Coverage

Monaural or binaural hearing aids

 The agency covers new, nonrefurbished, monaural or binaural hearing aid(s), which includes the ear mold and batteries, for eligible clients age 20 and younger. In order for the provider to receive payment, the hearing aid must meet the client's specific hearing needs and be under warranty for a minimum of one year. 

Replacement 

The agency pays for the following replacements as long as the need for replacements is not due to the client’s carelessness, negligence, recklessness, or misuse in accordance with WAC 182- 501-0050(8): 

• Hearing aid(s), which includes the ear mold, when all warranties are expired and the hearing aid(s) are one of the following: 
• Lost 
• Beyond repair 
• Not sufficient for the client's hearing loss 
• Ear mold(s) when the client's existing ear mold is damaged or no longer fits the client's ear. 
• Batteries with a valid prescription from an audiologist. 

Repair 

The agency pays for a maximum of two repairs, per hearing aid, per year, when the repair is less than 50% of the cost of a new hearing aid. To receive payment, all the following must be met: 

• All warranties are expired. 
• The repair is under warranty for a minimum of 90 days.

Rental 

The agency pays for a rental hearing aid(s) for up to two months while the client's own hearing aid is being repaired. In the case of a rental hearing aid(s), the agency pays separately for an ear mold(s). 

Cochlear implant – replacement parts

The agency covers: 

Cochlear implant external speech processors, including maintenance, repair, and batteries.

Baha® speech processors, including maintenance, repair, and batteries. 

The agency pays for cochlear implant and Baha® replacement parts when: 

• The manufacturer's warranty has expired. 
• The part is for immediate use, not a back-up part. 
• The part needs to be replaced due to normal wear and tear and is not related to misuse or abuse of the item (see WAC 182-502-0160).

The client must pay for repairs to additional speech processors and parts. 

When reimbursing for battery packs, the agency covers the least costly, equally effective product. 

Note: The agency does not pay providers for repairs or replacements that are covered under the manufacturer’s warranty.

Replacement parts - EPA criteria 

The following expedited prior authorization (EPA) criteria must be met: 

• The cochlear implant or bone conduction (Baha®) is unilateral (bilateral requires PA). 
• The manufacturer’s warranty has expired. 
• The part is for immediate use (not a back-up part). 

Note: If the client does not meet the EPA criteria, then PA is required. 

Use EPA 870000001 with HCPCS codes L8615-L8618, L8621-L8624 when billing for cochlear implant and bone conduction (Baha®) replacement parts

Usual & customary fee

The rate that may be billed to the agency for a certain service or equipment. This rate may not exceed either of the following:

1) The usual and customary charge that you bill the general public for the same services 

2) If the general public is not served, the rate normally offered to other contractors for the same services

Client Eligibility

How can I verify a patient’s eligibility?

Providers must verify that a patient has Washington Apple Health coverage for the date of service, and that the client’s benefit package covers the applicable service. This helps prevent delivering a service the agency will not pay for.

 Verifying eligibility is a two-step process:

Step 1. Verify the patient’s eligibility for Washington Apple Health. For detailed instructions on verifying a patient’s eligibility for Washington Apple Health, see the Client Eligibility, Benefit Packages, and Coverage Limits section in the agency’s current ProviderOne Billing and Resource Guide. If the patient is eligible for Washington Apple Health, proceed to Step 2. If the patient is not eligible, see the note box below. 

Step 2. Verify service coverage under the Washington Apple Health client’s benefit package. To determine if the requested service is a covered benefit under the Washington Apple Health client’s benefit package, see the agency’s Program Benefit Packages and Scope of Services web page. 

Note: Patients who are not Washington Apple Health clients may submit an application for health care coverage in one of the following ways: 

1. By visiting the Washington Healthplanfinder’s website at: www.wahealthplanfinder.org 

2. By calling the Customer Support Center toll-free at: 855-WAFINDER (855-923-4633) or 855-627-9604 (TTY) 

3. By mailing the application to: Washington Healthplanfinder PO Box 946 Olympia, WA 98507 In-person application assistance is also available. 

To get information about inperson application assistance available in their area, people may visit www.wahealthplanfinder.org or call the Customer Support Center. 

