Schedule of Medical Fees

The Kansas Workers Compensation Schedule of Medical Fees has utilized portions of the following documents:

1. The Current Procedural Terminology, Fourth Edition, copyright 2014 (a.k.a. CPT 2013) by the American Medical Association 

2. The CDT(Current Dental Terminology) Companion, CDT-2013/2014, copyright 2012, published by the American Dental Association 

3. The 2014 Relative Value Guide, copyright 2012, developed by the American Society of Anesthesiologists 

4. The 2014 Essential RBRVS, a comprehensive listing of RBRVS values for CPT and HCPCS Codes, copyright 2013 Ingenix.

5. The January 2014 HCPCS allowances that were obtained from the DMEPOS Fee Schedule of the Centers for Medicare & Medicaid Services (CMS). 

6. Medicare Severity Diagnosis Related Groups (MS-DRGs) Definitions Manual, Version 31.  

Some of the most important revisions that have been utilized within this Schedule of Medical Fees are as follows:

1. The Conversion Factors for all CPT codes in the Medicine and Evaluation and Management Sections have been increased by 3%. 

2. ICD-10 is not mandated by Kansas Workers Compensation. However, it is strongly recommended that ICD-10 be employed for billing purposes on the CMS 1500 Form or an equivalent form containing the same information. 

3. Surgical CPT code 36415 has been moved to the Pathology and Laboratory Section of the fee schedule. 

4. Trauma Alerts in Ground Rule 7 of Inpatient Hospital and Ground Rule 4 of Ambulatory Surgical Centers/Hospital Outpatient are increased by 7%.

5. Compound drugs and physician dispensed medications shall be reimbursed the same as pharmacies based on the original manufacturer NDC but must be preapproved by the payer. 

6. An inpatient stay requires documentation of official admission to the hospital pursuant to an order for inpatient admission by a physician or other qualified practitioner and the order must be present in the medical record.   

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.

What is not covered?

The agency does not cover the following hearing and hearing aid-related items and services for clients age 20 and younger:

• Tinnitus maskers 
• Group screenings for hearing loss, except as provided under the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program (refer to the agency’s Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Program Billing Guide) 
• FM systems, including the computer-aided hearing devices for FM systems 

When EPSDT applies, the agency evaluates a noncovered service, equipment, or supply according to the process in WAC 182-501-0165 to determine if it is medically necessary, safe, effective, and not experimental. 

Exception to Rule (ETR) 

The agency evaluates a request for medical services, equipment, and/or supplies that are listed as noncovered under the provisions of WAC 182-501-0160 that relates to noncovered services. The request for a noncovered medical service, equipment, or supply is called a “request for an exception to rule.” 

HCPCS

Code                Short Description                                     Policy

L7510              Prosthetic device repair rep                       PA

L8615             Coch implant headset replace                 EPA/PA

L8616             Coch implant microphone repl               EPA/PA

L8617             Coch implant trans coil repl                    EPA/PA

L8618             Coch implant tran cable repl                   EPA/PA

L8619             Coch imp ext proc/contr rplc                       PA

L8621              Repl zinc air battery                               EPA/PA

L8622              Repl alkaline battery                              EPA/PA

L8623              Lith ion batt CID,non-earlvl                  EPA/PA

L8624              Lith ion batt CID, ear level                    EPA/PA

L8627              CID ext speech process repl                       PA

L8628              CID ext controller repl                               PA

L8629              CID transmit coil and cable                        PA

L8691               Osseointegrated snd proc rpl                     PA

L8692                Non-osseointegrated snd proc                  PA

L8693            Auditory osseointegrated device abutment,

                           replacement only                                    PA

L9900                O&P supply/accessory/service               PA

Legend

EPA: Expedited Prior Authorization 

PA: Prior Authorization required

Authorization

What is prior authorization (PA)? 

PA is agency approval for certain medical services, equipment, or supplies, before the services are provided to clients, as a precondition for provider payment.

Does the agency require prior authorization for hearing hardware? (WAC 182-547-1000) 

No. Except for certain services specified in the Coverage table, PA is not required for clients age 20 and younger for hearing aids and services. Providers must send claims for clients age 20 and younger directly to the agency. Providers do not need to obtain authorization from the local Children with Special Health Care Needs (CSHCN) Coordinator. 

Note: The agency evaluates requests for covered services that are subject to limitations or other restrictions and approves such services beyond those limitations or restrictions as described in WAC 182-501-0169. (WAC 182-547-1000 (2)) 

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).

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.

Late Bill Override Date (LBOD)

The Late Bill Override Date (LBOD) allows providers to document compliance with timely filing requirements when the initial timely filing period has expired. Colorado Medical Assistance Program providers have 120 days from the date of service to submit their claim.

Making false statements about timely filing compliance is a misrepresentation and falsification that, upon conviction, makes the individual who prepares the claim and the enrolled provider subject to a fine and imprisonment under state and/or federal law. 

Billing Instruction Detail  -  LBOD Completion Requirements 

Instructions 

•  Electronic claim formats provide specific fields for documenting the LBOD. 
• Supporting documentation must be kept on file for 6 years. 
• For paper claims, follow the instructions appropriate for the claim form you are using. 

1. UB-04: Occurrence code 53 and the date are required in FL 31-34. 
2. CMS-1500: Indicate “LBOD” and the date in box 19 – Remarks.

Billing Instruction Detail  -  Adjusting Paid Claims

Instructions 

If the initial timely filing period has expired and a previously submitted claim that was filed within the original Colorado Medical Assistance Program timely filing period or the allowed 60 day follow-up period was paid and now needs to be adjusted, resulting in additional payment to the provider

Adjust the claim within 60 days of the claim payment. Retain all documents that prove compliance with timely filing requirements. 

Note: There is no time limit for providers to adjust paid claims that would result in repayment to the Colorado Medical Assistance Program. 

LBOD = the run date of the Colorado Medical Assistance Program Provider Claim Report showing the payment.

Billing Instruction Detail  -  Denied Paper Claims

 Instructions 

If the initial timely filing period has expired and a previously submitted paper claim that was filed within the original Colorado Medical Assistance Program timely filing period or the allowed 60 day follow-up period was denied. 

Correct the claim errors and refile within 60 days of the claim denial or rejection. Retain all documents that prove compliance with timely filing requirements. 

LBOD = the run date of the Colorado Medical Assistance Program Provider Claim Report showing the denial.

Billing Instruction Detail  -  Returned Paper Claims

 Instructions 

An electronic claim that was previously entered within the original Colorado Medical Assistance Program timely filing period or the allowed 60 day follow-up period was rejected and information needed to submit the claim was not available to refile at the time of the rejection.

Correct claim errors and refile within 60 days of the rejection. Maintain a printed copy of the rejection notice that identifies the claim and date of rejection. 

LBOD = the date shown on the claim rejection report.

Billing Instruction Detail  -  Denied/Rejected Due to Member Eligibility

 Instructions 

An electronic eligibility verification response processed during the original Colorado Medical Assistance Program timely filing period states that the individual was not eligible but you were subsequently able to verify eligibility. Read also instructions for retroactive eligibility. 

File the claim within 60 days of the date of the rejected eligibility verification response. Retain a printed copy of the rejection notice that identifies the member and date of eligibility rejection. 

LBOD = the date shown on the eligibility rejection report.