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Medicare Frequently Asked Questions

Medicare Frequently Asked Questions

From the Advanced Beneficiary Notice to Referral Pads

I AM ENROLLING IN MEDICARE. WHERE DO I START?

WHAT IS MEDICALLY REASONABLE AND NECESSARY?

WHAT IS OPTING OUT OF MEDICARE?

WHAT ARE THE OPTIONS FOR PARTICIPATION IN PART B MEDICARE

WHAT IS AN ADVANCED BENEFICIARY NOTICE?

WHAT MODIFIER DO I USE WHEN I FILE A CLAIM TO MEDICARE WITH AN ABN ON FILE?

WHEN CAN I PERFORM FREE HEARING TESTS?

MAY I PROVIDE PHYSICIANS WITH A REFERRAL PAD?

WHEN IS IT ADVISABLE TO USE REMINDER CARDS FOR ANNUAL AND/OR ROUTINE HEARING TESTING?

DOES MEDICARE REQUIRE PHYSICIAN ORDERS BEFORE AN AUDIOLOGIST CAN PERFORM AN EVALUATION?

IS A PHYSICIAN'S SIGNED ORDER REQUIRED IN THE PATIENT'S MEDICAL RECORD?

WHAT ARE MEDICARE DOCUMENTATION REQUIREMENTS?

WHAT IS CPT CODE 92547 (Use of vertical electrodes (List separately in addition to code for primary procedure)?

HOW DO I INDICATE THAT I PERFORMED ONLY UNILATERAL TESTING?


Question: I AM ENROLLING IN MEDICARE. WHERE DO I START?

Answer:
Basic information about the enrollment process is available on the Centers for Medicare Services (CMS) website . You may also find this on your local Medicare contractor's website, located by state, here

Audiologists who choose to see Medicare beneficiaries can become either Medicare participating or non-participating providers by using the 855I enrollment form. In order to be assigned your Medicare specific Provider Transaction Access Number (PTAN), formerly known as the Provider Identifier Number (PIN), you must file this form. You will need to have your National Provider Identifier (NPI) available when completing the form. If you don't have your NPI, you can enroll by clicking here . You must have completed your terminal audiology degree and received the diploma before you can apply for an NPI. The 855I may be filed hard copy or online.

For those providing audiologic services as an employee or as a contractor with that contractor filing the claims with the NPI of the audiologist on the CMS 1500 claim form, the 855R needs to be filed to assign the benefits to the employer or contractor. If filing hard copy, these forms can be found here
and here .

For those providing audiologic services as part of a group, the 855B can be located here .

If possible, audiologists should use the Provider Enrollment Chain & Ownership System (PECOS), found here . This electronic enrollment system will also require the hard copy submission of your supporting documentation such as your degree(s), state license, and NPI notification in addition to the signed certification statement found in section 15 in order for the application to be considered complete.

As an enrolled audiologist, you must complete the Medicare Participating Physician or Supplier Agreement .
This form enters you "…into an agreement with the Medicare program to accept assignment of the Medicare Part B payment for all services for which the participant is eligible to accept assignment under the Medicare law and regulations and which are furnished while this agreement is in effect." 

You can also file the CMS Electronic Transfer Fund 588 form , to allow payments to be deposited directly into your bank account. Audiologists may choose to see Medicare beneficiaries and not charge for diagnostic services.

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Question: WHAT IS MEDICALLY REASONABLE AND NECESSARY?

Answer:
Program Memorandum AB-02-080 states "diagnostic testing, including hearing and balance assessment services, performed by a qualified audiologist is paid for as 'other diagnostic tests' under §1861(s)(3) of the Social Security Act (the Act) when a physician orders testing to obtain information as part of his/her diagnostic evaluation or to determine the appropriate medical or surgical treatment of a hearing deficit or related medical problem." Medical necessity includes the patient noting a change in one or more conditions, which may be new, or a change in a previous condition(s) such as hearing loss, tinnitus and/or dizziness. Information specifically related to the medical necessity of audiologic procedures can be found in the CMS Update to Audiology Policies .

