Hearing Aids

3. Hearing Aids

The hearing aid should be adequate for the member’s condition and a reasonable expenditure as well.

An invoice must be submitted with claims for monaural hearing aids with a submitted charge of $401 or more and binaural hearing aids with a submitted charge of $802 or more.

If a hearing aid is returned to the provider within the allowable period of time, the provider should return the aid to the manufacturer. Notify the IME Provider Services Unit of the situation. Include copies of claims and invoices, remittance statements, and any peer review documentation. An adjustment to the payment for the hearing aid will be made.

a. Binaural Amplification

Binaural amplification is covered when suitable for bilateral hearing loss. Examples include:

♦ The aid is for a blind person

♦ The aid is needed for educational or vocational purposes 

♦ Lack of binaural amplification poses a hazard to a member’s safety 

♦ The member’s hearing loss has caused marked restriction of daily activities and constriction of interests, resulting in seriously impaired ability to relate to other people

The member record must document the reason for binaural hearing aids.

b. Dispensing Service

A dispensing service is covered to allow for the fitting and adjustment of the hearing aid when one is provided. It is considered to include follow up services for the first six months after the aid is provided.

When the member is unable to travel to the provider’s business due to medical reasons, the U-3 modifier should be used. Dispensing fees should be billed as follows:

Procedure                      Code Description 

V5241                       Monaural hearing aid 

V5241-U3                 Monaural hearing aid, nursing home 

V5160                       Binaural hearing aids 

V5160-U3                 Binaural hearing aids, nursing home 

When binaural hearing aids are appropriate but the member prefers to receive only one hearing aid initially and later returns for the second aid for binaural hearing, the monaural dispensing code should be billed for each hearing aid.

c. Ear Molds, Replacement

Payment for a service charge in addition to the cost of material for ear molds is allowed if it is the provider’s practice to make such a service charge to the general public. 

When a service charge is made, it is considered to include all functions performed in connection with fitting of the ear mold, including travel, if necessary. Therefore, no additional charge may be made to the member or others for the service.

d. Maintenance Items

Maintenance items, such as batteries, cords, and dry storage devices are payable when obtained from a participating provider. An invoice must be included with claims with a submitted charge of $51 or more.

Dispensing of hearing aid batteries is considered a service and must be documented in the member’s chart with the date of service and number of batteries dispensed. Up to 30 hearing aid batteries are covered within a 90-day period for a member with a monaural hearing aid. Up to 60 hearing aid batteries are covered within a 90-day period for a member with binaural hearing aids.

e. Prior Authorization

Prior authorization is required for the following: 

♦ A monaural hearing aid costing more than $650

♦ Binaural hearing aids costing more than $1,300 

♦ Replacement of a hearing aid in less than four years for members 21 years of age and older 

♦ FM systems

COVERAGE OF SERVICES

1. Audiologist

Services provided by an audiologist are covered subject to the following limitations.

a. Audiological Testing

Payment will be approved for testing performed by an audiologist to establish the member’s need for a hearing aid. Covered testing services are:

♦ Hearing evaluation, which must include bone conduction and air conduction tests 

♦ Speech audiometry 

♦ Hearing aid selection

The services of the audiologist also include at least one visit with the patient after the purchase of the hearing aid to determine whether the device is functioning adequately.

No payment is to be made to audiologists for services before the member’s examination by a physician, except as noted under Physician Examination.

A physician referral is required when comprehensive audiometry threshold evaluation and recognition, procedure code 92557 is provided to Medicare and Medicaid dual eligibles. The claim must first be submitted to Medicare for those members. A copy of the Medicare Explanation of Medicaid Benefits (EOMB) must be included with the Medicaid claim.

No payment is made for duplicate testing procedures.

b. Cerumen Removal

Removal of impacted cerumen (69210) is considered included with reimbursement for hearing testing and should not be separately billed. It is covered when otherwise medically necessary. The “SC” modifier should be used when billing for members who are eligible for both Medicare and Medicaid.

c. Newborn and Infant Hearing Screening

All newborns and infants born in Iowa, except those born with a condition that is incompatible with life, must be screened for hearing loss.

The primary goals for the EHDI program are:

1 month All infants will be screened for hearing loss before 1 month of age, preferably before hospital discharge. 

3 months All infants who do not pass the screening will have diagnostic audiologic evaluation before 3 months of age. 

6 months All infants identified with hearing loss receive appropriate early intervention services before 6 months of age. 

d. Travel

Travel by the audiologist to perform testing services may be approved when the member is unable to travel due to medical reasons. Travel will be approved only from the provider’s local base of operation to the member’s home or care facility.

e. Vestibular Testing

Payment will be approved for vestibular function tests when prescribed by a physician to evaluate problems with vertigo and balance.

2. FM Systems

FM systems require prior authorization and may be allowed for children who use hearing aids but need additional amplification in settings such as a classroom. The device should be billed using V5274 for the FM system and V5299 for the dispensing fee.

COVERAGE OF SERVICES

1. Audiologist

Services provided by an audiologist are covered subject to the following limitations.

a. Audiological Testing

Payment will be approved for testing performed by an audiologist to establish the member’s need for a hearing aid. Covered testing services are:

♦ Hearing evaluation, which must include bone conduction and air conduction tests 

♦ Speech audiometry 

♦ Hearing aid selection

The services of the audiologist also include at least one visit with the patient after the purchase of the hearing aid to determine whether the device is functioning adequately.

No payment is to be made to audiologists for services before the member’s examination by a physician, except as noted under Physician Examination.

A physician referral is required when comprehensive audiometry threshold evaluation and recognition, procedure code 92557 is provided to Medicare and Medicaid dual eligibles. The claim must first be submitted to Medicare for those members. A copy of the Medicare Explanation of Medicaid Benefits (EOMB) must be included with the Medicaid claim.

No payment is made for duplicate testing procedures.

b. Cerumen Removal

Removal of impacted cerumen (69210) is considered included with reimbursement for hearing testing and should not be separately billed. It is covered when otherwise medically necessary. The “SC” modifier should be used when billing for members who are eligible for both Medicare and Medicaid.

c. Newborn and Infant Hearing Screening

All newborns and infants born in Iowa, except those born with a condition that is incompatible with life, must be screened for hearing loss.

The primary goals for the EHDI program are: 1 month All infants will be screened for hearing loss before 1 month of age, preferably before hospital discharge. 3 months All infants who do not pass the screening will have diagnostic audiologic evaluation before 3 months of age. 6 months All infants identified with hearing loss receive appropriate early intervention services before 6 months of age.

d. Travel 

Travel by the audiologist to perform testing services may be approved when the member is unable to travel due to medical reasons. Travel will be approved only from the provider’s local base of operation to the member’s home or care facility.

e. Vestibular Testing 

Payment will be approved for vestibular function tests when prescribed by a physician to evaluate problems with vertigo and balance

2.FM Systems 

FM systems require prior authorization and may be allowed for children who use hearing aids but need additional amplification in settings such as a classroom. The device should be billed using V5274 for the FM system and V5299 for the dispensing fee.