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Coding and Reimbursement: Optimizing Your Reimbursement
Montana Speech and Hearing Association
October 21, 2016
Debbie Abel, AuD
Manager, Coding and Contract Services
Today’s Agenda

Social Security Act Definition of Audiologists and Speech-Language
Pathologists

Sec. 1861. [42 U.S.C. 1395x]

Definition of Medical Necessity

Coding Systems

CPT©, ICD-10-CM, HCPCS codes for audiologists and speech-language
pathologists
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Medicare:
 Requirements
 Enrollment
 PQRS
 MACRA
 Prevalent legal /ethical concerns

Tools for revenue for audiologists as the hearing aid landscape changes
Agenda

PQRS 2016 for audiologists
 3 previous measures retained (#261, #130, #134)
 New measures:
 #154 Falls Risk Screening
 #155 Falls Risk Plan of Care
 #226 Tobacco Use
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PQRS 2016 for speech-language pathologists
PQRS 2017
 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)
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ICD-10’s
ICD-10 common denials
Prevalent ethical/legal concerns
Thoughts for the changing audiologic landscape
 MACRA (2015) requires the elimination of Social
Security Numbers from Medicare cards by April 2019
 An Medicare Beneficiary Identifier (MBI) will be assigned
to each beneficiary
 A new card will be issued no later than 4/18
 Your systems will need to be able to transition to the MBI
 https://www.cms.gov/Medicare/SSNRI/Index.html
 https://www.cms.gov/Medicare/SSNRI/Providers/Providers.html
Additional Resources:

For additional information on the Social Security Number Removal Initiative
(SSNRI) home page click here:
https://www.cms.gov/Medicare/SSNRI/Index.html
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Other helpful links:
SSNRI MBI format link: https://www.cms.gov/Medicare/SSNRI/MBI-FormatPDF.PDF
SSNRI Health & Drug Plans: https://www.cms.gov/Medicare/SSNRI/Health-andDrug-Plans/Health-and-drug-plans.html
SSNRI States: https://www.cms.gov/Medicare/SSNRI/States/States.html
SSNRI Partners /Employers: https://www.cms.gov/Medicare/SSNRI/Partnersand-Employers/Partners-and-employers.html
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Medicare’s Definition of Medical Necessity
 Title XVIII of the Social Security Act, section 1862 (a)(1)(a):
 Notwithstanding any other provisions of this tile, no
payment may be made under Part A or Part B for any
expenses incurred for items or services, which are not
reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the
functioning of a malformed body member
Coding Thoughts:
 The three coding systems support each other and must
be reported for filing claims
 Required:
 CPT (and/or HCPCS)
AND ICD codes
 If billing HCPCS codes
 May also be billing CPT simultaneously
 Always have to have a minimum of one ICD code with each claim;
more with the ICD-10s
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Where to Purchase?

AMA bookstore: https://commerce.amaassn.org/store/catalog/categoryDetail.jsp?category_id=cat1150004&
navAction=jump
 Optum 360:
https://www.optumcoding.com/Campaign/?sourcecode=000008LQ&
ppcid=optum%20code%20books&pstc=12389030514
 Amazon:
http://www.amazon.com/gp/search/ref=sr_nr_n_0?fst=as%3Aoff&rh
=n%3A283155%2Cn%3A227568%2Ck%3Acpt+code+book&keywor
ds=cpt+code+book&ie=UTF8&qid=1437795274&rnid=1000
Thoughts:
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Case-building for differential diagnosis
Provides value in the healthcare system
Fiscal recognition for services
Hearing instrument specialists can test for the sole
purpose of fitting a hearing aid per state licensure
 Perform only those procedures recognized by your
state licensure law
 They determine scope of practice
Considerations:
 CPT codes (procedures/services) must be ones typically
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performed by audiologists or speech-language pathologists
(SLPs)
CPT codes must support the chosen ICD (diagnoses) code(s)
CPT codes selected must be apparent to an insurance
company as to why test was performed
Hearing aid claims will predominantly utilize the HCPCS
codes
For SLPs, there are 4 HCPCS codes, 3 of them for screening
Claim Form
 Lists the CPT(s), ICD(s) and HCPCS codes:
 What you performed (CPT)
 Diagnosis results (ICD)
 Resulting recommendations if product (HCPCS)
 Ties the coding systems together
Current Procedural Terminology (CPT) AND International Classification of Diseases
(ICD)
 Have to support each other
 It needs to be apparent that what you performed
would result in the disease code chosen
 What is being billed has to be appropriate to
what you are licensed to perform
 Documentation has to reflect the above points
Coding Mantra:
 Code for the reason for the visit (Medicare transmittal)
 Code with signs and/or symptoms
 Why the patient presented to your office
 Code by patient complaints (medical necessity)
 Tinnitus?
 Hearing loss?
 Disequilibrium?
 Code by outcome of the procedure results
 SNHL?
 Tinnitus?
 Conductive hearing loss, middle ear?
Coding Mantra (cont.)
 Must code for what you did and what it indicates
CODING IS NOT TO BE DRIVEN BY REIMBURSEMENT
CPT codes