Medicare contractors have Local Coverage Determination policies (LCDs) that are coverage guidelines developed by the contractor to provide rules either for determination of coverage in the absence of a National Coverage Determination policy (NCDs) or for further clarification of a NCD or LCD. Please click here to find information related to specific LCDs in your area. are not an inclusive list and may not address audiology and/or vestibular procedures. If an audiology/hearing/vestibular LCD is in effect, your Medicare contractor may define "medically necessary" as well as the appropriate codes that are reimbursed based on medical necessity. NCDs are established by Medicare and stipulate the conditions for a reimbursable procedure for a Medicare beneficiary. Currently, two NCDs relate to audiology and address cochlear implantation and tinnitus devices.

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Question: WHAT IS OPTING OUT OF MEDICARE?

Answer :
Opting out of Medicare allows certain providers the ability to not participate in the Medicare program and charge Medicare patients without being subject to the Medicare Physician Fee Schedule. Audiologists are not included on the list of providers who are allowed to opt out of Medicare. Audiologists are not required to accept assignment for Medicare covered services if enrolled as a non-participating provider. If a patient requests that a claim be filed to Medicare for a covered service, the mandatory claims statute requires that the claim be filed. This will therefore require the audiologist to enroll in the Medicare program and obtain a Provider Transaction Access Number (PTAN). A non-enrolled Medicare provider could provide a service at no charge as long as no other patients were charged for the same service.

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Question: WHAT ARE THE OPTIONS FOR PARTICIPATION IN PART B MEDICARE

Answer:
There are two categories of participation within Medicare: Participating provider (who must accept assignment) and non-participating provider (who does not accept assignment).

You may agree to be a participating provider with Medicare. Once enrolled, you are required to bill on an assignment basis and accept the Medicare allowable fee as payment in full. Medicare will accept 80% of the allowable amount of the Medicare Physician Fee Schedule (MPFS) and the patient will pay a 20 % co-insurance at the time services are rendered or ask you to bill their Medicare supplemental policy. Both participating and nonparticipating providers are required to file the claim to Medicare.

As a nonparticipating provider you are permitted to decide on an individual claim basis whether or not to accept assignment or bill the patient on an unassigned basis. The allowable fee for a nonparticipating provider is reduced by five percent in comparison to a participating provider. Thus, if the allowable fee is $100 for a participating provider, the allowable fee for a nonparticipating provider is $95. Medicare will pay 80% of the $95. If assignment is accepted the patient is responsible for 20% of the $95. If assignment is not accepted, the patient will pay out of pocket for the service. In this case, the most the provider is permitted to charge the patient is 115% of the allowable fee. This is known as the limiting charge. Thus, using the example of the $95 allowable fee, the most you can charge the patient is $109.25 as long as the practitioner's standard fee is at least 15% above the MPFS fee. For further information on Medicare provider status, click here .

Your status with Medicare may be changed by informing your contractor of your contracted status for the next calendar year, but only in November of the preceding year.

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Question: WHAT IS AN ADVANCED BENEFICIARY NOTICE?

Answer:
An Advanced Beneficiary Notice (ABN) is used to notify patients when a procedure is likely not to be reimbursed by Medicare and allows them to decide if they still want the service and, if so, that they agree to pay for it out of pocket.

By signing the notice, the patient acknowledges their fiscal responsibility if the procedure is denied, based on medical necessity or if the service is statutorily excluded and is therefore a non-covered service. There are required and voluntary uses of the ABN. An ABN is required if a service is covered by Medicare but may be denied because medical necessity was not established. The use of ABN is voluntary if the services are statutorily excluded from Medicare coverage or no benefit category exists. Some examples may be a hearing test for the sole purpose of obtaining a hearing aid; annual, routine hearing tests where a patient has not reported any change in history of symptoms; cerumen removal; vestibular rehabilitation; aural rehabilitation; or tinnitus management. The form (in English and Spanish) and directions may be found here .

