Often Posed Questions (and Answers) Regarding Medicare, Contracting, and Non-Hearing Aid Services

Abstract

Medicare Part B provider participation is often met with grumbling and disdain by most health care providers, including audiologists. Other pain points for audiologists likely include insurance contracts, third-party administrators, and the unknown of the future. The dynamic landscape that will include technology and delivery systems was, until recently, mere thoughts on paper and in conference rooms. With the moderate amount of misunderstanding about Medicare and contracting rules among the members of the profession, it is this article's intent to dispel these Medicare myths as they pertain to hearing and balance services provided by Medicare Part B–enrolled audiologists, to offer considerations in a practice's decision whether to accept commercial insurance and third-party payer contracts, and to offer the tools to position a practice to provide non-hearing aid–related services based on today's current information.

In the realm of audiology, Medicare Part B provider participation is often met with grumbling and disdain. With the current restriction of being recognized only for payment for diagnostic procedures, coupled with less than stellar and declining reimbursement and rules that appear to be draconian compared with other payers, there is a misunderstanding about those rules among the members of the profession. It is this article's intent to dispel these Medicare myths as they pertain to hearing and balance services provided by Medicare Part B–enrolled audiologists.

Instead of reading paragraphs of Medicare policy from the Medicare Benefits Policy Manual Chapter 15, sections 80.3, Audiology Services, and 80.6, Requirements for Ordering and Following Orders for Diagnostic Tests, a more digestible format is used below to assist in understanding the nuances of Medicare policy requirements for payment as it pertains to audiologists. It is recommended that these resources be reviewed on an annual basis.

Another pain point for most audiologists is that of insurance contracts and the emergence of third-party administrators, entities that have been contracted by the Medicare Part C Advantage Plans. Addressing these concerns also will have a similar format, answering many common questions.

Finally, looking toward the future in this dynamic and changing landscape, how to position your practice by diversifying your audiologic services is essential. A toolbox of codes will be offered for consideration.

Questions and Answers

Medicare

• Q. Do I have to enroll in Medicare? Can't I just bill my services directly to the patient?

• A. Currently, audiologists are one of the professions that cannot opt out of Medicare; therefore, you must enroll. For those who have not enrolled or whose number may have been deactivated due to inactivity, you cannot bill any patient for any diagnostic services (page 104 of the Medicare Benefits Policy Manual, https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf ), thereby rendering all of your diagnostic services at no charge for all patients. In addition, secondary commercial payers and Medicaid/Medi-Cal who provide a hearing aid benefit may require you to be enrolled in Medicare Part B. The Medicare Part C Advantage plans also require enrollment in Medicare Part B.

• Q. How do I enroll?

• A. You will need to visit the Provider Enrollment, Chain, Ownership System (PECOS) here: https://pecos.cms.hhs.gov/pecos/login.do#headingLv1 and enroll to obtain your provider transaction access number (PTAN) that corresponds with your national provider identifier (NPI). Have a copy of your terminal degree, state license, and NPI number to complete your submission. You also can file a hard copy version of the 855I: https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/cms855i.pdf . Other forms may be required such as the 855R, reassignment of benefits (to an employer or contractor), the 855B (group enrollment), and/or the 8550 (referring and ordering physicians). All can be found here, https://www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/enrollmentapplications.html . You also will need to file an electronic transfer fund form, CMS 588, to have the funds deposited in your account of choice. This is a one-way valve where only deposits can be made. CMS cannot withdraw funds from your designated account for deposits.

• Q. What are the requirements when providing services to a Medicare Part B beneficiary?

• A. Currently, you must have a physician order for a medically necessary reason. Medically necessary is defined in Title XVII of the Social Security Act, section 1862(a)(1)(a) as: “Notwithstanding any other provisions of this title, no payment may be made under Part A or Part B for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member” ( https://www.ssa.gov/OP_Home/ssact/title18/1862.htm ).

If you have an order for a patient visit, it does not guarantee meeting the requirements of medical necessity. Both must be in place to have the claim covered; an order is not a pass go card. Also check the Local Coverage Determination (LCD) policy, if one is active, on your Medicare Administrator Contractor Web site.

After the visit, you should send the physician a report of your findings and recommendations given that Medicare believes this physician referred this patient to you to help that physician diagnose and treat their patient. It is a good patient care and closes the loop in the process.

• Q. When do I need to use an advanced beneficiary notice (ABN)?

• A. There are two uses for the ABN, mandatory and voluntary. Simply, mandatory use is when an ABN (CMS form 131-R) is given to the patient prior to the service or procedure that you will be providing when you are uncertain if the visit will meet medical necessity. You will want to append the claim with the GA modifier, waiver of liability statement on file. If you do not include the GA modifier and the claim is denied, you will not be permitted to bill the patient and will have to write off the charge.