Examples:
 92557 Basic comprehensive audiometry
 Was the only audiology bundled code until 1/1/10:
 92553 (Pure tone air and bone conduction audiometry)
 92555 (SRT) and 92556 (WRS)
 3 bundled codes:
 CPT 92540 Vestibular (92541, 92542, 92544, 92545)
 CPT 92550 Tympanometry, ART (92567 and 92568)
 CPT 92570 Tympanometry, ART, ARD (92567, 92568, 92569)
CPTTM five-digit codes, descriptions, and other data only are copyright 2016 by the American
Medical Association (AMA). All Rights Reserved. No fee schedules, basic units, relative values
or related listings are included in CPT.TM CPTTM is a trademark of the American Medical
Association.
CPT Codes Utilized by Audiologists:
 92531 Spontaneous nystagmus, including gaze
 92532 Positional nystagmus test
 92533 Caloric vestibular test, each irrigation
(binaural, bithermal stimulation constitutes four tests)
 92534 Optokinetic nystagmus test
Because these do not include “with recording,”
Medicare will not recognize them.
CPT codes (cont.)
 92537 Caloric vestibular test with recording, bilateral;
bithermal (ie, one warm and one cool irrigation in each
ear for a total of four irrigations)
• 92538 Monothermal, (ie, one irrigation in each ear for a
total of two irrigations)
• Same temperature in both ears
 92540 Basic vestibular evaluation
 92541 Spontaneous nystagmus test, including gaze and
fixation nystagmus, with recording
CPT Codes (cont.)
 92542 Positional nystagmus test, minimum of 4
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positions, with recording
92544 Optokinetic nystagmus test, bidirectional, foveal
or peripheral stimulation, with recording
92545 Oscillating tracking test, with recording
92546 Sinusoidal vertical axis rotational testing
92547 Use of vertical electrodes (list separately in
addition to code for primary procedure)
92548 Computerized dynamic posturography
CPT Codes (cont.)
 92550 Tympanometry and reflex thresh
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measurements
92551 Screening test, pure tone, air only
92552 Pure tone audiometry (threshold), air only
92553 Pure tone audiometry (threshold); air and
bone
92555 Speech audiometry threshold
92556 Speech audiometry threshold, with speech
recognition
CPT Codes (cont.)
 92557 Comprehensive audiometry threshold evaluation and
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speech recognition (92553 and 92556 combined)
92558 Evoked otoacoustic emissions, screening (qualitative
measurement of distortion product or transient evoked
otoacoustic emissions), automated analysis
92559 Audiometric testing of groups
92560 Bekesy audiometry, screening
92561 Bekesy audiometry, diagnostic
92562 Loudness balance test, alternate binaural or monaural
CPT Codes (cont.)
 92563 Tone decay test
 92564 Short increment sensitivity index (SISI)
 92565 Stenger test, pure tone
 92567 Tympanometry (impedance testing)
 92568 Acoustic reflex testing, threshold
 92570 Acoustic immittance testing
 92571 Filtered speech test
CPT Codes (cont.)
 92572 Staggered spondaic word test
 92575 Sensorineural acuity level test
 92576 Synthetic sentence identification test
 92577 Stenger test, speech
 92579 Visual reinforcement audiometry (VRA)
 92582 Conditioned play audiometry (CPA)
CPT codes (cont.)
 92583 Select picture audiometry
 92584 Electrocochleography (NRT)
 92585 Auditory evoked potentials for evoked
response audiometry and/or testing of the central
nervous system, comprehensive
 92586 Auditory evoked potentials for evoked
response audiometry and/or testing of the central
nervous system, limited
CPT Codes (cont.)
 92587 Distortion product evoked otoacoustic emissions,
limited evaluation (to confirm the presence or absence of
hearing disorder, 3–6 frequencies) or transient evoked
otoacoustic emissions, with interpretation and report
 92588 Distortion product evoked otoacoustic emissions,
comprehensive diagnostic evaluation (quantitative
analysis of outer hair cell function by cochlear mapping,
minimum of 12 frequencies), with interpretation and
report
CPT codes (cont.)
 92590 Hearing aid examination and selection,
monaural
 92591 Hearing aid examination and selection, binaural
 92592 Hearing aid check, monaural
 92593 Hearing aid check, binaural
 92594 Electroacoustic evaluation for hearing aid,
monaural
CPT Codes (cont.)
 92595 Electroacoustic evaluation for hearing aid,
binaural
 92596 Ear protector attenuation measurements
 92601 Diagnostic analysis of cochlear implant,
patient under 7 years of age; with programming
 92602 Diagnostic analysis of cochlear implant,
patient under 7 years of age; subsequent
reprogramming
CPT Codes (cont.)
 92603 Diagnostic analysis of cochlear implant, age
7 years or older with programming
 92604 Diagnostic analysis of cochlear implant, age
7 years or older with reprogramming
 92620 Evaluation of central auditory function, with
report; initial 60 minutes
 92621 Evaluation of central auditory function, with
report; each additional 15 minutes
CPT Codes (cont.)
 92625 Assessment of tinnitus (includes pitch,
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loudness matching, and masking)
92626 Assessment of auditory rehabilitation status;
first hour
92627 each additional 15 minutes
92630 Auditory rehabilitation; prelingual hearing loss
92633 Auditory rehabilitation; postlingual hearing
loss
CPT Codes (cont.)
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92640 Diagnostic analysis with
programming of auditory brainstem
implant, per hour
 92700 Unlisted otorhinolaryngological
service or procedure
 For those procedures that do not have
dedicated codes
 Likely will be denied, need to submit
documentation for:
 What you did
 Why you did it
 What you learned from it that impacted that
patient’s diagnosis and treatment
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VEMPs
ASSRs
Saccades
Head shake
Tinnitus
Removal of non-impacted
cerumen
 Eustachian Tube dysfunction
 Frenzel goggles
CPT Codes (cont.)-an aside
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CPT 92626 and 92627 (AMA’s CPT Assistant, July 2014)
 Evaluation of auditory rehabilitation status, first hour/each additional 15
minutes
 Utilize when evaluating patient’s function prior or post fitting of unilateral or
bilateral (and to identify acoustic characteristics of sounds):
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Hearing aids (don’t bill to Medicare)
Osseo-integrated devices
Cochlear implants
Brainstem implants
 Confirm with payer
 92626 must be for procedures greater than 31 minutes
 Document start and end time in chart with time based codes
CPT Codes (cont.)
 Vestibular codes:
 CPT 92537-92546, 92548
 Audiologic procedures:
 CPT 92550-92583
 Evoked potential codes:
 CPT 92585-6
 OAE codes:
 CPT 92558, 92587-8
CPT Codes (cont.)
 Hearing aid related codes:
 CPT 92590-92596
 Cochlear implant codes:
 CPT 92601-92604
 Central auditory test codes:
 CPT 92620-1
 Tinnitus code:
 CPT 92625
CPT Codes (cont.)
 Audiologic (aural) (re)habilitation
 CPT code 92626-92633
 “Nameless codes”----unlisted otorhinolaryngological
service or procedure
 CPT 92700
 VEMPs (per AMA’s CPT Assistant, March 2011)
 Saccades with recording (per CPT Assistant
September 2015)
Modifiers (cont.)
 Requires documentation to be submitted attesting to why
additional time and/or work was necessary
 An audit and/or a delay in payment may occur
Modifiers
 -22 Unusual Procedural Services
 Utilized when procedure is greater than what is typically required
 Involves increase in provider work, time and complexity of what is typically
performed
 Many insurance carriers state that if it is less than 25% more work, should not append
 May yield a 20-50% increase of the allowable rate
 Example: 92557-22
Modifiers (cont.)
 -26 Professional component
 Utilized with:
 ENG (CPT 92540-92546, 92458)
 ABR (CPT 92585)
 OAE (CPT 92587, 92588)
 Utilized:
 When another professional performed the procedure
 You do the interpretation and prepare the report
 Example: 92585-26
Modifiers (cont.)
 TC Technical component
 Utilized with:
 ENG (CPT 92540-92546, 92548)
 ABR (CPT 92585)
 OAE (CPT 92587, 92588)
 Utilized:
 When you only performed the test
 Bill TC
 Another provider does the interpretation
 They bill –26
 This equals the same reimbursement as the global fee
 Example: 92585-TC
Technician Services
 TC may be performed by a technician under a
physician’s supervision
 May need to demonstrate tech’s qualifications
 Must be filed by a physician who provided direct supervision (must
be in the facility and available)
 TC services can not be filed by an audiologist when
performed by another provider, including an audiologist
Modifiers (cont.)
 -33 Preventative Service
 Use with newborn hearing screening code(s)
 92558 (OAE screening)
 92586 (ABR screening)
 No co-pay or deductible is to be applied
Modifiers (cont.)
 -52 Reduced services
 Procedure is partially reduced or eliminated
 Discontinued at provider’s discretion after the procedure commenced
 Can be used to indicate monaural vs binaural testing
 Not recognized by all carriers
 Example: 92557-52
Modifiers (cont.)
 -53 Discontinued procedure
 Procedure started, patient’s well being becomes jeopardized during
the procedure, provider discontinues
 Example: Patient having ototoxicity monitoring, becomes ill during
procedure
 Reimbursed at 25% of the allowed amount
 Example: 92557-53
Modifiers (cont.)
 -59 Distinct procedural service
 Will need to append to CPT codes 92541, 92542, 92544 or
92545…
 ONLY if performing 1-3 tests of the 4 code bundle
 Documentation should include why you performed the tests you did
Modifiers (cont.)
 -76 Procedure was performed more than one time on the
same date of service
 Glycerol or urea test
 Ototoxicity monitoring
Medicare Modifiers