On the ABN, the patient or their representative is to choose one of three options:

  • Option 1: "This option allows the beneficiary to receive the items and/or services at issue and requires the notifier to submit a claim to Medicare. This will result in a payment decision that can be appealed."  See Ch. 30, §50.14.1 of the online Medicare Claims Processing Manual for instructions on the notifier's obligation to bill Medicare.
  • Option 2: "This option allows the beneficiary to receive the noncovered items and/or services and pay for them out of pocket. No claim will be filed and Medicare will not be billed. Thus, there are no appeal rights associated with this option."


For audiologists, this option might be used for statutorily excluded services such as with annual audiograms, hearing aids, and treatment, such as canalith repositioning procedure. Evaluation and Management (E/M) codes are also non-covered Medicare services when performed by an audiologist and hearing testing when not ordered by a physician. You will want to check with your commercial payors for their payment policies regarding E/M codes.

  • Option 3: According to Medicare, "This option means the beneficiary does not want the care in question. By checking this box, the beneficiary understands that no additional care will be provided and thus, there are no appeal rights associated with this option."

This option indicates that the patient declines the services recommended for that date of service.

Please note that all three options allow for the collection of payment at the time of the visit.

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Question: WHAT MODIFIER DO I USE WHEN I FILE A CLAIM TO MEDICARE WITH AN ABN ON FILE?

Answer:
There are three modifiers of interest to audiologists that are specific to Medicare:

-GY : "Item or service statutorily excluded or does not meet the definition of any Medicare benefit." This modifier is often used to indicate that a denial is required for a secondary, commercial payor's reimbursement for the patient's contracted benefit. For audiologists, this is most commonly utilized for a hearing aid benefit.

-GA: As of April 1, 2010, this is defined as "Waiver of Liability Statement Issued as Required by Payer Policy" and is to be used only when an ABN is required for covered services and should not be reported with any other Medicare modifier. This modifier is not used if the definition of medical necessity is met for that particular patient. If not, with a signed ABN, this would allow the patient to be billed for the procedure(s).

-GX: This new modifier is effective as of April 1, 2010, and is defined as the "Notice of Liability Issued, Voluntary Under Payer Policy." It is to be used when a voluntary ABN was issued. Audiologists would typically report this modifier when performing statutorily excluded, non-covered services such as annual audiologic evaluations, and for treatment such as tinnitus retraining therapy, and/or vestibular rehabilitation. It is also applicable for hearing aids.

Note : The –GY and –GX modifiers may be reported for the same procedure, on the same line on the CMS 1500 form.

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Question: WHEN CAN I PERFORM FREE HEARING TESTS?

Answer:
Providing free hearing tests when you are a Medicare provider appears to be a clear violation of Medicare rules and regulations. Medicare prohibits offering free services such as hearing testing as an inducement to generate other services such as diagnostic audiologic services.

The Centers of Medicare and Medicaid Services has a question and answer area available on their website. This exchange from March 3, 2006, addresses the issue of free tests:

Question: There is an advertisement in my local newspaper that says that if I will come to a particular clinic in town to have my cataract examined, that they will provide a ride to the clinic and will do the examination for free. Is this ok with Medicare?"
Answer from CMS: "You are right to be skeptical. Medicare has rules against providing inducements to beneficiaries to encourage them to use their services. Providing inducements like free transportation or free services is forbidden by Medicare and should be reported to us or the Office of the Inspector General for follow-up." 

This link can be found here

Chapter 16, section 40, of the Medicare Benefit Policy Manual describes the prohibition against inducing Medicare beneficiaries (such as providing free services) to Medicare provider settings:

40. No Legal Obligation to Pay for or Provide Services 
Program payment may not be made for items or services which neither the beneficiary nor any other person or organization has a legal obligation to pay for or provide. This exclusion applies when items and services are furnished gratuitously without regard to the beneficiary's ability to pay and without expectation of payment from any source, such as free x-rays or immunizations provided by health organizations. However, Medicare reimbursement is not precluded merely because a physician or supplier waives the charges in the case of a particular patient or a group or class of patients, as the waiver of charges for some patients does not impair the right to charge others, including Medicare patients. The determinative factor in applying this exclusion is the reason the particular individual is not charged.

The following sections illustrate the applicability of this exclusion to various situations involving services other than those paid for directly or indirectly by a governmental entity. (For a discussion of the latter, see §2309).

