Standardized Billing Form

Any insurance company, employer, or other payer who reduces or denies charges from a provider according to the general instructions, ground rules, or maximum fees contained within this fee schedule must show the specific basis of the reduction or denial by use of an "Explanation of Benefits" form. The specific general instruction, specific ground rule, or specific maximum fee that was used for the reduction or denial must be indicated or identified. When payment is reduced or denied on some other basis, the "Explanation of Benefits" form must contain a complete explanation as to why, for example, the service was unreasonable, the service was more appropriately defined by another procedure code, or the service was not related to a compensable injury. When any such reduction or denial occurs, the "Explanation of Benefits" form shall also include: 1) the identity of the person or entity that made the decision for the reduction or denial; 2) the identity of the person or entity that is ultimately responsible for payment; and 3) the telephone number of such person or entity where further explanation of the reduction or denial can be obtained. In the event a controversy arises between the provider and the payer, an attempt should be made by the involved parties to resolve said issue(s). Issues which cannot satisfactorily be resolved should then be referred to the Director of Workers Compensation for review.

As a further attempt to avoid controversy arising between the provider and the payer for failure to make timely payment for any medical services provided, it is recommended that the insurance company or self-insured employer make payment for any medical services that were provided either: 1) within 30 days of receiving the bill submitted and any necessary documentation required by the fee schedule, or; 2) within 30 days of it being determined that the medical service provided is the result of an injury that is compensable under the Workers Compensation Law.

SPECIAL NOTE: The five-digit codes included in this Schedule of Medical Fees (with the exception of the Dentistry Section and the Durable Medical Equipment and Supplies Section) are obtained from 2014 Current Procedural Terminology (CPT), copyright 2013 by the American Medical Association (AMA). CPT is developed by the AMA as a listing of descriptive terms and five-digit codes and modifiers for reporting medical services and procedures performed by physicians.  

The responsibility for the content of the Schedule of Medical Fees is with the state of Kansas Division of Workers Compensation and no endorsement by the AMA is intended or should be implied. The AMA disclaims responsibility for any consequences or liability attributable or related to any use, nonuse or interpretation of information contained in the Schedule of Medical Fees. No fee schedules, basic unit values, relative value guides, conversion factors or scales are included in any part of CPT. Any use of CPT outside of Workers Compensation Schedule of Medical Fees, should require reference to the most recent publication of the AMA Current Procedural Terminology which contains the complete and most current listing of CPT codes and descriptive terms.

Billing for Audiology Services

Audiology services may not be billed when the place of service is a comprehensive outpatient rehabilitation facility (CORF) or a rehabilitation agency.

Audiology services may be furnished and billed by audiologists and, when these services are furnished by an audiologist, no physician supervision is required. 

The interpretation and report shall be written in the medical record by the audiologist, physician, or NPP who personally furnished any audiology service, or by the physician who supervised the service. Technicians shall not interpret audiology services, but may record objective test results of those services they may furnish under direct physician supervision.

Payment for the interpretation and report of the services is included in payment for all audiology services, and specifically in the professional component if the audiology service has a professional component/technical component split.

1. 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

FUNDING

For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) and/or Carriers: 

No additional funding will be provided by CMS; contractor activities are to be carried out within their operating budgets.

For Medicare Administrative Contractors (MACs): 

The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined in your contract. CMS does not construe this as a change to the MAC Statement of Work. The contractor is not obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically authorized by the contracting officer. If the contractor considers anything provided, as described above, to be outside the current scope of work, the contractor shall withhold performance on the part(s) in question and immediately notify the contracting officer, in writing or by e-mail, and request formal directions regarding continued performance requirements.

SUBJECT: Revisions and Re-issuance of Audiology Policies

Background: In February of 2008, CMS issued CR5717, Transmittals 1470 (Pub.100-04) and 84 (Pub. 100-02), with clarifications to policies relative to audiological diagnostic tests. Among the new language was implementation of changes relative to a 2005 policy concerning services incident to physician services that are paid under the Medicare Physician Fee Schedule (MPFS). Under the MPFS, services with their own benefit category must be furnished and billed according to that benefit and may not also be billed incident to physician services. Diagnostic tests were given as an example. Audiology services are “other diagnostic tests.” Since that transmittal there have been continuing questions about the policy, and there is a need for further clarification. 