GY-Item or service is statutorily excluded or does not meet the definition of any
Medicare benefit
 Often used when a secondary insurance has a hearing aid benefit
 On the Office of the Inspector General’s list for 2009
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GA-Waiver of liability on file
 To be used when a denial is expected and an ABN is on file
 No ABN, no billing the patient
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GX- “Notice of Liability Issued, Voluntary Under Payer Policy”
 For services that are non-covered, statutorily excluded
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GZ- “Must be used when physicians, practitioners, or suppliers want to indicate that
they expect that Medicare will deny an item or service as not reasonable and
necessary and they have not had an Advance Beneficiary Notification (ABN) signed
by the beneficiary.”
Evaluation and Management Codes (E/M)
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Medicare and commercial payors (e.g.,TriWest, Aetna) do not recognize audiologists
for E/M codes; don’t bill the same date with an ENT service
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Ensure that your state licensure laws allow E/M codes
 Do NOT file to Medicare
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Time, complexity and review of systems are required
 Document, include start and end times for diagnostic procedures only
 Personal thought: would not code beyond a level 2 so as not to trigger an audit
 Bill all payers and patients if you bill anyone for E/M codes
 Read the CPT codebook’s first section for information
 Read CMS’ Medlearn Guide to E/M codes
http://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-MLN/MLNProducts/Downloads/eval_
mgmt_serv_guide-ICN006764.pdf
E/M
 New and established patient codes
 New: CPT 99201-99205
 Established: CPT 99211-99215
 If patient has been seen in your practice in the last 3 years
Need to include Review of Systems (ROS):
 Head, including the face
 Neck
 Chest, including breasts and axilla
 Abdomen
 Genitalia, groin, buttocks
 Back
 Each extremity
ROS (cont.)
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Eyes
Ears, nose, mouth and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hemotologic/lymphatic/immunologic
E/M Codes
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CPT 99201
 A problem focused history
 A problem focused examination
 Straightforward medical decision making
 “Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient’s and/or family’s needs”
 Physicians typically spend 10 minutes face-to-face with the patient and/or
family
E/M Codes (cont.)
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CPT 99202
 An expanded problem focused history
 An expanded problem focused examination
 Straightforward medical decision making
 Problems are of low-moderate severity
 “Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient’s and/or family’s needs”
 Physicians typically spend 20 minutes face-to-face with the patient and/or
family
E/M Codes (cont.)
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CPT 99203
 A detailed history
 A detailed examination
 Medical decision making of low complexity
 Problems are of moderate severity
 “Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient’s and/or family’s needs”
 Physicians typically spend 30 minutes face-to-face with the patient and/or
family
E/M Codes (cont.)
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CPT 99204
 A comprehensive history
 A comprehensive examination
 Medical decision making of moderate complexity
 Problems are of moderate to high severity
 “Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient’s and/or family’s needs”
 Physicians typically spend 45 minutes face-to-face with the patient and/or
family
E/M Codes (cont.)
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CPT 99205
 A comprehensive history
 A comprehensive examination
 Medical decision making of high complexity
 Problems are of moderate to high severity
 “Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient’s and/or family’s needs”
 Physicians typically spend 60 minutes face-to-face with the patient and/or
family
E/M Codes (cont.)