Clients age 20 and younger who are receiving services under a Benefit Package:

Are eligible for the covered hearing aids and services listed in this billing guide and for the audiology services listed in the agency’s Physician-Related Services/Health Care Professional Services Billing Guide. 

 Must have a complete hearing evaluation, including an audiogram and/or developmentally appropriate diagnostic physiologic test results performed by a hearing healthcare professional. 

Must be referred by a licensed audiologist, otorhinolaryngologist, or otologist for a hearing aid.

Hearing aids are covered under agency-contracted managed care organizations (MCO). Clients who are enrolled in an agency-contracted MCO are eligible for covered hearing aids. Bill the MCO directly for these services. Additionally, clients enrolled in an agency-contracted MCO must obtain replacement parts for cochlear implants and bone anchored hearing aids (Baha®), including batteries, through their MCO.

Apple Health Core Connections (AHCC)

Coordinated Care of Washington (CCW) will provide all physical health care (medical) benefits, lower-intensity outpatient mental health benefits, and care coordination for all Washington State foster care enrollees. These clients include: 

• Children and youth under the age of 21 who are in foster care 
• Children and youth under the age of 21 who are receiving adoption support 
• Young adults age 18 to 26 years old who age out of foster care on or after their 18th birthday

American Indian/Alaska Native (AI/AN) children will not be auto-enrolled, but may opt into CCW. All other eligible clients will be auto-enrolled.

AHCC complex mental health and substance use disorder services  

AHCC clients who live in Skamania or Clark County receive complex behavioral health benefits through the Behavioral Health Services Only (BHSO) program in the SW WA region. These clients will choose between CHPW or MHW for behavioral health services, or they will be autoenrolled into one of the two plans. CHPW and MHW will use the BHO Access to Care Standards to support determining appropriate level of care, and whether the services should be provided by the BHSO program or CCW.

AHCC clients who live outside Skamania or Clark County will receive complex mental health and substance use disorder services from the BHO and managed by DSHS.

Bone-anchored hearing aid (Baha) – A type of hearing aid based on bone conduction. It is primarily suited to people who have conductive hearing losses, unilateral hearing loss, and people with mixed hearing losses who cannot otherwise wear ‘in the ear’ or ‘behind the ear’ hearing aids. 

Cochlear implants - A cochlear implant is a small, complex electronic device that can help to provide a sense of sound to a person who is profoundly deaf or severely hard-of-hearing. The implant consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin. 

Developmental Disabilities Administration (DDA) – A division administration within the Department of Social and Health Services. DDA provides services to children and adults with developmental disabilities. 

Digital hearing aids – Hearing aids that use a digital circuit to analyze and process sound. (WAC 182-547-0200)

Hearing aids - Wearable sound-amplifying devices that are intended to compensate for hearing loss. Hearing aids are described by where they are worn in the ear as in-the-ear (ITE), behind-the-ear (BTE), etc. Hearing aids can also be described by how they process the amplified signal. This would include analog conventional, analog programmable, digital conventional, and digital programmable. (WAC 182-547-0200) 

Hearing health care professional – An audiologist or hearing aid fitter/dispenser licensed 

 RCW, or an otorhinolaryngologist or otologist licensed

Maximum allowable fee - The maximum dollar amount that the agency will pay a provider for specific services, supplies, and equipment.

Prior authorization – A form of authorization used by the provider to obtain approval for a specific hearing aid and service(s). The approval is based on medical necessity and must be received before service(s) are provided to clients as a precondition for payment. (WAC 182-547-0200) 

Programmable hearing aids – Hearing aids that can be “programmed” digitally by a computer. All digital hearing aids are programmable, but not all programmable hearing aids are digital. 

Social Services Authorization – A form of authorization used by the Department of Social and Health Services to preauthorize services. The approval is based on medical necessity and client eligibility for the program or service. A Social Services Authorization can be viewed in ProviderOne. 

Behavioral Health Organization (BHO)

The Department of Social and Health Services (DSHS) manages the contracts for behavioral health (mental health and substance use disorder (SUD)) services for nine of the Regional Service Areas (RSA) in the state, excluding Clark and Skamania counties in the Southwest Washington (SW WA) Region. BHOs will replace the Regional Support Networks (RSNs). Inpatient mental health services continue to be provided as described in the inpatient section of the Mental Health Billing Guide. BHOs use the Access to Care Standards (ACS) for mental health conditions and American Society of Addiction Medicine (ASAM) criteria for SUD conditions to determine client’s appropriateness for this level of care.

Fully Integrated Managed Care (FIMC) 

Clark and Skamania Counties, also known as SW WA region, is the first region in Washington State to implement the FIMC system. This means that physical health services, all levels of mental health services, and drug and alcohol treatment are coordinated through one managed care plan. Neither the RSN nor the BHO will provide behavioral health services in these counties. 

Clients must choose to enroll in either Community Health Plan of Washington (CHPW) or Molina Healthcare of Washington (MHW). If they do not choose, they are auto-enrolled into one of the two plans. Each plan is responsible for providing integrated services that include inpatient and outpatient behavioral health services, including all SUD services, inpatient mental health and all levels of outpatient mental health services, as well as providing its own provider credentialing, prior authorization requirements and billing requirements. 

Beacon Health Options provides mental health crisis services to the entire population in Southwest Washington. This includes inpatient mental health services that fall under the Involuntary Treatment Act for individuals who are not eligible for or enrolled in Medicaid, and short-term substance use disorder (SUD) crisis services in the SW WA region. Within their available funding, Beacon has the discretion to provide outpatient or voluntary inpatient mental health services for individuals who are not eligible for Medicaid. Beacon Health Options is also responsible for managing voluntary psychiatric inpatient hospital admissions for non-Medicaid clients.

In the SW WA region some clients are not enrolled in CHPW or Molina for FIMC, but will remain in Apple Health fee-for-service managed by the agency. These clients include:

•  Dual eligible – Medicare/Medicaid
•  American Indian/Alaska Native (AI/AN) 
•  Medically needy
•  Clients who have met their spenddown 
•  Noncitizen pregnant women 
• Individuals in Institutions for Mental Diseases (IMD) 
• Long-term care residents who are currently in fee-for-service 
• Clients who have coverage with another carrier 

Since there is no BHO (RSN) in these counties, Medicaid fee-for-service clients receive complex behavioral health services through the Behavioral Health Services Only (BHSO) program managed by MHW and CHPW in SW WA region. These clients choose from CHPW or MHW for behavioral health services offered with the BHSO or will be auto-enrolled into one of the two plans.

Audiology CPT codes

What code or codes do I use when I perform auditory brainstem response (ABR) testing?

The limited auditory evoked potential code (92586) is generally used by Universal Newborn Hearing Screening (UNHS) programs for screening and is occasionally used by neurology for single high level ABR stimuli.

The comprehensive auditory evoked potential code (92585) should be used for all other auditory evoked response testing, including testing via air and bone conduction.

At this time there is not a CPT code that differentiates "threshold-search" ABR from "diagnostic" ABR.

If I perform threshold-search ABR and auditory steady-state response (ASSR) testing on the same day, what procedures should I bill?

ASSR is considered to be a type of auditory evoked potential test and currently does not have a specific CPT code. The comprehensive auditory evoked potential code (92585) is the most appropriate code for billing ASSR at this time.

92585 is a session-based code; this means that it can only be billed one time per day, even if both ABR and ASSR testing are completed on that day.

As discussed above, an extended service modifier (-22) could be considered when both ABR and ASSR are completed on the same day. Detailed documentation of the justification for the extended service should be included in the patient’s medical record.

When would it be appropriate to use the -33 CPT code modifier for OAE or ABR tests that are part of newborn hearing screening?

The -33 modifier was designed to allow providers a means to identify preventative services such as newborn hearing screening or re-screening procedures. In some cases these services are mandated by the Patient Protection and Affordable Care Act (ACA) and should not be subject to a patient cost share (i.e., co-pay, deductible, etc.).

As the use of modifiers varies widely between payers, it is recommended that you consult your payers to determine the recommended utilization for the -33 modifier for newborn hearing screening or re-screening procedures.

For more information regarding the -33 modifier, please review resources available from the American Medical Association [PDF].

I see two codes for an auditory processing evaluation (92620 and 92621) and two codes for an evaluation of aural rehabilitation status (92626 and 92627). How do I use these codes?

These codes require that the primary evaluation codes (92620 or 92626), which include the first 60 minutes of evaluation time, be billed before the additional 15-minute codes (92621 or 92627).

For example, first bill 92620 (Evaluation of central auditory function, with report; initial 60 minutes), then 92621 for each additional 15 minutes of evaluation time.

When using time-based codes, the audiologist is required to properly document evaluation start and end times in the patient’s medical record.

Why are there timed codes for aural rehabilitation status evaluation (92626 and 92627)?

Note: The use of 92626 and 92627 as described below is specifically for pediatric applications. Please see other professional guidance for the correct use of this code when evaluating Medicare-eligible recipients.

92626 and 92627 are codes that reflect the evaluation of a child’s ability to use residual hearing with a hearing aid or cochlear implant.

The evaluation process focuses on a battery of procedures designed to examine—in much greater detail than a standard audiogram—the magnitude of speech understanding abilities with and without amplification or cochlear implant devices, the suitability and usability of various assistive listening devices, and the appropriateness of alternative alerting devices.

92626 and 92627 are timed codes on the basis that there will be a battery of standardized tests used to make the assessment. The number of tests included in the evaluation will vary according to the age and capability of the child. Whereas a young child may be limited in the number of tests that can be completed, an older child will be able to complete a greater number and variety of tests.

Another purpose of the evaluation is to determine whether the child could be a cochlear implant candidate and to document progress in speech understanding post-implant. Evaluation results can be used as a diagnostic foundation that leads to a customized intervention program for that child.

92626 and 92627 cannot be used as counseling codes.

If I perform an evaluation for (central) auditory processing (92620) and include filtered fpeech (92571), staggered spondaic words (92572), and synthetic sentence identification (92576), can I bill the specific test codes in addition to the general auditory processing evaluation code?

Check with your payer. There is a National Correct Coding Initiative (NCCI) edit that prohibits billing 92571, 92572, and 92576 on the same day as 92620 for Medicare beneficiaries. Many Medicaid and private payers utilize NCCI edits in their coding guidelines.

If I spend two hours programming a cochlear implant (CI) processor for a new user, can I bill more than one unit of 92601 or 92603?

The CI codes (92601-92604) are session-based codes and only one unit (code) should be billed per day.

CI codes 92601 (diagnostic analysis of cochlear implant, younger than 7 years of age; with programming) and 92603 (diagnostic analysis of cochlear implant, age 7 years or older; with programming) describe the post-operative analysis and fitting, connection to the implant, and initial programming of the stimulator.

Codes 92602 (younger than 7 years of age, subsequent re-programming) and 92604 (7 years or older, subsequent re-programming) are used for subsequent sessions to include measurement, adjustments, and re-programming.

What should I code when programming or re-programming binaural cochlear implants?

Reimbursement for binaural CI programming varies between payers. Please consult your payer(s) to determine if CI programming codes (92601-92604) are considered unilateral or single device codes.

Some payers may accept two line items of the same code with –RT or –LT ear modifiers to designate which side was programmed.

Other payers may consider a binaural programming session as a same-day repeat procedure. In this case, a separate bill with the same date of service would be completed. The second CI programming code would be billed with a repeat procedure modifier added (-76: Repeat procedure by same provider; or -77: Repeat procedure by another provider).

CPT code

What CPT codes should I use for behavioral pediatric audiologic evaluations using visual reinforcement audiometry (VRA) and conditioning play audiometry (CPA) test techniques?

92579 (VRA) and 92582 (CPA) are codes that describe specific, independent pediatric test procedures. These codes are currently valued as stand-alone procedure codes and are not "add-on" or modifier codes. Generally, these codes should not be used in addition to pure tone audiometry, air only (92552) or air and bone donduction audiometry (92553) to indicate a method of testing.

Is speech audiometry included in the CPA and VRA codes?

92579 (VRA) and 92582 (CPA) are differentiated by the method of response reinforcement used and the types of stimuli that are considered part of the procedure. These codes are historical codes and currently do not have detailed code descriptions. Payers have relied on traditional practice standards that were available at the time the codes were last valued. Historically, descriptions of VRA test procedures included both speech and tonal stimuli as part of the test protocol. In contrast, CPA test protocols included tonal stimuli but did not include speech stimuli.