Policy: Audiology services must be personally furnished by an audiologist or nonphysician practitioner (NPP). Physicians may personally furnish audiology services, and technicians or other qualified staff may furnish those parts of a service that do not require professional skills under the direct supervision of physicians.

Interpreter Services

Interpretative services may be covered, whether done orally or through sign language. Interpreters must provide only interpretation services for the agency. The services must facilitate access to Medicaid covered services.

In order for interpretation services to be covered by Iowa Medicaid, the services must meet the following criteria: 

♦ Provided by interpreters who provide only interpretive services 

♦ Interpreters may be employed or contracted by the billing provider

♦ The interpretive services must facilitate access to Medicaid covered services

Providers may only bill for these services if offered in conjunction with an otherwise Medicaid covered service. Medical staff that are bilingual are not reimbursed for the interpretation but only for their medical services

a. Documentation of the Service

The billing provider must document in the member’s record the: 

♦ Interpreter’s name or company, 

♦ Date and time of the interpretation, 

♦ Service duration (time in and time out), and 

♦ Cost of providing the service.

b. Qualifications

It is the responsibility of the billing provider to determine the interpreter’s competency. Sign language interpreters should be licensed pursuant to 645 Iowa Administrative Code 361. Oral interpreters should be guided by the standards developed by the National Council on Interpreting in Health Care.

Following is the instruction for billing interpretive services when that service is provided by an outside commercial translation service:

 Bill code T1013

  • For telephonic interpretive services use modifier “UC” to indicate that the payment should be made at a per-minute unit.

 • The lack of the UC modifier will indicate that the charge is being made for the 15 minute face-to-face unit.

♦ Enter the number of minutes actually used for the provision of the service. The 15 minute unit should be rounded up if the service is provided for 8 minutes or more.

NOTE: Because the same code is being used but a conditional modifier may be necessary, any claim where the UC modifier is NOT used and the units exceed 24 will be paid at 24 units. 

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

The Request for Prior Authorization, form 470-0829, should be submitted with:

♦ Examiner Report of Need for a Hearing Aid, form 470-4767 

♦ Results of hearing tests 

♦ Member history and diagnosis 

♦ Date of purchase of the current hearing aid, if known, or the approximate age of the hearing aid 

♦ Whether the aid is covered under warranty, if less than one year old

♦ Reason for replacement

Payment will be approved for a monaural aid costing more than $650 and for binaural aids costing more than $1,300 for either of the following:

♦ Educational purposes when the member is participating in primary or secondary education or an academic program leading to a degree, and either:

 • An in-office comparison of an analog aid and a digital aid matched (+/- 5dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise

 • An in-office comparison of two aids, one of which is singlechannel, shows significantly improved audibility

♦ Vocational purposes when documentation submitted indicates the necessity such as varying amounts of background noise in the work environment and a need to converse in order to do the job, and either:

• An in-office comparison of an analog aid and a digital aid matched (+- 5 dB) for gain and output shows a significant improvement in either speech recognition in quiet or speech recognition in noise

 • An in-office comparison of two aids, one of which is singlechannel, shows significantly improved audibility

The following hearing aid services are covered when provided by audiologists or hearing aid dispensers.

f. Repair

Repair of hearing aids resulting from conditions not covered under the manufacturer’s warranty are covered.

(1) Parts and Labor

♦ In-house repairs are reimbursed at the current fee schedule amount. The U5 modifier must be billed with V5014 for in-house repairs.

♦ Out-of-house repairs are reimbursed at the amount shown on the manufacturer’s invoice plus a service charge, when applicable..

(2) Service Charge

Payment is allowed for a service charge in addition to the charge for parts and labor for out-of-house repairs if it is the provider’s practice to make such a charge to the general public. Bill the usual, customary, and reasonable service charge. Procedure code V5014 should be billed.

