This is the last of the coding and reimbursement modules and is related to audiology reimbursement and coding for health care settings.
This module starts with a recap of the two major coding systems. The ICD-9-CM codes describe the problem you diagnosed or is being addressed in rehabilitation or treatment. It is coordinated and maintained by the U.S. Department of Health and Human Services. The CPT codes describe the procedures you performed and is updated, copyrighted, and published by the American Medical Association.
Let's review the principles of diagnostic coding and then put them into practice. Coding to the highest degree of certainty means using a diagnostic code of 5 digits, if possible. The ICD-9-CM codebook will indicate when you have to use additional digits. The primary ICD-9-CM code is for the diagnosis, condition or problem chiefly responsible for the services provided. If results of diagnostic testing are NORMAL, code signs or symptoms to report the reason for test/procedure and explain normal result in report disease or diagnosis codes should support or coordinate with the procedure codes and vice versa.
These rules were established by Medicare, but many other payers adopt the same rules. The rules are:
These same principles will apply to ICD-10-CM once implemented.
The combination of a Diagnostic code (or ICD-9-CM code) with a Procedural code (or CPT code) must be logical. Most payers have lists of which diagnostic codes make sense with which procedure codes. For example, if the diagnostic code was fractured hip, providing audiology services doesn't make much sense. But, if the patient with a broken hip also has a diagnosis of Meniere's disease (386.01), then comprehensive hearing testing (such as 92557) is logical.
Refer to Medicare's National Correct Coding Initiative (CCI Edits) to determine which procedures may be delivered and billable to the same patient on the same day. These are CPT modifiers that may be accepted by payers. The facility where you work will explain how they want to use these modifiers on procedure codes.
Medicare is federal insurance for seniors 65 years of age and older and Americans with severe disabilities:
Medicaid was created to provide access to health care for people living in poverty. Private insurance is the kind of insurance most working Americans have as part of their employee benefits. Companies like Blue Cross Blue Shield, Aetna, and Humana offer health insurance for private citizens. They also administer many employer health plans. A preferred provider organization allows patients to see any health care professional (such as an audiologist) without a referral, but limits access to a panel of health care providers or pays less for those outside the panel network. Health maintenance organizations require the patient's care to be coordinated through one primary care physician. These types of plans often have special rules like obtaining pre-authorization before services are rendered. Health insurance exchanges, established as a result of the Patient Protection and Affordable Care Act, or ACA, are a one stop market place for affordable health insurance for consumers and small employers. Exchanges are run by the state or federal government. Accountable care organizations are designed to be patient-centered and to network physicians, hospitals, and other health care professionals with the patients and each other for partnering in making care decisions. Out of pocket payment occurs when a health plan does not cover the service or the patient does not have health insurance.
Private insurance payers often base their inpatient payment on Medicare's diagnosis-related group (or DRG) prospective payment system and their outpatient payment schedule on the Medicare Physician Fee Schedule. However, there is no rule for payers to follow so reimbursement methodology will vary among payers.
In most inpatient settings (such as hospitals and skilled nursing facilities) the payer pays on a per-case or per-day basis. This means that regardless of the number of services provided, the amount the facility receives will not change. In most outpatient settings, the payment is per procedure. Accountable care organizations will have additional shared savings arrangements to drive efficiency. Each of these settings has rules and regulations you'll learn if you work in that setting.
All third party payers require documentation of service. Usually, you will meet the requirements of most third party payers if you follow the same documentation rules for Medicare. You can always refer back to Module 4 for audiology documentation guidelines.
The simple proverb for you to remember is "If it isn't written, it didn't happen."
Medicare rules require that a physician order a diagnostic evaluation or specific audiometric tests due to audiology's diagnostic provider status in Medicare.
Medicare has limits on audiology coverage. It will reimburse audiologists for diagnostic services but not management or therapy. Therefore, evaluation and management and therapy codes cannot be reported to Medicare for payment. For example: Medicare will reimburse audiologists for CPT code 92626 (evaluation of auditory rehabilitation status), a diagnostic service, but not for CPT code 92633 (auditory rehabilitation; post lingual hearing loss), a therapy service.
Federal law prohibits Medicare from providing coverage for hearing aids or tests related to hearing aids. For Medicare payment, referral from physicians cannot be to determine candidacy for hearing aids and must be for diagnostic purposes. However, Medicare will reimburse for testing if the original referral was to determine hearing loss, regardless of whether the recommendation is for hearing aids.
Following a patient's initial visit, an additional complaint must be observed to justify an additional diagnostic evaluation. Possible reasons for a new evaluation may be an increase in tinnitus or perceived change in hearing. For example, patient's receiving ototoxic medications may be monitored due to a possible change in hearing.
Private insurance plans are usually not as restrictive as Medicare. Unfortunately, no two insurance plans are alike so coverage of audiology services can differ. It is important that both you and the patient are aware of what may or may not be a covered service. Where one insurance plan may allow you to bill for therapy and patient management services, the next one may not. Of course, if you have a contract as an enrolled provider, that contract will describe the covered audiology services.
Because no two insurance plans are alike, one plan may cover a procedure with a certain diagnosis code and the next one may not pay for the same procedure with the same diagnosis code. Unfortunately, some private insurance plans refuse to pay for any diagnosis code considered to be developmental in nature. The heading for the section for 315.32 is 315.3 developmental speech and language disorder. Many of these decisions may require an appeal of the insurance company's decision. Remember to always use the diagnostic code or codes you find to be the most accurate, even if it means they may not be covered by the payer.