If CPA (92582) testing is completed and speech measures are performed as part of the evaluation, then a code that best describes the speech measure, such as speech threshold audiometry (92555), select picture audiometry (92583), or speech audiometry threshold with speech recognition (92556), can also be reported.

What if I test individual ears using visual reinforcement audiometry techniques?

In this case, it would still be appropriate to report the VRA code (92579) as it best reflects the technique and equipment that has been utilized to conduct the assessment. Since the VRA and CPA (92582) codes cannot be billed in addition to pure-tone air or bone conduction threshold codes, you should choose the code that best aligns with your clinical assessment.

What if I attempt audiologic testing on a child but obtain limited results or no interpretable results?

The issue of limited or no audiologic test results is a complicated one; the codes that you select should accurately reflect the procedures, techniques, and effort that were used, not specifically the number of responses that were obtained.

A child may require frequent reconditioning or test reinstruction, yet limited audiologic information is obtained. In this case the audiologist has used considerable effort, various procedures, and/or different reinforcement techniques to obtain those limited results. This would not be considered a reduced service.

Documentation of the test session should include the efforts made to obtain test results; some clinicians may document a time notation in the patient’s medical record as an estimate of the time and effort involved when limited audiologic information is obtained.

There may be a number of reasons why no audiologic results are obtained. However, in a situation where a child is completely uncooperative with any test procedure, the audiologist has a choice of cancelling the appointment altogether or using a reduced service modifier (-52) to indicate that the entire protocol associated with the diagnostic procedure was not completed.

What CPT codes should I use when testing middle ear function?

New CPT codes were created in 2010, at the request of the Centers for Medicare and Medicaid Services (CMS), to report middle ear function tests that were frequently performed together on the same date of service. Four distinct codes are now available:

• 92567 Tympanometry (impedance testing)
• 92568 Acoustic reflex testing, threshold
• 92550 Tympanometry and reflex threshold measurements
• 92570 Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing

The individual code for acoustic reflex decay testing (92569) was deleted at the time of the 2010 code changes.

If acoustic reflex threshold testing or acoustic reflex threshold testing and acoustic reflex decay testing are performed on the same date of service as tympanometry, you must report the bundled code that describes what has been performed. You may not report tympanometry (92567) and acoustic reflex threshold testing (92568) separately on the same date of service.

If I perform a 1000 Hz ipsilateral acoustic reflex screening along with tympanometry, can I use CPT code 92550 (Tympanometry and reflex threshold measurement)?

CPT has defined acoustic reflex threshold testing (92568 and 92550) as including both ipsilateral and contralateral acoustic reflex threshold measurements. There is not a CPT code available for acoustic reflex screening. Only the tympanometry code (92567) would be allowed in this instance.

Are there CPT codes for the new wideband reflectance and multi-frequency tympanometry tests?

New methods of assessing middle ear function are now available in clinical test equipment. Although these advanced middle ear test methods are becoming accepted as part of a clinical test battery, there are no current CPT codes for these tests.

The tympanometry-only code (92567) should be used if wideband reflectance or multi-frequency tympanometry tests are completed. The code is a session-based code, meaning that 92567 can only be billed one time per day, even if standard and multi-frequency tympanometry as well as wideband reflectance testing are all completed on the same day.

An extended service modifier (-22) could be considered when multi-frequency tympanometry and wideband reflectance testing are completed on the same day. Detailed documentation of the justification for the extended service should be included in the patient’s medical record.

What CPT codes should I use when I test otoacoustic emissions (OAE)?

There are three (3) OAE codes that clearly describe the differences between screening OAE and limited versus comprehensive OAE evaluation. The OAE codes assume that testing is completed in both ears.

• 92558 Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis
• 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

The OAE screening code (92558) should be billed when only an overall Pass/Fail result is obtained and no other interpretation is performed or reported.

The OAE limited evaluation code (92587) should be used when the purpose of the test is to evaluate hearing status. 92587 specifies that three (3) to six (6) Distortion Product (DPOAE) frequencies should be evaluated per ear. Transient Evoked OAE testing (TEOAE) is included in this code.

The OAE comprehensive evaluation code (92588) should be used when the purpose of the test is to evaluate outer hair cell function or to perform cochlear mapping for purposes such as ototoxic monitoring or tinnitus evaluation. 92588 specifies that 12 or more distortion product OAE frequencies should be evaluated per ear.