A voluntary ABN can be issued, but is not required, for those services or procedures that are never covered and are statutorily excluded such as hearing aids or treatment such as tinnitus or vestibular treatment ( https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf ). If you need to file the claim to Medicare as directed by the patient or you need a denial for a secondary payer to pay for hearing aids, you would append the GY modifier, item or service statutorily excluded or does not meet the definition of any Medicare benefit, to indicate the item or service billed is a noncovered service.

Medicare Part C Advantage plans have their own version of the ABN and you will need to have that available; it can be obtained from their specific Web site.

• Q. Can I just give every patient an ABN and not worry about this?

• A. No. Medicare has regulations about the blanket use of ABNs. ( https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf )

• Q. How do I indicate to Medicare that I need a required denial for a secondary insurance to pay for hearing aids?

• A. You will need to append the GY modifier, item or service statutorily excluded or that does not meet the definition of any Medicare benefit, to indicate you need a denial on your CMS 1500 claim form for each code to which it pertains. If there is a coordination of benefits in place, Medicare will cross the claim over to the secondary payer. If not, they will issue a denial and you can submit that with the hearing aid claim.

• Q. What if the patient presents without an order?

• A. If they do not have the order, then it is a noncovered service and the patient is responsible for payment. This is an example of a voluntary ABN and it can be issued to the patient but is not required.

• Q. I have heard conflicting things about the use of referral pads (pads of referral slips provided to the physician by the audiologist). What is permitted?

• A. You will want to check with your Medicare Administrative Contractor (MAC) for guidance as they determine policies for your region. Given our current Medicare status category of “other diagnostic tests,” we are to receive the order from the physician to help them diagnose and treat their patient. Referral pads may be viewed as solicitation of the patient, something Medicare does not permit.

• Q. What is a LCD policy and why should I care?

• A. A Local Coverage Determinations (LCDs) is a decision made by a MAC on whether a particular service or item is reasonable or necessary and therefore covered by Medicare in that particular region. There are several LCDs in place and you will need to check your MAC's Web site to see if there are any active ones that apply to hearing and balance services. To find your MAC Web site: https://www.cms.gov/Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Downloads/AB-MAC-Jurisdiction-Map-Oct-2017.pdf

If an LCD exists for your MAC, you can locate them by state: https://www.cms.gov/medicare-coverage-database/indexes/lcd-state-index.aspx .

• Q. Is there a limit to the number of hearing tests a patient can have? I've heard it's once a year and also have heard it's only once in a lifetime. Which is it?

• A. While neither is true, medical necessity must be met and a physician order must be in place for the visit to be covered. Routine annual tests are never covered, and the patient is responsible for payment.

• Q. To ensure my patient is receiving the best results from their hearing aids, our office policy is to perform a routine annual visit that includes a hearing test. Can we bill this to Medicare?

• A. No. Medicare does not cover routine annual tests nor any hearing aid–related services. The patient is responsible for this testing.

• Q. What if I don't see any Medicare patients for a year or more?

• A. You will want to log onto PECOS and check your enrollment status as Medicare deactivates your number if a claim has not been submitted in one calendar year. If your Medicare PTAN was deactivated, you will need to reenroll, but do that before you will be submitting claims again.

• Q. I heard that Medicare has an Initial Physical Preventative Examination (IPPE) and an Annual Wellness Visit (AWV). What is required for that?

• A. In the first 12 months that a Part B Medicare beneficiary is enrolled in Medicare, they are to have the IPPE ( https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/mln-publications-items/cms1243320.html ). Their physician is to offer them a paper screening for hearing (the Hearing Handicap Inventory—Elderly) and for balance disorders, (the Dizziness Handicap Inventory). If the patient does not pass these screenings, the physician is to refer them for further evaluation. The AWV is performed on an annual basis.

• Q. Will Medicare reimburse for the visit if bilateral sensorineural hearing loss is the diagnosis and hearing aids are recommended?

• A. Yes, if you can document a change in hearing, balance, and/or tinnitus as the reason for the visit in your chart notes and you have the physician order.

• Q. I have a fourth year student. What are my responsibilities as the preceptor?

• A. You are to be in the booth while they are testing, focused on their activities 100% of the time. The student can assist in writing the report and the preceptor bills the services with their NPI.

• Q. I work in an otolaryngology department/office. Who is supposed to bill for my diagnostic services, me or the physician?

• A. Medicare requires the services of an audiologist be filed under the NPI of the audiologist in box 24J of the CMS 1500 form (Transmittal 84 released in April 2008). Because audiologists are in the category of “Other diagnostic tests,” a physician order is required. In this category, these services are not, nor were they ever, to be billed “incident to” a physician. As either the employee or a contractor, you will need to sign a CMS 855R to reassign the benefits to that practice as they are paying you either as an employee or contractor. Other payers may have other policies regarding their billing guidance.