CPT code 99211
 May not require a physician’s presence
 Minimal problem
 “Counseling and/or coordination of care with other physicians,
other qualified health care professionals, or agencies are provided
consistent with the nature of the problem(s) and the patient’s and/or
family’s needs”
 Typical time spent: 5 minutes
E/M Codes (cont.)

CPT code 99212
 A problem focused history
 A problem focused examination
 Straightforward medical decision making
 “Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient’s and/or family’s needs”
 Problems are minor
 Physicians typically spend 10 minutes face-to-face with the patient and/or
family
E/M Codes (cont.)

CPT code 99213
 An expanded problem focused history
 An expanded problem focused examination
 Problems are of low to moderate severity
 Medical decision making of low complexity
 “Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient’s and/or family’s needs”
 Physicians typically spend 15 minutes face-to-face with the patient and/or
family
E/M Codes (cont.)

CPT code 99214
 A detailed history
 A detailed examination
 Medical decision making of moderate complexity
 “Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient’s and/or family’s needs”
 Physicians typically spend 25 minutes face-to-face with the patient and/or
family
E/M Codes (cont.)
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CPT Code 99215
 A comprehensive history
 A comprehensive examination
 Medical decision making of high complexity
 Problems are of moderate to high severity
 “Counseling and/or coordination of care with other physicians, other qualified
health care professionals, or agencies are provided consistent with the nature
of the problem(s) and the patient’s and/or family’s needs”
 Physicians spend 40 minutes face-to-face with the patient and/or family
Cerumen Management
 Is in the scope of practice of audiology
 http://www.audiology.org/publications/documents/practice/
 Unless cerumen is impacted, should not be
billing for it separately
 July 2002, CPT Assistant defines impaction
“Cerumen Impaction”
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

