Q: Is there a resource that describes the accepted documentation requirements for audiology services? I am unfamiliar with what are considered “acceptable” documentation guidelines for audiology.
A: There is no “definitive” source of documentation for audiologists. However, under Medicare, audiologists may only see patients who are referred to them by a physician as part of the physician’s efforts to determine whether medical or surgical treatment is possible. The Academy suggests that the referral be written and signed by the physician on the physician’s letterhead or prescription pad. Chart notes detailing the purpose of the visit, symptoms, complaints, subjective and objective findings, test data, counseling and recommendations should be kept of each visit. Certainly a completed audiogram, and a copy of the report sent to the referring physician should be in the chart along with a signed CMS 1500 form (even if billing is done electronically).