• Q. I work in an otolaryngology department/office. We have a technician who was trained to do vestibular tests. As the audiologist, I do the interpretation and report. How are these procedures supposed to be filed?

• A. Several audiology codes have a technical and a professional component. Those codes are only the vestibular CPT ^© codes 92537–92546, 92548, the comprehensive ABR code 92585, and the two nonscreening OAE codes 92587 and 92588.

The technician can perform the test only under direct supervision of the physician. That means the physician must be in the office and available. That part of the visit is filed via the NPI of the physician with a TC modifier placed on the claim form next to the test code(s). If you are doing the interpretation and report, you bill the text code(s) with the −26 modifier, the professional component, under your own NPI. The reimbursement is the same amount for the test via the Medicare Physician Fee Schedule regardless of whether it was billed with the TC + PC or as the code with no modifiers. CPT ^© code 92557 does not have a separate technical and professional component.

• Q. For every patient who comes to our office the first time, we always perform pure tone air/bone conduction, speech reception thresholds, and word recognition scores (CPT ^© code 92557), tympanometry (CPT ^© code 92567), and otoacoustic emissions (CPT ^© code 92587). Why wouldn't Medicare support this since it's good patient care?

• A. Are all those tests medically necessary? If the patient does not report any middle ear symptoms and has no air–bone gap via pure tone thresholds, it would be difficult to defend medical necessity. Include the reasoning for all the tests you perform in your chart notes but be cognizant that you may be called to defend your decisions if there is an audit initiated by that payer.

• Q. Can I provide a hearing test via telehealth if the patient is a Medicare Part B beneficiary?

• A. At the time of writing this article, audiology is not one of the professions Medicare recognizes to provide telehealth services to their Part B beneficiaries. Other payers may. In addition, check with your state licensure laws to see if you can provide telehealth services for patients located in your state as well as those who are located out of your state and follow your licensure laws.

Contracting

There seem to be daily news reports noting that 10,000 baby boomers turn 65 each day. These potential patients have different needs and expectations than their parents and different tools in which to find solutions. When qualifying for Medicare as their parents did, they now have a choice of plans that their parents likely did not when they initially enrolled. Medicare Part C, the Medicare Advantage plans, offers additional services that traditional Part B Medicare does not, but at an additional premium cost that the patient pays above the cost of what they would for their Part B premium. These services may include gym memberships, vision and dental care, and audiology services that often include a hearing aid benefit. Many of these plans have thousands of providers signed on across the United States, covering many beneficiaries. When you call to verify hearing aid benefits for any plan, since many of these third-party administrators are contracted with your patients' plans, you want to ensure you are aware to whom to file the claim. This likely will impact what you can offer the patient, how you will be reimbursed, and in what time frame. Read the contracts carefully as some are boilerplate templates that may not apply to an audiology practice. As a safeguard, it is wise to have them reviewed by legal counsel versed in federal and state health care laws.

Like commercial insurance plans, each third-party administrator is managed individually and differently, and those differences need to be analyzed to assure this is a good fit for your practice if you choose to accept them. The demographics in an area may dictate whether you accept these plans or not. For a new practice trying to become established, these plans can provide patients to fill an empty seat or appointment time. Hopefully that patient has family and friends who do not have a third-party administrator's plan which will allow a less restrictive plan for payment and they will use your services. You may need to make scheduling adjustments to accommodate these and your other patients.

There are many questions to ask yourself and the insurance company as you consider a contract. These include but are not limited to the following:

1. How many patients may I expect to see if I am contracted?

2. Can my hourly rate sustain the lesser reimbursement these plans offer and if so, for how long?

3. Can the patient share in the cost of an upgrade for premium technology for the noncovered services and can they sign a waiver acknowledging their responsibility?

4. How are patients referred to me?

5. What are my requirements in terms of the device(s), fitting, and the number of follow-up visits? For how long of a period?

6. Do I need to verify the hearing aid function as proof of the fitting? Does the patient need to submit something to the payer regarding their satisfaction level?

7. Do I use a patient portal to order the devices? Do I pay for the devices directly?

8. Can I recommend and order any device for my patient or does it have to be a choice between two levels of technology?

9. How long is the trial period?

10. Do I need to itemize my services to capture my professional fees?

11. How will I be paid and in what time frame?

12. How are returns for credit handled? Am I allowed to retain a fee for my time?

13. How do I terminate this plan if I chose to do so?

14. May I offer an extended warranty plan and are there any restrictions to time and cost?

Toolbox for The Provision of Audiologic Services (Non-Hearing AID–Related Services)

There has been much discussion, concern from some, and excitement for new opportunities from others surrounding the shifting landscape in the world of audiology. There is the advent of over-the-counter hearing aids for those with self-perceived mild to moderate hearing loss, third-party administrators who are impacting the Medicare Part C plans and others, and telehealth services so that patients have access to immediate care and real-time technology changes. At the time of this publication, Medicare did not recognize audiologists for the provision of diagnostic services via telehealth. Check with your state licensure laws about the requirements for the provision of services via telehealth for in and out of state patients.