Defined by the American Medical Association publication CPT Assistant (CPT
Assistant, July 2005) must meet one or more of the following conditions to be
considered “impacted”:
Cerumen impairs exam of clinically significant portions of the external auditory
canal, tympanic membrane, or middle ear condition;
Extremely hard, dry, irritative cerumen causing symptoms such as pain, itching,
hearing loss, etc.;
Associated with foul odor, infection or dermatitis;
Obstructive, copious cerumen that cannot be removed without magnification and
multiple instrumentations”
CPT Assistant (cont.)
 The CPT Assistant article further states “removing wax that is
not impacted does not warrant the reporting of CPT code
69210 [Removal of impacted cerumen (separate procedure),
1 or both ears].”
 Documentation of cerumen removal should include the time,
effort, method(s) and equipment to provide the service
 Removal of impacted cerumen requires visualization with an
otoscope, head loupes, or operating microscope and the use
of specialized tools such as curettes, forceps, lavage, and/or
suction for proper removal
Cerumen Management Codes

NEW for 2016:

69209 Removal impacted cerumen using irrigation/lavage, unilateral
OR

69210 Removal impacted cerumen requiring instrumentation, unilateral

Impaction defined as “cerumen impairs exam of clinically significant portions of the external
auditory canal, tympanic membrane, or middle ear condition” and “obstructive, copious cerumen
that cannot be removed without magnification and multiple instrumentations requiring physician
skills.”

If bilateral, use -50 modifier
-AMA CPT Assistant, January 2016
Cerumen Management (cont.)
 Check with state licensure laws
 Some state licensure laws do not allow CM to be performed by an
audiologist
 Removal restrictions may apply
 Can offer a voluntary ABN
 Any patient can pay for cerumen removal by an
audiologist, if allowed by state licensure law
Speech-Language Pathology CPT codes
 31579 Laryngoscopy, flexible or rigid fiberoptic, with
stroboscopy
 (RWUw 2.26)
 74230 Swallowing function, with
cineradiography/videoradiography (0.53)
Speech-Language Pathology CPT Codes (cont.)
 92507 Treatment of speech, language, voice,
communication, and/or auditory processing disorder,
individual (RVUw 1.30)
 (Do not report 92507 in conjunction with 0364T, 0365T, 0368T, 0369T)
 92508




group, 2 or more individuals (RVUw 0.33)
(Do not report 92508 in conjunction with 0366T, 0367T, 0372T)
(For auditory rehabilitation, prelingual hearing loss, use 92630)
(For auditory rehabilitation, postlingual hearing loss, use 92633)
(For cochlear implant programming, see 92601-92604)
Speech-Language Pathology CPT Codes (cont.)
 92511 Nasopharyngoscopy with endoscope (separate
procedure) (RVUw .61)
 Both may be filed by an independent SLP without supervision
unless supervision is a requirement of state law(s) or Medicare
Administrative Contractor
 Manderly Cohen and Michael Setzen, The Essential Guide to Coding in
Otolaryngology: Coding, Billing, and Practice Management (2016)
Speech-Language Pathology Codes (cont.)

92520 Laryngeal function studies (i.e.,aerodynamic testing and acoustic
testing) (RVUw .75)
 Use -52 modifier if only aerodynamic testing only or acoustic testing only



92521 Evaluation of speech fluency (e.g., stuttering, cluttering) (1.75)
92522 Evaluation of speech sound production (e.g., articulation,
phonological process, apraxia, dysarthria) (1.50)
92523 with evaluation of language comprehension and expression
(e.g., receptive and expressive language) (3.00)
 Non-speech generating services are bundled and billed with this code
 -52 modifier for language only

92524 Behavioral and qualitative analysis of voice and resonance
(1.50)
Speech-Pathology Codes (cont.)


92526 Treatment of swallowing dysfunction and/or oral function for feeding (no group
therapy code for dysphagia, but Medicare may accept 92508) (RVUw 1.40/RVUw for 92527 (.33)
92597 Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech
 Under Medicare, applies to tracheoesophageal prostheses, voice amplifiers and artificial larynges
(1.26)

92605 Evaluation for prescription of non-speech generating augmentative and alternative
communication device, face-to-face with the patient, first hour (1.75)
 +92618 each additional 30 minutes (list separately in addition to primary procedure) (0.65)


92606 Therapeutic service(s) for use of non-speech generating device, including
programming and modification (1.40)
92607 Evaluation for prescription for speech generating augmentative and alternative
communication device, face-to-face with the patient, first hour (1.85)
 +92608 each additional 30 minutes (list separately in addition to code for primary procedure) (0.70)

92609 Therapeutic services for the use of speech-generating device, including
programming and modification (1.50)
Speech-Language Pathology Codes (cont.)
 92610 Evaluation of oral and pharyngeal swallowing function
(RVUw 1.30)
 92612 Flexible fiberoptic endoscopic evaluation of swallowing
by cine or video recording; (1.27)
 Use 92700 if performed without cine or video recording
 92613 interpretation and report only (0.71)
 92614 Flexible fiberoptic endoscopic evaluation, laryngeal sensory
testing by cine or video recording (1.27)
 92615 interpretation and report only (0.63)
Speech-Language Pathology Codes (cont.)