A. Indigency: This exclusion does not apply when items and services are furnished an indigent individual without charge because of their inability to pay, if the physician or supplier bills other patients to the extent that they are able to pay.

B. Physician or Supplier Bills Only Insured Patients: Some physicians and suppliers waive their charges for individuals of limited means, but they also expect to be paid if the patient has insurance, which covers the items or services they furnish.

C. Medicare Patient Has Other Health Insurance: Except as provided in §§3335ff., 3336ff.,
and 3340ff., payment is not precluded under Medicare even though the patient is covered by another health insurance plan or program which is obligated to provide or pay for the same services. This plan may be the type that pays money toward the cost of the services, such as a health insurance policy, or it may be the type, which organizes and maintains its own facilities and professional staff.

Also, in August 2002, the Office of the Inspector General (OIG) issued a Special Advisory Bulletin titled, "Offering Gifts and Other Inducements to Medicare Beneficiaries." This advisory reads:

"Under section 1128A(a)(5) of the Social Security Act (the Act), enacted as part of Health Insurance Portability and Accountability Act of 1996 (HIPAA), a person who offers or transfers to a Medicare or Medicaid beneficiary any remuneration that the person knows or should know is likely to influence the beneficiary's selection of a particular provider, practitioner, or supplier of Medicare or Medicaid payable items or services may be liable for civil money penalties (CMPs) of up to $10,000 for each wrongful act. For purposes of section 1128A(a)(5) of the Act, the statute defines "remuneration" to include, without limitation, waivers of copayments and deductible amounts (or any part thereof) and transfers of items or services for free or for other than fair market value. (See section 1128A(i)(6) of the Act.).
Offering valuable gifts to beneficiaries to influence their choice of a Medicare or Medicaid provider raises quality and cost concerns. Providers may have an economic incentive to offset the additional costs attributable to the giveaway by providing unnecessary services or by substituting cheaper or lower quality services. The use of giveaways to attract business also favors large providers with greater financial resources for such activities, disadvantaging smaller providers and businesses.

The Office of Inspector General is responsible for enforcing section 1128A(a)(5) through administrative remedies. This Bulletin is intended to alert the health care industry as to the scope of acceptable practices, providing right-line guidance to protect the Medicare and Medicaid programs, encourage compliance, and level the playing field among providers.

Unless a provider's practices fit within an exception (as implemented by regulations) or are the subject of a favorable advisory opinion covering a provider's own activity, any gifts or free services to beneficiaries should not exceed the $10 per item and $50 annual limits."

For further information on the OIG special advisory on offering gifts for inducements click here .

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Question:  MAY I PROVIDE PHYSICIANS WITH A REFERRAL PAD?

Answer:
The practice of creating practice specific referral pads that are used to elicit the required Medicare physician order for covered diagnostic services from that provider should be avoided as it may be construed to be a solicitation of a referral in violation of the anti-kickback statute.

The Medicare Anti-Kickback Statute provides for severe criminal penalties where you attempt to solicit a Medicare order or Medicare reimbursed services. You should consider obtaining legal advice as to the use of a particular promotional activity that might be construed as a violation of the anti-kickback rules. The Anti-Kickback Statute reads:

"Section 1128B(b) of the Social Security Act (42 U.S.C. 1320a-7b(b)), previously codified at sections 1877 and 1909 of the Act, provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit or receive remuneration in order to induce business reimbursed under the Medicare or State health care programs."

The offense is classified as a felony, and is punishable by fines of up to $25,000 and imprisonment for up to 5 years. This provision is extremely broad. The types of remuneration covered specifically include "kickbacks, bribes, and rebates made directly or indirectly, overtly or covertly, or in cash or in kind. In addition, prohibited conduct includes not only remuneration intended to induce referrals of patients, but remuneration also intended to induce the purchasing, leasing, ordering, or arranging for any good, facility, service, or item paid for by Medicare or State health care programs. Since the statute on its face is so broad, concern has arisen among a number of health care providers that many relatively innocuous, or even beneficial, commercial arrangements are technically covered by the statute and are, therefore, subject to criminal prosecution."

