Billing Guide for Non facility setting - professional and Technical skills

Billing under the MPFS for Audiology Services Outside the Facility Setting

The individuals who furnish audiology services in all settings must be qualified to furnish those services. The qualifications of the individual performing the services must be consistent with the number, type and complexity of the tests, the abilities of the individual, and the patient’s ability to interact to produce valid and reliable results. The physician who supervises and bills for the service is responsible for assuring the qualifications of the technician, if applicable are appropriate to the test.

a. Professional Skills.

When a professional personally furnishes an audiology service, that individual must interact with the patient to provide professional skills and be directly involved in decision-making and clinical judgment during the test.

The skills required when professionals furnish audiology services for payment under the MPFS are masters or doctoral level skills that involve clinical judgment or assessment and specialized knowledge and ability including, but not limited to, knowledge of anatomy and physiology, neurology, psychology, physics, psychometrics, and interpersonal communication. The interactions of these knowledge bases are required to attain the clinical expertise for audiology tests. Also required are skills to administer valid and reliable tests safely, especially when they involve stimulating the auditory nerve and testing complex brain functions.

Diagnostic audiology services also require skills and judgment to administer and modify tests, to make informed interpretations about the causes and implications of the test results in the context of the history and presenting complaints, and to provide both objective results and professional knowledge to the patient and to the ordering physician.

Examples include, but are not limited to:

• Comparison or consideration of the anatomical or physiological implications of test results or patient responsiveness to stimuli during the test;

• Development and modification of the test battery and test protocols;

• Clinical judgment, assessment, evaluation, and decision-making;

• Interpretation and reporting observations, in addition to the objective data, that may influence interpretation of the test outcomes;

• Tests related to implantation of auditory prosthetic devices, central auditory processing, contralateral masking; and/or

• Tests to identify central auditory processing disorders, tinnitus, or nonorganic hearing loss.

Audiology codes may be billed under the MPFS by audiologists, physicians, and NPPs using their own NPI in the rendering loop when those professionals personally furnish the test. Physicians and NPPs may not bill for these codes when an audiologist has furnished the service.



b. Technician Skills.

There may be subtests, or parts of a battery of tests, that may be appropriately furnished by an educated and experienced technician using a specific protocol under the direction of a supervising physician. These services are identified by local contractor determination as services that do not require professional skills. They may be furnished by a qualified technician under the direct supervision of a physician, but not under the supervision of an audiologist or an NPP. The supervising physician is responsible for rendering and documenting all clinical judgment and for the appropriate provision of the service by the technician.

A technician may not perform any part of a service that requires professional skills. A technician also may not perform a global service. For example, a technician may not interpret test results or engage in clinical decision-making.

c. Professional Component (PC)/Technical Component (TC) Split Codes.

• The PC of a PC/TC split code may be billed by the audiologist, physician, or NPP who personally furnishes the service. (Note this is also true in the facility setting.) A physician or NPP may bill for the PC when the physician or NPP furnish the PC and an (unsupervised) audiologist furnishes and bills for the TC. The PC may not be billed if a technician furnishes the service. A physician or NPP may not bill for a PC service furnished by an audiologist.

• The TC of a PC/TC split code may be billed by the audiologist, physician, or NPP who personally furnishes the service. Physicians may bill the TC for services furnished by technicians when the technician furnishes the service under the direct supervision of that physician. Audiologists and NPPs may not bill for the TC of the service when a technician furnishes the service, even if the technician is supervised by the NPP or audiologist.

• The “global” service is billed when both the PC and TC of a service are personally furnished by the same audiologist, physician, or NPP. The global service may also be billed by a physician, but not an audiologist or NPP, when a technician furnishes the TC of the service under direct physician supervision and that physician furnishes the PC, including the interpretation and report.



d. Tests that are Not Described by Specific CPT Codes. Tests that have no appropriate CPT code may be reported under CPT code 92700 (Unlisted otorhinolaryngological service or procedure).


e. Tests that are Contractor-Priced. For codes valued by contractors, the contractor determines whether and how much, if applicable, to pay for the service. The contractor
sets the requirements for personnel furnishing the tests.