When a service charge is billed, it is considered to include all service functions performed in connection with repair of the hearing aid, including necessary travel, “loaners,” or any other service or supplies. Therefore, no additional charge may be made to the member or to others.

PROVIDER-SPECIFIC POLICIES

PROVIDERS ELIGIBLE TO PARTICIPATE

All hearing aid dispensers and audiologists licensed in Iowa are eligible to participate in the Medicaid program. Audiologist in other states must be qualified by having a Certificate of Clinical Competence in Audiology granted by the American Speech-Language-Hearing Association or by having successfully completed a minimum of 350 clock-hours of supervised clinical practicum and successfully completed a nationally approved examination in audiology. Submit requests for participation to the Iowa Medicaid Enterprise (IME).

PROCEDURE FOR A MEMBER TO OBTAIN A HEARING AID

The steps in the process for a Medicaid member to obtain a hearing aid are: 

♦ Physician examination 

♦ Audiological evaluation 

♦ Hearing evaluation 

♦ Hearing aid selection 

♦ Purchase of hearing aid

1. Physician Examination

Members who believe themselves to be in need of a hearing aid, or who are advised of a possible need, should begin by contacting their primary care physician for an examination to determine whether there is any condition that would contraindicate the use of a hearing aid. An examination by an otologist or otolaryngologist is preferred.

EXCEPTION: A physical examination may be waived if the member is 18 years of age or older and has signed an informed consent statement acknowledging that:

 ♦ The member has been advised that it may be in the member’s best health interest to receive a medical evaluation from a licensed physician before purchasing a hearing aid, and 

 ♦ The member does not wish to receive a medical evaluation before the purchase.

A physician examination or waiver does not need to be repeated for replacement hearing aids, unless Medicaid payment for hearing aids was not previously made.

2. Audiologic Evaluation

A physician or an audiologist must perform pure-tone and speech audiometry to evaluate the member’s hearing sensitivity. 

Due to various factors, such as age and cognitive ability to understand and respond, pure-tone air conduction, bone conduction, and speech audiometry may not be applicable to all members. If alternative audiological evaluations are employed, written documentation or support reports should be included in the member’s record.

3. Hearing Evaluation

The hearing aid evaluation is performed to determine whether the member may benefit from the use of amplification. The evaluation procedures should be standard and appropriate as a means of determining the type of hearing aid and amplification characteristics needed for the member’s condition.

Hearing aid evaluation and selection codes 92590 and 92591 are payable only when provided by audiologists.

4. Hearing Aid Selection

A physician or audiologist may recommend a specific brand or model appropriate to the member’s condition. “Appropriate” shall mean adequate for the member’s condition and a reasonable expenditure as well. Reasonableness is determined by whether:

♦ The expense of the hearing aid would be clearly disproportionate to the therapeutic benefits which the member could derive from it;

♦ The hearing aid would be substantially more costly than an appropriate and realistically feasible alternative brand or model; or 

♦ The hearing aid serves essentially the same purpose as an item already available to the member.

When a physician or audiologist makes a general hearing aid recommendation, a hearing aid dispenser may perform tests to determine the specific brand or model appropriate to the member’s condition. Hearing aid selection, code V5010, is payable only to hearing aid dispensers.

A hearing aid selection fee is not allowed for replacement of hearing aids that are lost, broken beyond repair or stolen and the replacement aid is like for like.

5. Purchase of Hearing Aid

The member may obtain the hearing aid from the enrolled provider of the member’s choice who can provide the hearing aid recommended. 

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.

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

Oto-tech program

Q: What's happens to the oto-techs who are well-trained through our Academy's oto-tech program? 

Answer: Oto-techs can still perform the technical component of diagnostic audiology tests that have a professional and technical component. The physician must detail the specific tests the technician must perform, and provide direct supervision. The services can be billed under the name and NPI number of the physician. Contact your local Medicare contractor’s Medical Director to determine the specific diagnostic tests that technicians can perform and for which you will be reimbursed.

The Academy realizes this is a complex issue and other questions may arise, including those involving services performed by an Audiologist. The Academy has several resources available for members to help them navigate Medicare’s audiology billing requirements, including a newly revised Audiology FAQ available on our website at: http://www.entnet.org/Practice/Medicareupdates.cfm#CP_JUMP_149730.