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Question: WHEN IS IT ADVISABLE TO USE REMINDER CARDS FOR ANNUAL AND/OR ROUTINE HEARING TESTING?

Answer:
The use of reminder cards to solicit a patient for annual or routine hearing testing could be construed as a solicitation of a Medicare referral. Moreover, billing Medicare for annual or routine hearing tests even with a physician order but without true medical necessity is inappropriate and fraudulent, according to CMS.

Per the CMS Manual System, Pub 100-02 Medicare Benefit Policy, Transmittal 84, Change Request 5717 , dated February 28, 2009, "audiological tests may be ordered for a Medicare beneficiary when the reason for the test is not for the purpose of fitting or modifying a hearing aid."

Per this Update to Audiology Policies, "it is appropriate to pay for audiological services for patients who have sensorineural hearing loss and who wear hearing aids if the reason for the test is anything other than evaluation of the hearing aid." For example, there may be a perceived change in hearing or tinnitus that makes testing appropriate and covered. Such testing might rule out other reasons for the symptoms (auditory nerve lesions, middle ear infections) and result in subsequent evaluation of the hearing aid (not covered) or aural rehabilitation by a speech-language pathologist (covered)". But, per Section 1862(a)(7) of the Social Security Act "no payment may be made under part A or part B for any expenses incurred for items or services "where such expenses are for . . . hearing aids or examinations therefore. . . ." This policy is further reiterated at 42 CFR 411.15(d) which specifically states that "hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids" are excluded from coverage. Medicare contractors deny payment for an item or service that is associated with any hearing aid as defined above.

The payment for audiological diagnostic tests is determined by the reason the tests were performed, rather than by the diagnosis or the patient's condition.

Payment for audiological diagnostic tests is not allowed by virtue of §1862(a)(7) when:

  • The type and severity of the current hearing, tinnitus or balance status needed to determine the appropriate medical or surgical treatment is known to the physician before the test; or
  • The test was ordered for the specific purpose of fitting or modifying a hearing aid.

Payment of audiological diagnostic tests is allowed for other reasons and is not limited, for example, by:

  • Any information resulting from the test including, for example:
    •  Confirmation of a prior diagnosis;
    •  Post-evaluation diagnoses; or
    •  Treatment provided after diagnosis, including hearing aids, or
  • The type of evaluation or treatment the physician anticipates before the diagnostic test; or
  • Timing of re-evaluation. Re-evaluation is appropriate at a schedule dictated by the ordering physician when the information provided by the diagnostic test is required, for example, to determine changes in hearing, to evaluate the appropriate medical or surgical treatment or evaluate the results of treatment. For example, re-evaluation may be appropriate, even when the evaluation was recent, in cases where the hearing loss, balance or tinnitus may be progressive or fluctuating, the patient or caregiver complains of new symptoms, or treatment (such as medication or surgery) may have changed the patient's audiological condition with or without awareness by the patient."

In summary, Medicare allows for coverage of medically reasonable and necessary testing initiated by the ordering physician or NPP. Billing Medicare for annual or routine hearing tests with a physician order but without true medical necessity, is inappropriate and fraudulent.

Also, the use of reminder cards to solicit a patient for annual or routine hearing testing could be construed as a solicitation of a Medicare referral. The Medicare Anti-Kickback Statute could be applied in instances where you attempt to solicit a Medicare order for Medicare reimbursed services. The initiation of the hearing test through the use of a reminder card could be considered a solicitation. Violations of the Anti-Kickback Statute Section 1128B(b) of the Social Security Act (42 U.S.C. 1320a-7b(b)), (http://www.ssa.gov/OP_Home/ssact/title11/1128B.htm) previously codified at sections 1877 and 1909 of the Act, provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit or receive remuneration in order to induce business reimbursed under the Medicare or State health care programs. The offense is classified as a felony, and is punishable by fines of up to $25,000 and imprisonment for up to 5 years.

It is important for audiologists to be aware of the changes as a result of the Affordable Care Act (ACA) of 2010, also known as the health care reform bill. Overpayments must be returned to the Medicare contractor or Medicaid agency within 60 days after discovery, or the claim will be considered a False Claim and stiff penalties will apply.