92616 Flexible fiberoptic endoscopic evaluation of swallowing and laryngeal sensory testing by cine or video
recording; (RVUw 1.88)

92617 interpretation and report only (0.79)
92626 Evaluation of auditory rehabilitation status, first hour (1.40)
 +92627 each additional 15 minutes (.33)
92630 Auditory rehabilitation; pre-lingual hearing loss(0.00)
92633 Auditory rehabilitation; post-lingual hearing loss (0.00)
96105 Assessment of aphasia (includes assessment of expressive and receptive speech and language
function, language comprehension, speech production ability, reading, spelling, writing, eg, by Boston
Diagnostic Aphasia Examination) with interpretation and report, per hour (1.75)
96110 Developmental screening (eg, developmental milestone survey, speech and language delay
screen), with scoring and documentation, per standardized instrument (0.00)
96111 Developmental testing (includes assessment of motor, language, social, adaptive, and/or cognitive
functioning by standardized developmental instruments) with interpretation and report (2.6)
96125 Standardized cognitive performance testing (eg, Ross Information Processing Assessment) per
hour of a qualified health care professional’s time, both face-to-face administrating tests to the patient
and time interpreting these test results and preparing the report (1.70)
Speech-Language Pathology Codes (cont.)

97150 Therapeutic procedure(s), group (2 or more individuals) (.29)
 97532 Development of cognitive skills to improve attention, memory,
problem solving (includes compensatory training), direct (one-toone) patient contact, each 15 minutes (0.44)
 92533 Sensory integrative techniques to enhance sensory
processing and promote adaptive responses to environmental
demands, direct (one-to-one) patient contact, each 15 minutes
(0.44)
 92700 Unlisted otorhinolaryngological service or procedure (0.00)
Time based SLP CPT Codes
92605, 92618 (non-speech device)
92607, 92608 (speech-generating device)
92626, 92627 (aural rehabilitation)
96105 (aphasia)
96125, 97532 (cognitive)
97533 (sensory)


Can bill 1 hour if 31 minutes or more were spent with patient
For 97532 and 97533, minimum time is 8 minutes for a 15 minute code in order
to file the claim

V5336 Repair/Modification of AAC device (excluding adaptive hearing aid)
Just a few more…



98969 Online assessment and management service provided by a qualified
nonphysician health care professional to an established patient or guardian, not
originating from a related assessment and management service provided within
the previous 7 days, using the Internet or similar electronic communications
network (0.00)
99366 Medical team conference with interdisciplinary team of health care
professionals, face-to-face with patient and/or family, 30 minutes or more;
participation by nonphysician qualified health care professional (0.82)
99368 Medical team conference with interdisciplinary team of health care
professionals, patient and/or family not present, 30 minutes or more;
participation by nonphysician qualified health care professional (0.72)
And…
 Otoscopy, removal of non-impacted cerumen and
anterior rhinoscopy are included in the E/M service.
SLP modifiers

-22 Increased Procedural Services
 -52 Reduced Services
 -59 Distinct Procedural Service
 Use with edits for 2 procedures not typically performed on the same day by the
same provider, but may be appropriate to perform on the same date of service
 Includes but is not limited to:
 31579 (laryngeal videostroboscopy)/92520 (laryngeal function studies)
 92526 (dysphagia therapy)/92520(laryngeal function studies)
 92507 (individual therapy)/92508 (group therapy)

GN (Medicare) to indicate therapy service was performed by an SLP
Healthcare Common Procedure Coding System (HCPCS) Codes

Addresses what CPT did not with:
 Some services
 V5010 (Assessment for hearing aid)
 V5020 (Conformity evaluation)
 S0618 (Audiometry for hearing aid evaluation to determine the level
and degree of hearing loss)
 Supplies:
 Hearing aids
 Dispensing
 Earmold (and earmold impression)
 Batteries
 Assistive Listening Devices
HCPCS Codes (Procedures)
 V5010 Assessment for hearing aid
 V5011 Fitting/orientation/checking of hearing aid
 V5014 Repair/modification of hearing aid
 V5020 Conformity evaluation
HCPCS Codes (cont.)
 V5030 Hearing aid, monaural, body worn, air





conduction
V5040 Hearing aid, monaural, body worn, bone
conduction
V5050 Hearing aid, monaural, in the ear
V5060 Hearing aid, monaural, behind the ear
V5070 Glasses, air conduction
V5080 Glasses, bone conduction
HCPCS Codes (cont.)









V5090 Dispensing fee, unspecified hearing aid
V5095 Semi-implantable middle ear hearing prosthesis
V5100 Hearing aid, bilateral, body worn
V5110 Dispensing fee, bilateral
V5120 Binaural, body
V5130 Binaural, in the ear
V5140 Binaural, behind the ear
V5150 Binaural, glasses
V5160 Dispensing fee, binaural
HCPCS Codes (cont.)








