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Q: Are diagnostic audiograms with physician referral a covered Medicare benefit? How does a diagnosis code affect reimbursement?

A: Presently, all diagnostic audiological services billed to Medicare must have physician referral however the salient factor affecting reimbursement is the reason that testing is performed. Medicare pays for services that are considered medically reasonable and necessary to the diagnosis and treatment of a patient’s condition. For every service billed, the provider must indicate in the medical record the specific sign, symptom, or patient complaint necessitating the service. Although the service or test may be good healthcare practice, Medicare prohibits payment for services without symptoms or complaints. Therefore, for previously diagnosed hearing loss, repeat audiologic testing done for routine monitoring purposes in the absence of any changes in signs and symptoms, as well as any testing done to determine whether hearing aids are providing appropriate gain, are not a covered benefit under the Medicare program. In such cases, having the patient sign a Notice of Exclusions of Medicare Benefits (NEMB) would be appropriate to ensure that you will be reimbursed by the patient for the service(s) you provided. The NEMB informs patients that Medicare does not cover all healthcare services and that the patient must bear responsibility for non-covered services.

If the proper conditions are met, payment can be made by Medicare regardless of the diagnosis even if a recommendation for amplification is the result, as stated in Medicare (Transmittal AB-02-080). Note: The more specific the diagnostic code, the more likely reimbursement will occur.

Private practitioners are reimbursed based on the Medicare Physician Fees Schedule (MPFS), while audiology services furnished in a hospital outpatient department are billed by the hospital and reimbursed under the Outpatient Prospective Payment System (OPPS).

Q: If an annual audiological evaluation is recommended via a written referral from a physician, is that covered by Medicare? Is only the initial evaluation billable to Medicare unless there is ongoing pathology(i.e., ear infection)?

A: Medicare does not pay for routine/annual testing of any kind, including “annual audiological evaluations”. The Medicare carrier manual states:

“Diagnostic testing performed by a qualified audiologist is covered as “other diagnostic tests” when a physician orders such testing for the purpose of obtaining additional information necessary for his/her evaluation of the need for or appropriate type of medical or surgical treatment of a hearing deficit or a related medical problem.”

Diagnostic services performed by a qualified audiologist to measure hearing deficit or to identify pathology responsible for the deficit are covered where such services are necessary to enable the physician to determine whether otologic surgery or medical intervention is indicated. When the diagnosis is already known to the physician and tests are performed to determine appropriate amplification the services are excluded regardless of the provider of service.

Medicare pays for services considered medically reasonable and necessary to the overall diagnosis and treatment of a patient’s condition. Although a service or test might be considered good medical practice, Medicare prohibits payment for services without a sign, symptom or complaint. Therefore, subsequent evaluations may be covered if significant changes in hearing or balance symptoms are reported by the patient and documented in the medical record, as needed to assist a physician in determining appropriate medical treatment.

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