The False Claims Act, 31 U.S.C. § 3729 , addresses filing claims for incomplete procedures. A common example for audiologists is filing a claim for CPT code 92557, comprehensive audiometry, which includes bilateral testing of pure tone air and bone conduction, speech reception thresholds, word recognition testing. If bone conduction is not performed and 92557 is filed, this is a False Claim. In this example, air conduction (92552), speech reception thresholds (92555) and word recognition testing (92556) should be filed.

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Question: DOES MEDICARE REQUIRE PHYSICIAN ORDERS BEFORE AN AUDIOLOGIST CAN PERFORM AN EVALUATION?

Answer:
Chapter 15, section 80.3, of the Medicare Benefit Policy Manual is clear on this subject. Medicare audiology coverage is part of the "other diagnostic tests" benefit and the performance of diagnostic tests requires an order from a physician, or, where allowed by State and local law, by a non-physician practitioner (NPP) as well as medical necessity. Under Medicare, a NPP is a physician assistant, nurse practitioner, or clinical nurse specialist. The tests are not covered if the physician/NPP order is obtained after the tests are performed. For further information, click here . Please note, that the existence of a physician order does not guarantee that the threshold for medical necessity has been met. Medicare only reimburses the diagnostic testing if it is reasonable and necessary.

 

Question: IS A PHYSICIAN'S SIGNED ORDER REQUIRED IN THE PATIENT'S MEDICAL RECORD?

Answer: 
No signature is required. An e-mail or telephone call by the treating physician/NPP or his/her office to the testing site is sufficient if the physician/office and the testing site document the communication in their respective copies of the beneficiary's medical records.

The Medicare Beneficiary Manual (Chapter 15, §80.6.1) states:

Order
An "order" is a communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary. The order may conditionally request an additional diagnostic test for a particular beneficiary if the result of the initial diagnostic test ordered yields to a certain value determined by the treating physician/practitioner (e.g., if test X is negative, then perform test Y). An order may be delivered via the following forms of communication:

  • A written document signed by the treating physician/practitioner, which is hand-delivered, mailed, or faxed to the testing facility; NOTE: No signature is required on orders for clinical diagnostic tests paid on the basis of the clinical laboratory fee schedule, the physician fee schedule, or for physician pathology services;
  • A telephone call by the treating physician/practitioner or his/her office to the testing facility; and
  • An electronic mail by the treating physician/practitioner or his/her office to the testing facility.
If the order is communicated via telephone, both the treating physician/practitioner or his/her office, and the testing facility must document the telephone call in their respective copies of the beneficiary's medical records. While a physician order is not required to be signed, the physician must clearly document, in the medical record, his or her intent that the test be performed.

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Question: WHAT ARE MEDICARE DOCUMENTATION REQUIREMENTS?

Answer:
You should write clear and comprehensive information in each patient's records detailing the physician/NPP referral or order, the services and procedures performed, and the follow-up provided to the referring physician. Chapter 15 of the Medicare Benefit Policy Manual has specific instructions for documentation in section 80.3 - Audiological Diagnostic Testing .

They are:

Documenting for Audiological Tests.The reason for the test should be documented either on the order, and/on the audiological evaluation report, and/or in the patient's medical record. Examples of appropriate reasons include but are not limited to:

  • Evaluation of suspected change in hearing, tinnitus, or balance;
  • Evaluation of the cause of disorders of hearing, tinnitus, or balance.
  • Determination of the effect of medication, surgery or other treatment;

Reevaluation to follow-up changes in hearing, tinnitus or balance that may be caused for example, but not limited to otosclerosis, atelectatic tympanic membrane, tymposclerosis, cholesteatoma, resolving middle ear infection, Meniere's disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, acoustic neuroma, demyelinating diseases, ototoxicity secondary to medications, genetic, vascular and viral conditions. Screening tests are not payable, but failure of a screening test may be an appropriate reason for diagnostic audiological tests.