V5170 Hearing aid, CROS, in the ear
V5180 Hearing aid, CROS, behind the ear
V5190 Hearing aid, CROS, glasses
V5200 Dispensing fee, CROS
V5210 Hearing aid, BICROS, in the ear
V5220 Hearing aid, BICROS, behind the ear
V5230 Hearing aid, BICROS, glasses
V5240 Dispensing fee, BICROS
HCPCS Codes (cont.)
 V5241 Dispensing fee, monaural hearing aid, any type
 V5242 Hearing aid, analog, monaural, CIC
 V5243 Hearing aid, analog, monaural, ITC
HCPCS Codes (cont.)
 V5244 Hearing aid, digitally programmable analog,
monaural, CIC
 V5245 Hearing aid, digitally programmable, analog,
monaural, ITC
 V5246 Hearing aid, digitally programmable, analog,
monaural, ITE
 V5247 Hearing aid, digitally programmable, analog,
monaural, BTE
HCPCS Codes (cont.)
 V5248 Hearing aid, analog, binaural, CIC
 V5249 Hearing aid, analog, binaural, ITC
 V5250 Hearing aid, digitally programmable analog, binaural,
CIC
 V5251 Hearing aid, digitally programmable analog, binaural,
ITC
 V5252 Hearing aid, digitally programmable, binaural, ITE
 V5253 Hearing aid, digitally programmable, binaural, BTE
HCPCS Codes (cont.)
 V5254 Hearing aid, digital, monaural, CIC
 V5255 Hearing aid, digital, monaural, ITC
 V5256 Hearing aid, digital, monaural, ITE
 V5257 Hearing aid, digital, monaural, BTE
HCPCS Codes (cont.)
 V5258 Hearing aid, digital, binaural, CIC
 V5259 Hearing aid, digital, binaural, ITC
 V5260 Hearing aid, digital, binaural, ITE
 V5261 Hearing aid, digital, binaural, BTE
HCPCS Codes (cont.)
 V5262 Hearing aid, disposable, any type, monaural
 V5263 Hearing aid, disposable, any type, binaural
 V5264 Earmold/insert, not disposable, any type
 V5265 Earmold/insert, disposable, any type
HCPCS Codes (cont.)
 V5266 Battery for use in hearing device
 V5267 Hearing aid or ALD supplies/accessories, not
otherwise specified
 V5268 Assistive listening device, telephone
amplifier, any type
 V5269 Assistive listening device, alerting, any type
 V5270 Assistive listening device, television amplifier,
any type
HCPCS Codes (cont.)
 V5271 Assistive listening device, television caption




decoder
V5272 Assistive listening device, TDD
V5273 Assistive listening device, for use with cochlear
implant
V5274 Assistive listening device, not otherwise specified
V5275 Ear impression, each
HCPCS Codes (cont.)
 V5281 Assistive listening device, personal fm/dm
system, monaural, (1 receiver, transmitter,
microphone), any type
 V5282 ALD, personal fm/dm system, binaural (2
receivers, transmitter, microphone), any type
 V5283 ALD, personal fm/dm neck, loop induction
receiver
 V5284 ALD, personal fm/dm, ear level receiver
HCPCS Codes (cont.)
 V5285 ALD, personal fm/dm, direct audio input receiver
 V5286 ALD, personal blue tooth fm/dm receiver
 V5287 ALD, personal fm/dm receiver, not otherwise
specified
 V5288 ALD, personal fm/dm transmitter ALD
HCPCS Codes (cont.)
 V5289 ALD, personal fm/dm adapter/boot coupling
device for receiver, any type
 V5290 ALD, transmitter microphone, any type
 V5298 Hearing aid, not otherwise classified
 V5299 Hearing service, miscellaneous
Hearing Aid Modifiers
 May be payer dependent
 RT indicates right side (ear)
 LT indicates left side (ear)
 May need to bill monaural codes with modifier for each
ear separately instead of binaural codes
Speech-Language Pathology Codes
 HCPCS:
 V5336 Repair/modification of augmentative communicative system
or device (excludes adaptive hearing aid)
 V5362 Speech screening*
 V5363 Language screening*
 V5364 Dysphagia screening*
 *Screenings are not recognized by Medicare and subsequently,
may be not be recognized by commercial payers
Break!
ICD-10-CM
Differences between ICD-9 and ICD-10
 Tripled+ number of codes
 76% address laterality
 Alphanumeric and numeric
 Code length up to 7 characters
 Most audiology codes are still 5 “spaces”
 Decimal is in the same place
 7th digit indicates initial, long term follow up and subsequent
encounter should be used for T codes (poisoning section)
Differences (cont.)
 Continue to code for:
 “Coverage and, therefore, payment for audiological diagnostic tests is
determined by the reason the tests were performed, rather than by the
diagnosis or the patient’s condition” (CMS, Chapter 15, page 101)
and/or
 Signs and symptoms and/or
 The outcome of the test results
 Documentation must address this and correspond to the code
chosen
 Must make sense in a chart review or audit
In addition…

Code for co-morbidities as long as addressed in your chart notes
co·mor·bid·i·ty

(kō-mōr-bid'i-tē) 1. A concomitant but unrelated pathologic or disease process.

