic foundation that leads to a customized intervention program. A comprehensive evaluation reported with 92626 and 92627 may include a selection of standardized tests; the number of tests included in the evaluation will vary according to the age and capability of the patient. For example, the number of tests a young child can complete may be limited while an older child or adult may be able to complete a greater number and variety of tests. An evaluation for implant candidacy that doesn't lead to an implant (e.g., the patient is more suited for a head-worn sound processor) may still be billed using 92626 and 92627.

Do not use CPT codes 92626 and 92627 for activities unrelated to an implant, such as an auditory function evaluation for suitability of assistive technology or lipreading training, or before or after a patient receives hearing aids. In addition, clinicians shouldn't use them to report implant programming or troubleshooting. (See also: Do's and Dont's for Revised Implant-Related Auditory Function Evaluation CPT Codes)

Audiologists can use CPT codes 92601-92604 to report cochlear implant (CI) diagnostics and programming/reprogramming and CPT code 92700 for implant troubleshooting and programming. SLPs may also consider reporting 92523 for a speech-language evaluation that incorporates an assessment of functional communication and listening skills.

Same-Day Billing with Other Codes

The Medicare Part B (outpatient) program uses the National Correct Coding Initiative (NCCI) to determine code pairs that may or may not be billed together on the same day, commonly known as "CCI edits." State Medicaid agencies must also use CCI edits, but may modify them to meet their own needs. Other payers may also adopt CCI edits. According to the code parenthetical and Medicare CCI edits, audiologists should not bill 92626 and 92627 in conjunction with CPT codes 92590, 92591, 92592, 92593, 92594, or 92595 for services they provide to a patient on the same day.

CPT codes 92590-92595 describe services related to hearing aids, which are included in the auditory function evaluation codes for implants, when performed on the same day, by the same clinician. For example, if an audiologist performs an electroacoustic evaluation (92594 or 92595) and a pre-implant candidacy evaluation (92626 and 92627) for a patient on the same day, the hearing aid testing is bundled into the pre-implant candidacy evaluation and should not be billed separately. However, if different clinicians see the same patient on the same day, and one conducts the hearing aid evaluation and the other evaluates for implant candidacy, then each may separately bill the appropriate CPT code for the testing they provided. The same restrictions aren’t in place for corresponding V-codes or if the services are provided by different clinicians on the same day. Same-day billing restrictions typically only apply when each service is provided by the same clinician. Additionally, Medicare CCI edits allow audiologists to report 92626 and 92627 on the same day as CPT codes 92601-92604 for CI diagnostics and programming/reprogramming, using the appropriate CCI-associated modifier to indicate separate and distinct services. Documentation should support that the audiologist performed two complete and distinct evaluations, and that enough time was spent in each evaluation to justify billing for both services. See The Right Time for Billing Codes for important considerations when determining whether to report multiple services on the same day.

See also: Medicare CCI Edits for Audiologists and SLPs

Time-Based Codes

CPT codes 92626 and 92627 are time-based codes. 92626 represents the first hour of evaluation and can only be billed once per day. Report 92627 in conjunction with 92626 for each additional 15 minutes of evaluation. As an add-on code, 92627 must always be reported with 92626 and may not be billed as a stand-alone code.

To bill the first unit (92626 base code), you must complete at least 31 minutes of face-to-face evaluation time. Any time less than 31 minutes total is not billable. To report a second unit (92627 add-on code) you must first complete a full 60 minutes of evaluation (billed under 92626) plus at least 8 additional minutes (68 minutes total) to qualify to bill for 92627. To bill any subsequent add-on units, you must always complete the full time of the previous unit and exceed the halfway point of time to bill for the next unit, as illustrated below. Keep in mind that only direct face-to-face evaluation time with the patient or caregiver(s) may count towards billable units. It's also important to remember that the patient must be present even when a portion of the evaluation time is spent with the caregiver(s).

  • 1 unit (92626): 31 minutes to 67 minutes
  • 2 units (92626 + 92627): 68 minutes to 82 minutes
  • 3 units (92626 + 92627 + 92627): 83 minutes to 97 minutes
  • 4 units (92626 + 92627 + 92627 + 92627): 98 minutes to 112 minutes, and so on

Time-based codes may also include limits on how many units can be billed on the same day. For example, the Medicare Part B (outpatient) program publishes medically unlikely edits (MUEs) that limit 92626 to one (1) unit and 92627 to three (6) units per day for a total of four (4) units, even if the time spent exceeds four units. State Medicaid agencies must also use MUEs but may modify them to meet their own needs. Other payers may also adopt MUEs. (See: Medicare Part B MUEs for audiologists and SLPs)

See also: Billing Timed and Untimed Codes

Treatment

Use CPT codes 92630 and 92633 for aural rehabilitation for patients with pre- or post-lingual hearing loss. The treatment codes are broader than the evaluation codes and may be reported for patients with or without implants. In addition, ongoing assessment may be incorporated into treatment sessions to monitor the effectiveness of intervention, though assessment should not be the sole purpose of an ecounter billed with 92630 or 92633.

In general, services covered under 92630 and 92633 address the patient’s auditory skills and functional communication abilities. For children with pre-lingual hearing loss, this could mean teaching them how to hear with aided hearing (at first, this may be sound identification and discrimination, identification of distinct speech sounds, and progressing towards learning how to understand speech). For adults with post-lingual hearing loss, this could mean teaching techniques and compensatory strategies to help manage their listening environment, combine sensory inputs (visual plus audition), incorporate listening strategies, and/or optimize amplification characteristics of their hearing aids or implants, according to their specific needs. These services may not be used purely for counseling (e.g., answering questions about use of a hearing aid), though this may be an aspect of treatment. The focus should be on active treatment with specific long and short term goals as defined in the plan of care.

These codes are untimed and should only be reported once per day, regardless of the length of the session.

Note that Medicare restricts coverage of audiology services to diagnostic testing only, so audiologists may not bill these codes to the Medicare program. Medicare is also clear that SLPs must use CPT code 92507 for auditory rehabilitation, instead of 92630 and 92633. Use of CPT codes 92630 and 92633 varies widely among Medicaid programs and other third-party payers. Some may follow Medicare's guidelines, some may restrict their use based on provider type, while others may allow both audiologists and SLPs to report them for AR services.

See also: Medicare Coding Rules for Audiologists and SLPs

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