Billing & Coding for Pediatric Audiology Services

What is an ICD code?

The International Classification of Diseases (ICD) codes are numeric or alpha-numeric codes that are used to classify a diagnosis. The ICD-CM (Clinical Modification) is the version of ICD that is used in the United States.

The U.S. transitioned from ICD-9-CM (9th Revision) in October 2015 and is currently using the ICD-10-CM (10th Revision).

What ICD code do you report when results are normal?

Coding for diagnostic tests should be consistent with the following guidelines:

• Code for the result of the diagnostic test.
• In the case of a normal result, the next choice would be to choose a diagnosis code that reflects the reason for the referral and/or the chief presenting complaint.
• It is helpful to include other secondary diagnosis codes that will help paint a clear clinical picture of why the test(s) are being performed.

What ICD code should I report when newborn hearing screening follow-up tests are normal?

There is significant variability in payer policies regarding reporting a normal examination following a failed newborn hearing screening. Please confirm with your payer regarding diagnosis coding requirements for newborn hearing re-screening.

What is a CPT code?

Current Procedural Terminology (CPT®) codes (developed and maintained by the American Medical Association) are five-digit codes that designate a distinct test or therapeutic procedure. Each code has a description of the procedure or group of procedures that are included with the code. The procedure(s) included in the description are used to assess the value of that code.

What are some general principles of correct coding and billing for pediatric testing?

• Choose the CPT code that best represents the procedure that was performed. In other words, what type of testing technique was used to obtain your clinical findings?
• Most audiology CPT codes (with the exception of VRA) are valued based on the procedure being performed on both ears. If you are performing the testing on one ear, it may be appropriate to use a reduced service modifier (-52) to indicate that the entire procedure was not completed.
• General coding instructions indicate that, at times, it may be appropriate to append modifiers to services billed on a claim.
• The -52 modifier can be used for reduced services (e.g. unilateral testing as opposed to bilateral testing).
• The -22 modifier can be used when significantly extended services are provided that may require additional equipment (e.g. Auditory Steady State Response in addition to Auditory Brainstem Response testing).
• Be aware that some payers, including many state Medicaid programs, do not acknowledge all modifiers. In these cases, including a modifier with a code may delay the correct processing of the claim. If you utilize modifiers frequently for a particular service, it is best to check the payment policies of the payer.
• Documentation in the patient’s medical record should support the reason that testing was completed and the reason why particular codes are being billed. Payers may deny payment if documentation is missing or is not consistent with the codes billed.

Medicare Billing : 837P and Form CMS-1500

What are the 837P and Form CMS-1500? 

The 837P (Professional) is the standard format used by health care professionals and suppliers to transmit health care claims electronically. The Form CMS-1500 is the standard paper claim form to bill Medicare Fee-For-Service (FFS) Contractors when a paper claim is allowed. In addition to billing Medicare, the 837P and Form CMS-1500 may be suitable for billing various government and some private insurers.

Data elements in the Centers for Medicare & Medicaid Services (CMS) uniform electronic billing specifications are consistent with the hard copy data set to the extent that one processing system can handle both. CMS designates the 1500 Health Insurance Claim Form as the CMS-1500 (08/05) and the form is referred to throughout this fact sheet as the CMS-1500.

When Does Medicare Accept a Hard Copy Claim Form? 

Initial claims for payment under Medicare must be submitted electronically unless a health care professional or supplier qualifies for a waiver or exception from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of claims. 

Before submitting a hard copy claim, health care professionals and suppliers should self-assess to determine if they meet one or more of the ASCA exceptions. For example, health care professionals and suppliers that have fewer than 10 Full-Time Equivalent (FTE) employees and bill a Medicare FFS Contractor are considered to be small and might therefore qualify to be exempt from Medicare electronic billing requirements. If a health care professional or supplier meets an exception, there is no need to submit a waiver request. 

There are other situations when the ASCA electronic billing requirement could be waived for some or all claims, such as if disability of all members of a health care professional’s or supplier’s staff prevents use of a computer for electronic submission of claims. Health care professionals and suppliers must obtain Medicare pre-approval to submit paper claims in these situations by submitting a waiver request to their Medicare FFS Contractor. 

