Many of you may be familiar with, or may have even used, the Academy’s e-mail box for submitting coding, reimbursement, and compliance-related questions. This centralized mailbox (email@example.com) allows the Academy’s Coding and Reimbursement Committee (CRC) to review and discuss all inquiries posed to the Academy. The CRC is able to research, discuss, and vet responses to questions received. Having a centralized system for answering questions serves many purposes. It allows the CRC to identify trends in coding and reimbursement, develop coding and reimbursement resources, and engage in advocacy with payers regarding concerning policies.
As a national professional association, the Academy cannot become directly involved or provide legal opinions for individual-level disputes regarding contracts between members and insurance providers. However, we can identify problematic payer policies that affect audiologists nationally, and work with payers to modify those policies. In the past year, the CRC has been active in monitoring, updating, and addressing both Medicare and private-payer policies based on member concerns.
On January 1, 2016, CPT codes 92537 and 92538 replaced CPT code 92543 (Caloric vestibular test, each irrigation, with recording). Shortly after the effective date for the new caloric codes, the Academy received numerous reports of denials from audiologists across the country. Audiologists reported that when they attempted to use the new codes, they were denied because the new codes did not appear on the Audiology Code List provided by the Centers for Medicare and Medicaid Services (CMS). The Academy investigated further, and reached out to CMS on behalf of audiologists to remedy this issue and add the new caloric codes to Audiology Code List. CMS did make the change, and the Academy subsequently contacted all of the Medicare contractors to ensure they were aware of the update in order to prevent further denials. Though this particular issue was the result of an administrative oversight and easy to remedy, the error caused many issues for providers. Being able to track member concerns and identify the underlying issue based on national member feedback, allowed the CRC to act quickly regarding this policy issue.
The Academy’s CRC has also identified issues related to the ICD-10 transition. At the end of 2015, the Academy received reports from audiologists reporting denials for pertinent and appropriate ICD-10 codes that supported medical necessity for the audiology procedure codes being billed. Upon further research, the Academy discovered that the Novitas Medicare Local Coverage Determination (LCD) for Vestibular and Audiologic Function Studies was missing key audiology-specific ICD-10 codes, including the codes for conductive hearing loss, and R42, dizziness and giddiness, one of the diagnosis codes in the denominator for PQRS Measure #261, Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness. The Academy’s CRC submitted a reconsideration request to Novitas, requesting the addition of these codes. In February 2016, Novitas released a revision of this LCD, which included the addition of many new ICD-10 codes, including the conductive hearing loss codes. In their correspondence with the Academy, Novitas informed us that more revisions were scheduled for release. In April 2016, Novitas issued another revision of this LCD to include R42 (dizziness and giddiness). The CRC continues to regularly monitor all audiology-related Medicare LCDs.
As a result of their regular monitoring and communication with members, the CRC most recently identified concerns with the Palmetto GBA Medicare LCD for Vestibular Function Testing. In reviewing the ICD-10 updates that went into effect on October 1, 2016, the CRC noticed that, again, there were key ICD-10 codes describing conductive hearing loss and mixed hearing loss that did not appear on the Palmetto GBA LCD for Vestibular Function Testing. The CRC wrote to Palmetto GBA and asked them to include the ICD-10 codes for conductive hearing loss (H90.0, H90.11, H90.12, H90.A11, and H90.A12) and mixed hearing loss (H90.71 and H90.72). In their correspondence with Palmetto GBA, the CRC discussed that these were appropriate ICD-10 codes that can support medical necessity for the audiology procedures being billed. At the time of publication, the Palmetto GBA contacted the Academy stating that the ICD-10 codes for conductive and mixed hearing loss would be added to the LCD as requested. The CRC will monitor the LCD and inform member when these codes have been officially added.
The examples provided describe the CRC’s involvement in updating CMS-related policies, but the committee also intervenes with private payers when appropriate. Currently, the CRC has been working to address a recent change to Humana’s coverage policy on Chronic Vertigo Evaluations and Treatments (Policy Number: HGO-0471-009). The change in the coverage policy went into effect on June 23, 2016, and has resulted in the Academy receiving numerous reports of denials from audiologists across the country with reports of multiple denials in Indiana and Florida. In their updated policy, Humana has categorized caloric testing (CPT codes 92537 and 92538) as integral to the basic vestibular evaluation or office visit. As such, Humana has deemed caloric testing as not separately reimbursable. Humana also references other types of vestibular evaluations described in their coverage policy as being integral to a basic vestibular evaluation or typical office visit, and therefore not separately reimbursable. The Academy’s CRC reviewed this issue and has contacted Humana about reversing their policy, citing that vestibular testing is medically necessary for a number of reasons and is critical to assist with the diagnosis and treatment of a hearing and/or balance disorder. Caloric vestibular testing, ENG, and VNG are distinct procedures that should remain separately reimbursable. These procedures are outside of what is typically performed during an office visit and should remain separately covered services. The CRC will continue to inform Academy members of any changes to Humana’s policy.
The Academy’s CRC encourages all Academy members to continue to submit coding questions and concerns to firstname.lastname@example.org. The CRC will continue to work to modify problematic payer policies and advocate on behalf of audiologists and the patients they serve!