The Academy also provides a coding hotline to members for specific questions about coding which can be reached Monday through Friday 7 am- 4 pm MST at 800-584-7773. Additional questions can be submitted to the Health Policy team at healthpolicy@entnet.org. 

CPT Code - 92540

Description - ENG Testing

Split PC/TC? - Yes 

CPT Code - 92541

Description - Spontaneous Nystagmus Test, w/Gaze & Fixation Nyst..

Split PC/TC? - Yes 

CPT Code - 92542

Description - Positional Nystagmus Test, Minimum, 4 Positions, w… 

Split PC/TC? - Yes 

CPT Code - 92543

Description - Caloric Testing

Split PC/TC? - Yes 

CPT Code - 92544

Description - Optokinetic Nystagmus Test, Bidirectional, Foveal…

Split PC/TC? - Yes 

CPT Code - 92545

Description - Oscillating Tracking Test, w/Recording

Split PC/TC? - Yes 

CPT Code - 92546

Description - Sinusoidal Vertical Axis Rotational Testing

Split PC/TC? - Yes 

CPT Code - 92547

Description - Use of vertical electrodes

Split PC/TC? - No

CPT Code - 92548

Description - Computerized Dynamic Posturography

Split PC/TC? - Yes 

CPT Code - 92550

Description - Tympanometry and Reflex Threshold

Split PC/TC? - No

CPT Code - 92552

Description - Pure Tone Audiometry (Threshold); Air Only

Split PC/TC? - No

Medicare Audiology Billing Services

Clarifying Medicare Audiology Billing Services: Audiology and OTO-Techs

Recently, the Academy has received numerous questions from members on Medicare audiology billing and what services audiology/ otolaryngology-technicians (oto-techs) can bill. In response, resources on the Academy’s website have been developed to help to clarify this issue. (http://www.entnet.org/Practice/Medicareupdates.cfm#CP_JUMP_149730). A frequently asked question and answer is provided below, followed by a summary of information provided on our website.

This is meant to be a guide to assist with questions and not a definitive source. For a definitive list of what procedures audiology/ oto-tech’s can provide and bill, contact your Medicare Administrative Contractor because Medicare allows them to determine what services oto-techs can perform and the qualifications needed, based on state and/or local law. 

Q: What Services Can Oto-Techs Provide and Bill?

Answer: A physician orders a comprehensive audiometry threshold evaluation and speech recognition test (CPT 92557), but wonders if their certified audiology technician or oto-tech can perform and bill for this? In most states, the answer is no, they cannot. According to Medicare, audiology/oto-techs cannot bill Medicare for 92557 because there is no separate professional component (-26)/ technical component (TC) breakout where the technician would be able to bill for the TC. However, qualified professionals that have their own Medicare NPI, such as an Audiologist, may bill for this.

In June 2010, CMS released MedLearn Matters 6447, URL http://www.cms.gov/MLNMattersArticles/downloads/MM6447.pdf, which clarified the Medicare policy on billing for audiology services. CMS indicated that qualified technicians, including those trained in the Academy’s oto-tech program, can only perform diagnostic audiology tests (under direct physician supervision) that have a technical and professional component. In such cases, the technicians can only perform the technical component of the test. This revised policy took effect September 30, 2010. 

Tests that have a split professional and technical component (TC/ -26) most likely do not likely require an audiologist. The full list of Audiology codes can be found here, 

http://www.cms.gov/Medicare/Billing/TherapyServices/Downloads/Audiology_Codes.pdf. 

For codes that do have a split, an oto-tech (or other practitioners that furnishes the technical component) may perform the technical component of the service under direct physician supervision (note that for CPT codes with a split, the physician, non-physician practitioner or audiologist must perform the professional component of the tests). However, as mentioned previously, be sure to check with your local Medicare contractor for guidelines. 

The medical record must contain the name and professional identity of the technician who actually performed the service. The physician must order the audiological diagnostic testing specifically, listing each test individually. Again, check with your local Medicare contractor for guidelines.