CPT Codes, Bundling, and Reimbursement: Interview with Debbie Abel, AuD
Douglas L. Beck, AuD, speaks with Dr. Debbie Abel, Academy director of reimbursement and practice compliance, regarding new 2010 CPT codes, bundling, reimbursement, de-valuation, audiometry, vestibular, cochlear implant codes, and more.
Beck: Hi, Deb. Thanks so much for meeting with me, today.
Abel: Hi, Doug. My pleasure, thanks for your interest!
Beck: I think the readers know you’re the coding and reimbursement guru at the American Academy of Audiology (Academy), and I can only presume all the new codes and questions must be keeping you busy?
Abel: Absolutely. In fact the thing that’s drawing the most attention lately has been the combining of codes as required by the Centers for Medicare and Medicaid Services (CMS), in what’s referred to as “bundling.”
Beck: Just to clarify, in the past, an audiologist might have billed separately for tympanograms, reflexes, and reflex decay—but now, all that has been “bundled” into one code, is that right?
Abel: Exactly. And it goes beyond the immittance battery example you just gave. Bundling also involves the vestibular codes with 92541, 92542, 92544, and 92545 being combined into the new 92540. Previously, our only exposure to a bundled code was 92557. Many other questions have arisen, too, due to the de-valuation of many of our codes.
Beck: How much has the standard 92557 been de-valued?
Abel: Good question. For example, 92557 (comprehensive audiometry evaluation) in 2005 may have had a typical reimbursement on the Medicare Physician fee schedule of perhaps $47.00 but now in 2010, the same code is reimbursed at approximately $30.00. This amount is without the geographic price index being factored in (one of the relative value unit components) as that is based on your practice’s location and varies from place to place.
Beck: And I believe CMS has eliminated the non-physician work pool, which means CMS has decided the cost of getting our education, training, knowledge, diagnostic ability, counseling, rehab strategies, etc., are essentially things they don’t reimburse us for?
Abel: Well, somewhat. It was based on the pool of money from which our codes were paid that was phased out. The reality is that the entire CPT code system is owned by the American Medical Association (AMA). The Centers for Medicare and Medicare Services (CMS), per the Social Security Act statute, allows audiologists to file claims only for "other diagnostic tests," and does not allow audiologists access to “Evaluation and Management” (E&M) codes as they are not in this category. Medicare allows physicians to bill for their management, level of complexity, time and other issues, but we have essentially just the value of the test itself, without a “full-service” component such as E&M codes. Currently, there is a time factor built in, but as we know, it often takes more time and increased complexity to perform diagnostic tests including what precedes and follows the actual test in the way of a case history as well as the recommended detailed plan of care.
Beck: Agreed. In fact, the most efficient health-care system is the one our millions of senators, congressmen, congresswomen, soldiers, sailors, airmen , marines, veterans, VA patients, and more, use. All of those people go directly to the audiologist for their balance, tinnitus, and hearing diagnosis and management—and, of course, they’re referred to physicians if a medical or surgical problem is found, but as we all know, some 90 to 95 percent of all hearing problems are noise-induced hearing loss and presbycusis, both of which are diagnosed and managed by audiologists, not physicians. Sending those millions of military people, department of defense (DOD) employees and politicians to physicians would easily double or triple the bill! So why doesn’t CMS employ and recognize the excellent and streamlined system our politicians, military, and DOD personnel have honed into a maximally efficient system?
Abel: That’s an excellent question, Doug. Utilizing the best of that very same proven mechanism of direct access to audiology services could easily be the model for direct access for Medicare beneficiaries. However, it seems that once direct access to our services occurs within Medicare, that policy will continue to be based on “medical necessity,” which is Medicare’s benchmark and gold standard for a referral.
Beck: Okay, so CMS does not directly reimburse audiologists for unique or professional or diagnostic components, counseling, or taking the case history, or the physical exam of the ear?
Abel: Well, you’re essentially correct, but checking the ear canals for obstruction is actually considered to be part of 92557. However, otoscopy as a unique event itself would not be billable by an audiologist. As for case history, most audiologists perform this routinely, but Medicare incorrectly assumes a case history is something the referring physician passes along to the referred provider.
Beck: And in addition to specific codes being de-valued, and core audiological services not being reimbursed, we now bundle more codes into fewer codes, and then CMS will pay less for the bundled code? And I should mention that as always, all of our codes are considered binaural.
Abel: Correct, all audiology diagnostic codes are binaural and, yes, you’re correct with your explanation. CMS is looking at all codes performed during the same office visit across all professions, and if two or more codes are performed at the same time bundling them will likely occur if they are billed in tandem more than 75 percent of the time, all done based on the presumption of saving money. The reality is that the Medicare trust fund is running out of money.
Beck: So, am I correct that we’re required to bundle 92567 (tympanometry) and 92568 (reflexes) and 92569 (reflex decay) and bill that as the new all inclusive code 92570? Which will reimburse to a lesser rate than the three combined previous codes? And if you only do tympanometry and reflexes, that’s a new code, 92550. However, if you only do 92567, then it’s appropriate to continue billing 92567 by itself?
Abel: Yes, that’s correct. And to give you an example, if one were to bill 92567, and 92568 and 92569 in 2005, the typical reimbursement might be about $55.00 without the geographic price index, whereas today, in 2010, billing 92570 is likely to reimburse approximately $23.50. And just to clarify, because you cannot instrumentally perform decay without doing reflexes first (to establish the reflex threshold), CPT code 92569, acoustic reflex decay has gone the way of the Lombard Test and has been eliminated from the CPT codebook.
Beck: And please tell me what’s happened with the vestibular and cochlear implant codes in terms of de-valuation and bundling?
Abel: Well, pretty much the same thing has happened to the core audiology codes. Between the transition to work from practice expense and the four vestibular codes being bundled into one, that results in half the reimbursement, this will have a severe impact on those who are providing vestibular services.
Beck: And with regard to cochlear implant mapping?
Abel: The reimbursement for cochlear implant diagnostic analysis and subsequent reprogramming codes (92601-92604) have remained fairly stable since 2007.
Beck: And so Deb, this gets pretty complicated pretty quickly. Can you recommend some resources and Web site addresses where these topics are clarified? Or perhaps, does the Academy have a document or two that sheds light on these issues?
Abel: Sure. First of all, I’d refer Academy members to the Practice Management are of our Web site.
There’s a lot of information on Medicare and coding. The next recommendation is for members to have current CPT, ICD-9-CM, and HCPCS code books, which can be obtained on the AMA bookstore.
Beck: Thanks, Deb! I am very appreciative of your time and expertise. And if individual audiologists have questions, what’s the best way for them to contact you?
Abel: My direct line is 703-226-1024 and e-mail is firstname.lastname@example.org.
Beck: Thanks, Deb!
Abel: Thank you, Doug!
Debbie Abel, AuD, is the director of reimbursement and practice compliance with the American Academy of Audiology.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology.