Audiology Services

30.3 - Audiology Services (Rev. 2044, Issued: 09-03-10, Effective: 09-30-10, Implementation: 09-30-10) Section 1861(ll)(3)of the Social Security Act (the Act) defines “audiology services” as such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise by covered if furnished by a physician. In this section, these hearing and balance assessment services are termed “audiology services,” regardless of whether they are furnished by an audiologist, physician, nonphysician practitioner (NPP), or hospital. Because audiology services are diagnostic tests, when furnished in an office or hospital outpatient department, they must be furnished by or under the appropriate level of supervision of a physician as established in 42 CFR 410.32(b)(1) and 410.28(e). If not personally furnished by a physician, audiologist, or NPP, audiology services must be performed under direct physician supervision. As specified in 42 CFR 410.32(b)(2)(ii) or (v), respectively, these services are excepted from physician supervision when they are personally furnished by a qualified audiologist or performed by a nurse practitioner or clinical nurse specialist authorized to perform the tests under applicable State laws. References to technicians apply also to other qualified clinical staff. See Pub. 100-02, chapter 15, section 80.3.D. A. Correct Reporting 1. General. Contact the A/B MAC (B) for guidance if the CPT codebook changes the description of codes mentioned in this section. Other policies concerning audiological services are found in Pub. 100-02, chapter 15, section 80.3. See chapter 26 of this manual for place of service and type of service coding. Section 4541(a)(2) of the Balanced Budget Act (BBA) (P.L. 105-33), which added section 1834(k)(5) to (the Act), required that all claims for certain audiology services be reported using a uniform coding system. CMS chose HCPCS (Healthcare Common Procedure Coding System) as the coding system for the reporting of these services. This coding requirement is effective for all claims for audiology services submitted on or after April 1, 1998. The BBA also required payment under a prospective payment system for audiology services. Effective for claims with dates of service on or after January 1, 1999, the Medicare Physician Fee Schedule (MPFS) became the method of payment for audiology services furnished in the office setting and for the associated professional services furnished in physician’s office and hospital outpatient settings. 2. Use of the NPI. For audiologists who are enrolled and bill independently for services they render, the audiologist’s NPI is required on all claims they submit. For example, in offices and private practice settings, an enrolled audiologist shall use his or her own NPI in the rendering loop to bill under the MPFS for the services the audiologist furnished. If an enrolled audiologist furnishing services to hospital outpatients reassigns his/her benefits to the hospital, the hospital may bill the A/B MAC (B) for the professional services of the audiologist under the MPFS using the NPI of the audiologist. If an audiologist is employed by a hospital but is not enrolled in Medicare, the only payment for a hospital outpatient audiology service that can be made is the payment to the hospital for its facility services under the hospital Outpatient Prospective Payment System (OPPS) or other applicable hospital payment system. No payment can be made under the MPFS for professional services of an audiologist who is not enrolled. Audiologists must be enrolled and use their NPI on claims for services they render in office settings on or after October 1, 2008 (for additional information about enrollment, refer to Pub. 100-08, Medicare Program Integrity Manual, chapter 15). Before October 1, 2008, the services of audiologists who were not yet enrolled in Medicare were billed by a physician or group who employed the audiologist. Audiologists shall use the billing instructions in the Medicare manuals; for example, see this manual, chapter 1, section 30. See the most recent MPFS for pricing and physician supervision levels for audiology services: http://www.cms.hhs.gov/PFSlookup/01_Overview.asp#TopOfPage. The NPI of the supervising physician shall be used to bill audiology services when supervision is appropriate. The most recent OPPS pricing for audiology services is available in Addendum B at: http://www.cms.gov/HospitalOutpatientPPS/AU/list.asp#TopOfPage. B. Billing for Audiology Services See the CMS Web site at: www.cms.gov/Medicare/Medicare-Fee-for-Service- Payment/PhysicianFeeSched/index.html? and select Audiology from the column on the left for a listing of all CPT codes for audiology services. For information concerning codes that are not on the list, and which codes may be billed when furnished by technicians, A/B MACs (B) shall provide guidance. The Physician Fee Schedule at http://www.cms.gov/PFSlookup/01_Overview.asp#TopOfPage allows you to search pricing amounts, various payment policy indicators, RVUs, and GPCIs. Audiology services may not be billed when the place of service is a comprehensive outpatient rehabilitation facility (CORF) or a rehabilitation agency. Audiology services may be furnished and billed by audiologists and, when these services are furnished by an audiologist, no physician supervision is required. The interpretation and report shall be written in the medical record by the audiologist, physician, or NPP who personally furnished any audiology service, or by the physician who supervised the service. Technicians shall not interpret audiology services, but may record objective test results of those services they may furnish under direct physician supervision. Payment for the interpretation and report of the services is included in payment for all audiology services, and specifically in the professional component if the audiology service has a professional component/technical component split. 