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Medicare Hearing Assessments Provided by Audiologists Without a Physician Order

Implementing Medicare's Waived Order Requirements for a Limited Selection of Nonacute Hearing Assessments

Starting January 1, 2023, audiologists can provide select hearing assessment services to Medicare Part B (outpatient) beneficiaries without a physician order under specific circumstances. Providing hearing assessment services for nonacute hearing loss without a physician order to Medicare beneficiaries requires careful attention to claims submission, medical record documentation, and patient balance billing.

This rule applies to hearing assessment services already covered under Medicare and does not expand coverage in any way beyond removing the physician order requirement under the limited circumstances described below.

On this page:

Services That Can Be Provided Without a Physician Order

A Medicare beneficiary can receive hearing assessment services without a physician order:

  1. once every 12 calendar months on the same date of service,
  2. for a select number of services, outlined below, and
  3. when presenting with nonacute hearing loss.

Medicare defines nonacute hearing loss as “a more gradual hearing loss that one may experience with advancing age, known as presbycusis.” In addition, only 36 Current Procedural Terminology (CPT® American Medical Association) codes can be provided without a physician order, as listed below. 

CPT Code Description
92550 Tympanometry and reflex threshold measurements
92552 Pure tone audiometry (threshold); air only
92553 Pure tone audiometry (threshold); air and bone
92555 Speech audiometry threshold
92556 Speech audiometry threshold; with speech recognition
92557 Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)
92562 Loudness balance test, alternate binaural or monaural
92563 Tone decay test
92565 Stenger test, pure tone
92567 Tympanometry (impedance testing)
92568 Acoustic reflex testing, threshold
92570 Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing
92571 Filtered speech test
92572 Staggered spondaic word test
92575 Sensorineural acuity level test
92576 Synthetic sentence identification test
92577 Stenger test, speech
92579 Visual reinforcement audiometry (VRA)
92583 Select picture audiometry
92584 Electrocochleography
92587 Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report
92588 Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report
92601 Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming
92602 Diagnostic analysis of cochlear implant, patient younger than 7 years of age; subsequent reprogramming
92603 Diagnostic analysis of cochlear implant, age 7 years or older; with programming
92604 Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming
92620 Evaluation of central auditory function, with report; initial 60 minutes
92621 Evaluation of central auditory function, with report; each additional 15 minutes (List separately in addition to code for primary procedure)
92625 Assessment of tinnitus (includes pitch, loudness matching, and masking)
92626 Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour
92627 Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); each additional 15 minutes (List separately in addition to code for primary procedure)
92640 Diagnostic analysis with programming of auditory brainstem implant, per hour
92651 Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report
92652 Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report
92653 Auditory evoked potentials; neurodiagnostic, with interpretation and report

Coding and Billing

When billing for approved nonacute hearing assessment services without a physician order, the “AB” modifier must be placed on the same claim line as the CPT code. On the CMS 1500 claim form, the CPT code and associated modifier are placed in Box 24D. If an audiologist provides three approved CPT codes on a date of service, the “AB” modifier would be applied three times, once for each CPT code. Audiologists should also continue to report CPT codes according to current coding guidelines, Correct Coding Initiative (CCI) edits, and Medically Unlikely Edits (MUEs)

As noted above, the hearing assessment services must be provided on the same date of service and can only be provided without an order once per Medicare beneficiary in a 12-month period. In the final rule, CMS states that it will provide future guidance on how to track when audiology services have been provided without a physician order. For example, other CMS limitations are tracked through an online portal known as the Common Working File (CWF) and via Medicare Administrative Contractor (MAC) phone-based Interactive Voice Response (IVR) systems. CMS might use these mechanisms to help audiologists determine if audiology services have been billed with the “AB” modifier in the last 12-months.

To help explain how these limitations work, please consider the following scenarios:

Scenario 1

A Medicare beneficiary sees an audiologist in Vermont in June and the audiologist bills for these services with the “AB” modifier. In January of the following year, the beneficiary seeks hearing assessment services from an audiologist in Florida. Due to the 12-calendar month limitation, the Florida audiologist must obtain an order from the physician to receive Medicare payment for these services and could not bill for these services with the “AB” modifier. In this scenario, billing for audiology services with the “AB” modifier can occur after June.

Scenario 2

A Medicare beneficiary sees an audiologist on Monday reporting nonacute hearing difficulties and does not have a physician order. The audiologist provides two hearing assessment services and bills each service with the “AB” modifier. On Thursday, the patient returns for additional testing. These services cannot be billed with the “AB” modifier and there must be a physician order on file for Medicare payment. 

Vestibular Diagnoses

Audiology hearing assessment services can only be provided for nonacute hearing loss. Therefore, audiologists should not bill for services with the “AB” modifier and without a physician order for vestibular conditions.

Beneficiary Liability and Use of the ABN

In the future, CMS will provide additional guidance regarding beneficiary liability and the need for an advance beneficiary notice (ABN). For example, if an audiologist accidentally bills using the “AB” modifier on a second date of service for the same beneficiary within 12-months and the services are denied, this guidance will highlight if the beneficiary would bear financial liability and if an ABN is required.

Documentation

As finalized, hearing assessment services can only be provided for nonacute hearing loss. Therefore, if an audiologist provides hearing assessment services for acute hearing loss, as defined by CMS, they should not bill for the services without an order and should not use the “AB” modifier. If documentation shows that an audiologist provided services to a Medicare beneficiary with acute hearing loss, the services could be denied on a post-payment review and Medicare could recoup the payments.

Next Steps

ASHA will continue to advocate for passage of the bipartisan and bicameral Medicare Audiologist Access and Services Act (H.R. 1587/S. 1731), which removes the physician referral requirement completely while appropriately expanding Medicare coverage to include both diagnostic and treatment services provided by audiologists.

As noted above, several key elements of this proposal still require additional guidance from CMS including:

  1. if and when to use an ABN,
  2. if and when a beneficiary is financially liable if more than one audiology visit is provided without a physician order within a 12-month period, and
  3. how audiologists can track when an audiology service has been provided without a physician order within the last 12 months.

This has potential financial consequences for audiologists and ASHA will provide updates as soon as more information is available. Audiologists should consider how and when to implement this in their practice and might even consider waiting until such guidance is available to mitigate their financial risk.

Questions?

Contact reimbursement@asha.org.

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