Health insurance plans vary because of their local board of directors. Just because a particular Blue Cross Blue Shield covers audiology or hearing aids in one location does not mean that another Blue Cross Blue Shield Plan will cover the same services in another location (for example, eastern Pennsylvania versus western Pennsylvania). In some states, hearing aids, especially those for children, must be covered by state law. However, this does not mean that all hearing aids are covered. A plan may also be responsible for federal employees health insurance, and that will be dictated by the contract between the health insurance company and the federal government.
Coverage for hearing aids is also very inconsistent across the country and varies a great deal from policy to policy. It is crucial providers review any contract they have with an insurance company to determine if and when hearing aids may be covered. It is also very important that you, as the provider of services, check with the insurance company to determine coverage.
Managed care contracts should be read with great care. You should know if the hearing aid is covered in full but with a cap on reimbursement. There are instances where hearing aid payment contract language prohibits billing the balance to the client when there is a difference between the cost of dispensing the hearing aid and the capped reimbursement rate.
Some patients may choose to not have health insurance. Others may not be able to afford health insurance. Others may not have audiology as a covered benefit. In all of these cases, billing should be made directly to the patient.
The types of policies offered in each state may vary depending upon state law. One of the more remarkable recent changes is the mandate of newborn infant hearing screening and intervention that includes hearing aid coverage, especially for children whose hearing loss was detected through the program. State Medicaid audiology and hearing aid coverage varies widely from state-to-state but audiology services and hearing aids must be covered as a federal requirement.
Reimbursement may vary a great deal depending upon who provides the service and where the service is provided. Individual insurance companies may also negotiate different rates from provider to provider. Medicare rules are consistent across the entire country and are based on a prospective payment approach for the particular provider. Inpatient hospitals are paid based on diagnosis-related groups or DRGs and outpatient audiology is reimbursed according to the Medicare outpatient prospective payment system.
If audiologists want to provide services to patients with Medicare, they must enroll as Medicare providers. Payment from Medicare is based on a resource-based relative value scale (or RBRVS) Medicare Physician Fee Schedule. Under the Medicare fee schedule, each procedure has its own reimbursement rate. Medicare requires the beneficiary to pay the audiologist for 20% of the established fee. This copayment is usually covered by the patient's supplemental insurance policy.
While Medicare determines what price they will pay for each CPT code, you are not restricted to make this your fee. Each office needs to establish their own price for each service they provide based on the "cost of doing business" for each location they serve. Frequently the "cost of doing business" is greater than what Medicare pays for the service provided. You must remember your income comes from a variety of sources and fees should be reflective of this.
A superbill is a common way of billing for your services. It should list all of the necessary items for a patient to submit a claim to their health insurance company.
Here is a scenario for billing a hearing evaluation. A patient is referred by their family physician due to "a change in hearing" with a request for a hearing evaluation. After reviewing the referral information, a patient history is obtained. Testing included pure tone testing by air and bone conduction, speech reception thresholds, and assessment of speech recognition ability. Test results were reviewed with the patient, recommendations were made and the referring physician was contacted with the results.
As mentioned in the documentation module, all of the required information listed may be in a summary paragraph at the bottom of the audiogram. The documentation should justify the CPT code or codes and the ICD-9-code or codes used in diagnosis.
You must indicate the CPT and ICD-9-CM codes in your billing report.
For Medicare and Medicaid, you are required to submit the billing on Form CMS-1500 to a designated contractor or the Medicaid agency directly. Frequently this is done electronically. For private insurance, you may or may not choose to submit the billing for the patient. When you ask the patient to submit their own charges, make sure your superbill has all of the required information for submission to the insurance company.
ASHA's website has considerable information related to Medicare, Medicaid, private health plans, and coding.
In order to bill Medicare and other payers, you need to apply for a National Provider Identifier or NPI. Once you have an NPI, you will be ready to provide services and receive reimbursement for them. This link will take you to the Centers for Medicare and Medicaid Services site for NPI application.
Once you have your NPI, your employer will use that number for all billing for your services. Your employer may also have a group number for billing Medicare. Your NPI number will be used to enroll in Medicare if you are a solo practitioner. Remember you are personally responsible for all billing done under your NPI even if your employer is doing the billing.
Medicaid billing varies from state to state. We say, "once you've seen one Medicaid program you've seen one Medicaid program." As a result of each state's unique Medicaid program rules, it is important to check your state's requirements for providing services to Medicaid patients. As indicated with Medicare billing, you are personally responsible for all billing done under your NPI.
Since every private health plan is different, there may be a different process to become enrolled as a provider in the plan. It may be different if you or your employer decide to be a participating provider in a particular plan. Because of the great variability in plans, as well as variability from state-to-state, it is difficult to know what the process is without checking with the particular plan you are working with. Again, it cannot be emphasized enough that you are personally responsible for any billing done in your name.
Starting a practice on your own will require many different decisions. For example, with Medicare you have to decide if you will be a participating or non-participating provider. Both situations require you to be an enrolled provider. Finding a mentor who has successfully navigated the world of private practice will be very helpful. It is also crucial to obtain the advice of attorneys and accountants who are familiar with health law. ASHA will also be a valuable resource if you decide to go into private practice.
Once again, take advantage of your membership in ASHA to help you navigate the world of reimbursement. You should avail yourself to online and direct services. You may also search the Centers for Medicare and Medicaid Services Web site and your state Medicaid site.
At this point, please proceed to the next module, Module Seven: Advocating for Our Professions.