To provide a full-service audiology practice, consider adding the services listed below to your clinic offerings, being mindful that some of these niche services also can lead to technology purchase and the more effective use of the audiologist's time and areas of expertise.

As for technology purchased elsewhere, including over-the-counter devices, an office policy on the services you can provide with the costs associated with those services will be helpful when a patient or potential patient asks.

In this new landscape, consider expanding your services and include at least one niche area of audiology. Here are the CPT ^© and ICD-10-CM codes for your toolbox as you consider adding these to your practice offerings:

• Vestibular services:

  • CPT ^© codes:

    • 92540 Basic vestibular evaluation.

    • 92541 Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording.

    • 92542 Positional nystagmus test, minimum of four positions, with recording.

  • One of these two caloric codes:

    • 92537 Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation in each ear for a total of four irrigations).

    • 92538 Monothermal (i.e., one irrigation in each ear for a total of two irrigations).

    • 92544 Optokinetic nystagmus test, bidirectional, foveal, or peripheral stimulation, with recording.

    • 92545 Oscillating tracking test, with recording.

    • 92546 Sinusoidal vertical axis rotational testing.

    • 92547 Use of vertical electrodes (list separately in addition to code for primary procedure).

    • 92548 Computerized dynamic posturography.

    • 95992 Canalith repositioning procedure (check with payers; Medicare and others will not recognize audiologists for this procedure).

  • ICD-10 codes:

    • R42 Dizziness and giddiness.

    • H81.1 BPPV.

    • H81.0-H83.2X Other dizzy-related codes.

• Tinnitus services:

  • CPT ^© codes:

    • 92625 Assessment of tinnitus (includes pitch, loudness matching, and masking).

    • 92700, unlisted otorhinolaryngological service or procedure for other tests performed that may not have a dedicated procedure code.

  • HCPCS code V5299 for hearing services; miscellaneous for devices that are for tinnitus treatment and are not hearing aids.

  • ICD-10 codes:

    • H93.11 Tinnitus, right ear.

    • H93.12 Tinnitus, left ear.

    • H93.13 Tinnitus, bilateral.

    • H93.19 Tinnitus, unspecified ear.

• Cochlear implant services :

  • CPT ^© codes:

    • 92601 Diagnostic analysis of cochlear implant, patient under 7 years of age, with programming.

    • 92602 Diagnostic analysis of cochlear implant, patient under 7 years of age, subsequent reprogramming.

    • 92603 Diagnostic analysis of cochlear implant, age 7 years or older, with programming.

    • 92604 Diagnostic analysis of cochlear implant, age 7 years or older, with reprogramming.

    • 92626/7 Evaluation of auditory rehabilitation status, first hour/each additional 15 minutes (document your start and end times in the patient's record).

  • ICD-10 codes:

    • H90.3 SNHL, bilateral.

    • H90.41 SNHL, right ear.

    • H90.42 SNHL, left ear.

    • H90.5 Unspecified HL (several listed as NOS, not otherwise specified).

• Central auditory processing diagnostics and treatment:

  • CPT ^© codes:

    • 92620 Evaluation of central auditory function, with report; initial 60 minutes.

    • 92621 Evaluation of central auditory function, with report; each additional 15 minutes.

  • ICD-10 codes:

    • H93.25 Central auditory processing disorder.

    • H93.29 Other abnormal auditory perceptions.

    • H93.291 Other abnormal auditory perceptions, right ear.

    • H93.292 Other abnormal auditory perceptions, left ear.

    • H93.293 Other abnormal auditory perceptions, bilateral.

    • H93.299 Other abnormal auditory perceptions, unspecified ear.

• Assistive listening devices:

  • HCPCS codes V5268-V5290.

• Looping services :

  • While there are no specific codes, this is a service that can benefit your community if you choose to provide a loop system for local places of worship, community rooms, theaters, etc.

  • Support staff such as audiology aides/assistants, if recognized by state licensure.

Summary

Being enrolled in Medicare as an audiologist is often fraught with misunderstanding and persistent myths. Hopefully all your questions were answered and if needed, changes can be made to be compliant. As the profession advances into the future, there will be challenges and opportunities. It was hoped that this article could assist you in positioning your practice for success in the future.