1. Billing under the MPFS for Audiology Services Outside the Facility Setting The individuals who furnish audiology services in all settings must be qualified to furnish those services. The qualifications of the individual performing the services must be consistent with the number, type and complexity of the tests, the abilities of the individual, and the patient’s ability to interact to produce valid and reliable results. The physician who supervises and bills for the service is responsible for assuring the qualifications of the technician, if applicable are appropriate to the test. a. Professional Skills. When a professional personally furnishes an audiology service, that individual must interact with the patient to provide professional skills and be directly involved in decision-making and clinical judgment during the test. The skills required when professionals furnish audiology services for payment under the MPFS are masters or doctoral level skills that involve clinical judgment or assessment and specialized knowledge and ability including, but not limited to, knowledge of anatomy and physiology, neurology, psychology, physics, psychometrics, and interpersonal communication. The interactions of these knowledge bases are required to attain the clinical expertise for audiology tests. Also required are skills to administer valid and reliable tests safely, especially when they involve stimulating the auditory nerve and testing complex brain functions. Diagnostic audiology services also require skills and judgment to administer and modify tests, to make informed interpretations about the causes and implications of the test results in the context of the history and presenting complaints, and to provide both objective results and professional knowledge to the patient and to the ordering physician. Examples include, but are not limited to: • Comparison or consideration of the anatomical or physiological implications of test results or patient responsiveness to stimuli during the test; • Development and modification of the test battery and test protocols; • Clinical judgment, assessment, evaluation, and decision-making; • Interpretation and reporting observations, in addition to the objective data, that may influence interpretation of the test outcomes; • Tests related to implantation of auditory prosthetic devices, central auditory processing, contralateral masking; and/or • Tests to identify central auditory processing disorders, tinnitus, or nonorganic hearing loss. Audiology codes may be billed under the MPFS by audiologists, physicians, and NPPs using their own NPI in the rendering loop when those professionals personally furnish the test. Physicians and NPPs may not bill for these codes when an audiologist has furnished the service. b. Technician Skills. There may be subtests, or parts of a battery of tests, that may be appropriately furnished by an educated and experienced technician using a specific protocol under the direction of a supervising physician. These services are identified by A/B MAC (B) determination as services that do not require professional skills. They may be furnished by a qualified technician under the direct supervision of a physician, but not under the supervision of an audiologist or an NPP. The supervising physician is responsible for rendering and documenting all clinical judgment and for the appropriate provision of the service by the technician. A technician may not perform any part of a service that requires professional skills. A technician also may not perform a global service. For example, a technician may not interpret test results or engage in clinical decision-making. c. Professional Component (PC)/Technical Component (TC) Split Codes. • The PC of a PC/TC split code may be billed by the audiologist, physician, or NPP who personally furnishes the service. (Note this is also true in the facility setting.) A physician or NPP may bill for the PC when the physician or NPP furnish the PC and an (unsupervised) audiologist furnishes and bills for the TC. The PC may not be billed if a technician furnishes the service. A physician or NPP may not bill for a PC service furnished by an audiologist. • The TC of a PC/TC split code may be billed by the audiologist, physician, or NPP who personally furnishes the service. Physicians may bill the TC for services furnished by technicians when the technician furnishes the service under the direct supervision of that physician. Audiologists and NPPs may not bill for the TC of the service when a technician furnishes the service, even if the technician is supervised by the NPP or audiologist. • The “global” service is billed when both the PC and TC of a service are personally furnished by the same audiologist, physician, or NPP. The global service may also be billed by a physician, but not an audiologist or NPP, when a technician furnishes the TC of the service under direct physician supervision and that physician furnishes the PC, including the interpretation and report. d. Tests that are Not Described by Specific CPT Codes. Tests that have no appropriate CPT code may be reported under CPT code 92700 (Unlisted otorhinolaryngological service or procedure). e. Tests that are A/B MAC (B)-Priced. For codes valued by A/B MACs (B), the A/B MAC (B) determines whether and how much, if applicable, to pay for the service. The A/B MAC (B) sets the requirements for personnel furnishing the tests. 