The medical record shall identify the name and professional identity of the person who ordered the evaluation and the person who actually performed the service. When the medical record is subject to medical review, it is necessary that the contractor determine that the service qualifies as an audiological diagnostic test that requires the skills of an audiologist. A technician must meet qualifications determined by the Medicare contractor to whom the claim is billed. At a minimum, the qualifications must include the requirements of any applicable State or local laws, and successful completion of a curriculum including both classroom training and supervised clinical experience in administration of the audiological service.
If a technician performs the technical component of a service that does not require the skills of an audiologist, the physician supervisor shall provide and document the physician's professional component of the service including, e.g., clinical decision making, and other active participation in the delivery of the service. Direct supervision rules apply to the physician for the technical component, requiring them to be in the facility and accessible. This participation may also be billed as evaluation and management code or as part of other billed services.

Documentation should also include a section describing the procedures that were completed and their outcomes; a section on clinical assessment of the findings; recommendations; signature; and date of service.

The "other diagnostic tests" benefit requires an order from a physician, or, where allowed by State and local law, by a non-physician practitioner. See section 80.6 of this chapter for policies concerning orders for diagnostic tests. The reason for the test should be documented either on the order, on the audiological evaluation report, or in the patient's medical record.

Examples of appropriate reasons include but are not limited to:

  • Evaluation of suspected change in hearing, tinnitus, or balance
  • Evaluation of the cause of disorders of hearing, tinnitus, or balance.
  • Determination of the effect of medication, surgery or other treatment;

There are other things to consider besides the guidance in §80.3. In the final rule for the 2010 Medicare Physician Fee Schedule, CMS cautioned audiologists on calculating time attributed to the five timed audiology evaluation codes; CMS accepted the professional component RVUs for these codes in the 2009 fee schedule. CMS stressed that activities such as counseling, establishment of interventional goals, or evaluating potential for remediation are not included as diagnostic tests, and that time spent on these activities should not be included in billing for:

92620 (evaluation of central auditory function, with report; initial 60 minutes)
92621 (evaluation of central auditory function, with report; each additional 15 minutes)
92626 (evaluation of auditory rehabilitation status; first hour)
92627 (evaluation of auditory rehabilitation status; each additional 15 minutes)
92640 (diagnostic analysis with programming of auditory brainstem implant, per hour).

Documentation should also include a section describing the procedures that were completed and their outcomes; a section on clinical assessment of the findings; recommendations; signature; and date of service. An acronym to keep in mind is the SOAP note - Subjective findings, Objective findings, Assessment, Plan.

CMS has a document related to appropriate documentation, which can be found here.

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Question: WHAT IS CPT CODE 92547 (Use of vertical electrodes (List separately in addition to code for primary procedure)?

Answer:
This add on code has historically been utilized for the use of electrodes when performing electronystagmography (ENG). CPT code 92547 should be utilized for ENG only.

It is suggested you consult with commercial payors as to their guidance with videonystagmography (VNG) and the vertical channel as electrodes are not utilized with VNG. For use of vertical electrodes please consult the payors guidance as to the number of units allowed. The numbers of units may range from one unit per date of service to one unit for each test for which the electrodes were utilized.

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Question: HOW DO I INDICATE THAT I PERFORMED ONLY UNILATERAL TESTING?

Answer:
As indicated in the Current Procedural Terminology (CPT) manual, the Audiologic Function Tests (Codes 92550 through 92700) include the testing of both ears. If only one ear instead of two ears is tested, the -52 modifier (Reduced Services) should be utilized.
The one exception to this relates to the use of 92601-92604, which involves the post-operative analysis, fitting, and adjustments of a cochlear implant. Given that this code is described in the singular application, this code in isolation would be insufficient to address the analysis, fitting and adjustments of a bilateral cochlear implantation. In these circumstances, where bilateral cochlear implants are fit and managed, we recommend that a -22 modifier (Unusual procedural service) be added to the applicable code of 92601-92604 and that the necessary documentation be submitted with the claim. This documentation should outline what differentiates a singular cochlear implant fitting/remapping from a bilateral cochlear implant fitting/remapping and it should address any additional time, equipment, staffing, etc. required. Some payors may require the RT modifier to indicate the right ear and the LT modifier to indicate the left ear when there are bilateral cochlear implants.

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Also of Interest