Timely Filing 

The timely filing period for both paper and electronic Medicare claims is 12 months, or one calendar year, after the date of service. 

Claims are denied if they arrive after the deadline date. When a claim is denied for having been filed after the timely filing period, such a denial does not constitute an initial determination. As such, the determination that a claim was not filed timely is not subject to appeal. 

Medicare uses the line item ‘From’ date to determine the date of service for claims filing timeliness for claims submitted by health care professionals and suppliers that include span dates of service. (This includes DME supplies and rental items.) If a line item ‘From’ date is not timely but the ‘To’ date is timely, contractors must split the line item and deny the untimely services as not timely filed.

CPT Code

CPT Code - 92553

Description - Pure Tone Audiometry (Threshold); Air & Bone

Split PC/TC? - No

CPT Code - 92555

Description - Speech Audiometry Threshold

Split PC/TC? - No

CPT Code - 92556

Description - Speech Audiometry Threshold; w/Speech Recognition

Split PC/TC? - No

CPT Code - 92557

Description - Comprehensive Audiometry Threshold Eval & Speech R..

Split PC/TC? - No

CPT Code - 92567

Description - Tympanometry (Impedance Testing)

Split PC/TC? - No

CPT Code - 92568

Description - Acoustic reflex testing, threshold

Split PC/TC? - No

CPT Code - 92570

Description - Acoustic Immittance, Tympanometry

Split PC/TC? - No

CPT Code - 92579

Description - Visual Reinforcement Audiometry (VRA)

Split PC/TC? - No

CPT Code - 92601

Description - Diagnostic analysis of cochlear implant, patient younger...

Split PC/TC? - No

CPT Code - 92602

Description - …subsequent reprogramming

Split PC/TC? - No

CPT Code - 92603

Description - Diagnostic analysis of cochlear implant, age 7 years +…

Split PC/TC? - No

CPT Code - 92604

Description - …subsequent reprogramming

Split PC/TC? - No

CPT Code - 92561

Description - …Bekesy audiometry, diagnostic

Split PC/TC? - No

CPT Code - 92562

Description - Loudness balance test, alternate binaural or monaural

Split PC/TC? - No

CPT Code - 92563

Description - Tone decay test

Split PC/TC? - No

CPT Code - 92564

Description - Short increment sensitivity index (SISI)

Split PC/TC? - No

CPT Code - 92565

Description - Stenger test, pure tone

Split PC/TC? - No

CPT Code - 92571

Description - Filtered speech test

Split PC/TC? - No

CPT Code - 92572

Description - Staggered spondaic word test

Split PC/TC? - No

CPT Code - 92575

Description - Sensorineural acuity level test

Split PC/TC? - No

CPT Code - 92576

Description - Synthetic sentence identification test

Split PC/TC? - No

CPT Code - 92577

Description - Stenger test, speech

Split PC/TC? - No

CPT Code - 92582

Description - Conditioning play audiometry

Split PC/TC? - No

CPT Code - 92583

Description - Select picture audiometry

Split PC/TC? - No

CPT Code - 92584

Description - Electrocochleography

Split PC/TC? - No

CPT Code - 92585

Description - Auditory Evoked Potentials, Evoked Response

Split PC/TC? - Yes

CPT Code - 92586

Description - Auditory Evoked Potentials for Evoked Response; Limited

Split PC/TC? - Yes

CPT Code - 92587

Description - Evoked Otoacoustic Emissions; Limited

Split PC/TC? - Yes

CPT Code - 92588

Description - Evoked Otoacoustic Emissions; Comprehensive/Dx

Split PC/TC? - Yes

CPT Code - 92620

Description - Evaluation of central auditory function, with report; initial

Split PC/TC? - No

CPT Code - 92621

Description - …Each additional 15 minutes

Split PC/TC? - No

CPT Code - 92625

Description - Assessment of tinnitus (includes pitch, loudness matching..

Split PC/TC? - No

CPT Code - 92626

Description - Evaluation of auditory rehabilitation status; first hour

Split PC/TC? - No

CPT Code - 92627

Description - …Each additional 15 minutes

Split PC/TC? - No

CPT Code - 92640

Description - Diagnostic analysis with programming of auditory brain…

Split PC/TC? - No