2. Billing for Audiology Services Furnished to Hospital Outpatients. All codes may be reported for audiology services furnished in the hospital outpatient setting and, in such cases, the code represents the facility service for the diagnostic test. All audiology services furnished to hospital outpatients must be billed and paid to the hospital under the OPPS or other applicable hospital payment system. The hospital bills its A/B MAC (A) and is paid for the facility resources required to furnish the services, regardless of whether the service is furnished by a physician, NPP, audiologist, or technician. Physicians, NPPs, and audiologists cannot bill and be paid for the TC of PC/TC split codes when these services are furnished to hospital outpatients. The associated professional services (represented by the PC or the CPT code for the audiology test which has no PC/TC split) of an enrolled audiologist, physician, or NPP who has reassigned benefits may be billed by the hospital to the A/B MAC (B), as appropriate. Alternatively, if the physician, NPP, or audiologist has not assigned benefits, the professional would bill his/her A/B MAC (B) for the professional services furnished. The appropriate revenue code for reporting audiology services is 0470 (Audiology; General Classification). Providers are required to report a line-item date of service per revenue code line for audiology services. 3. Billing for Audiology Services Furnished to Skilled Nursing Facility (SNF) Patients. Payment for the facility resources (including the TC of PC/TC split codes) of audiology services provided to Part A inpatients of SNFs is included in the PPS rate. For SNFs, if the beneficiary has Part B but not Part A coverage (e.g., Part A benefits are exhausted), the SNF may elect to bill for audiology services but is not required to do so. As explained in Pub. 100- 04, chapter 7, section 40.1, since audiology services furnished during a noncovered SNF stay are not bundled with speech-language pathology services, payment can be made either to the SNF or to the audiology service provider/supplier. Audiologists, physicians, and NPPs enrolled in Medicare may bill directly for services rendered to Medicare beneficiaries who are in a SNF stay that is not covered by Part A but who have Part B eligibility. Payment is made based on the MPFS, whether on an institutional or professional claim. For beneficiaries in a noncovered SNF stay, audiology services are payable under Part B when billed by the SNF on an institutional claim as type of bill 22X, or when billed directly by the provider or supplier of the service (the audiologist, physician, or NPP who personally furnishes the test) on a professional claim. For PC/TC split codes, the SNF may elect to bill for the TC of the test on an institutional claim but is not required to bill for the service. C. Implant Processing Payment for diagnostic testing of implants, such as cochlear, osseointegrated or brainstem implants, including programming or reprogramming following implantation surgery is not included in the global fee for the surgery. The diagnostic analysis of a cochlear implant shall be billed using CPT codes 92601 through 92604. Osseointegrated prosthetic devices should be billed and paid for under provisions of the applicable payment system. For example, payment may differ depending upon whether the device is furnished on an inpatient or outpatient basis, and by a hospital subject to the OPPS, or by a Critical Access Hospital, physician’s clinic, or a Federally Qualified Health Center. D. Aural Rehabilitation Services General policy for evaluation and treatment of conditions related to the auditory system. For evaluation of auditory processing disorders and speech-reading or lip-reading by a speech- language pathologist, use the untimed code 92506 with “1” as the unit of service, regardless of the duration of the service on a given day. This “always therapy” evaluation code must be provided by speech-language pathologists according to the policies in Pub. 100-02, chapter 15, sections 220 and 230. The codes 92620 and 92621 are diagnostic audiological tests and may not be used for SLP services. For treatment of auditory processing disorders or auditory rehabilitation/auditory training (including speech-reading or lip-reading), 92507, and 92508 are used to report a single encounter with “1” as the unit of service, regardless of the duration of the service on a given day. These codes always represent SLP services. See Pub. 100-02, chapter 15, sections 220 and 230 for SLP policies. These SLP evaluation and treatment services are not covered when performed or billed by audiologists, even if they are supervised by physicians or qualified NPPs. For evaluation of auditory rehabilitation to instruct the use of residual hearing provided by an implant or hearing aid related to hearing loss, the timed codes 92626 and 92627 are used. These are not “always therapy” codes. Evaluation of auditory rehabilitation shall be appropriately provided and billed by an audiologist or speech-language pathologist. Also, these services may be provided incident to a physician’s or qualified NPP’s service by a speech-language pathologist, or personally by a physician or qualified NPP within their scope of practice. Evaluation of auditory rehabilitation is a covered diagnostic test when performed and billed by an audiologist and is an SLP evaluation service covered under the SLP benefit when performed by a speech-language pathologist. General policies for post implant services. The services of a speech-language pathologist may be covered for SLP services provided after implantation of auditory devices. For example, a speech-language pathologist may provide evaluation and treatment of speech, language, cognition, voice, and auditory processing using code 92506 and 92507. Use 92626 and 92627 for auditory (aural) rehabilitation evaluation following cochlear implantation or for other hearing impairments. For diagnostic testing of cochlear implants, audiologists use codes 92601, 92602, 92603 and 92604. These services may not be provided by speech-language pathologists or others, with the exception of physicians and NPPs who may personally provide the services that are within their scope of practice.