2. EPIDEMIOLOGY Coexistence of two or more disease processes. [co- + L. morbidus, diseased]
 http://medical-dictionary.thefreedictionary.com/comorbidity
 Diabetes
 Falls/dizziness
 Depression
It’s not just about hearing loss or balance! Or Speech! Or
Swallowing!
Basics of ICD-10’s
 Laterality
 Adds to the volume of the number of codes (76%)
 There are a few exceptions to the rules
 Bilateral codes end in “3”
 Exceptions:
 Bilateral CHL (H90.0)
 Bilateral Mixed (H90.6)
SlidesCarnival icons are editable shapes.
This means that you can:
●
Resize them without losing quality.
●
Change fill color and opacity.
●
Change line color, width and style.
Isn’t that nice? :)
Examples:
Legend for this map
 1st digit is alphanumeric
 For audiologists, predominantly will be F, H, Q, R, T, and/or Z
 For speech-language pathologists will be F, R, and I
SlidesCarnival icons are editable shapes.
This means that you can:
●
Resize them without losing quality.
●
Change fill color and opacity.
●
Change line color, width and style.
Isn’t that nice? :)
Examples:
ICD-10 Composition

Organized in 21 chapters
 Each chapter is uniquely identified by letter
 Letter does not indicate content
 1st digit—always alphabetic (HL is H90-H95)
 2nd and 3rd digits—always numeric




There is always a decimal after the first three digits, like ICD-9’s
First 3 digits—define the code category
Second three digits—etiology, anatomical site, or severity
4-6 digits—may be letters or numbers, or may be a placeholder (x)
 4th- etiology
 5th- body part
 6th- severity
ICD-10’s (cont.)

Seventh digit—”extension” describes the encounter type (initial,
subsequent, sequela). Used predominantly by audiologists for those
codes beginning with “T.”
 A is initial encounter (active treatment)
 D is subsequent encounter (post active tx, routine care)
 S is sequela for complications or conditions that arise from a direct result of a
condition not specifically under treatment
 Ototoxicity monitoring
A dash (-) indicates additional specificity in the 5th and 6th digit
positions (H91.0-)
 “x” indicates a placeholder

 Used as a 5th character placeholder for certain 6 digit codes
Rules
 Hearing loss codes begin with “H”
 Not for “hearing”
 It is Chapter 8, “Diseases of the Ear and Mastoid Process” of 21
chapters
 You’ll need other codes for certain situations or
processes
 There’s plenty of room on the CMS 1500 claim form
 12 lines instead of 4
 May need 7th character, code dependent
Rules (cont.)
 Be aware of the codes in other chapters:
 F: Mental, Behavioral and Neurodevelopmental Disorders
 I: Sequelae of Cerebrovascular Disease
 Q: Congenital Malformations, Deformations and Chromosomal
Abnormalities
 R: Symptoms, Signs and Abnormal Clinical and Laboratory Findings
 T: Injury, Poisoning, and Certain Other Consequences of External
Causes
 Z: Factors Influencing Health Status and Contact with Health Services
Sample Codes-CHL
 H90.0 Bilateral conductive hearing loss
 H90.11 Conductive hearing loss, unilateral, right ear, with
unrestricted hearing on the contralateral side
 CHL right ear, no hearing loss in the left
 H90.12 Conductive hearing loss, unilateral, left ear, with
unrestricted hearing on the contralateral side
 CHL left ear, no hearing loss in the right
Sample Codes-SNHL
 H90.3 Sensorineural hearing loss, bilateral
 H90.41 Sensorineural unilateral hearing loss with
unrestricted hearing on opposite side, right ear
 SNHL right ear, no hearing loss left ear
 H90.42 Sensorineural unilateral hearing loss with
unrestricted hearing on opposite side, left ear
 SNHL left ear, no hearing loss right ear
Changes
 More specific tinnitus codes (objective, subjective) are
non-existent
 Conductive HL codes are no longer specified as to
anatomy
 H90.0x
 SNHL are no longer categorized as sensory nor neural
 H90.3 is SNHL
Additions
 Laterality is addressed with code indicator
 Threshold shift codes
 H93.24 Ototoxicity code
 H91.0 H91.3 Ototoxic HL, bilateral
 T36.5X5 Adverse effects of aminoglycosides
 Intra-operative and post procedural complications
 H95
NOS/NEC

Not otherwise specified (NOS). Should be avoided. Codes titled
“unspecified” are for use when the information in the medical record is
insufficient to assign a more specific code.

Not elsewhere classified (NEC). Codes titled “other” or “other specified”
are for use when the information in the medical record provides detail for
which a specific code does not exist. These represent specific disease
entities for which no specific code exists so the term is included within an
“other” code.
Coding and Laterality

1 = Right
 2 = Left
 3 = Bilateral
 0 or 9 = Unspecified
EXCEPTIONS:
H90.0 Conductive HL, bilateral
H90.6 MHL, bilateral
Code Sections

H60-H62: Diseases of external ear
 Includes acquired deformity of pinna, stenosis, exostoses, cerumen, and
hematomas
 H65-H75: Diseases of middle ear and mastoid
 Includes Eustachian Tube disorders, perforations
 H80-H83: Diseases of inner ear
 Includes otosclerosis, vestibular/balance disorders, and noise effects (HL)
 H90-H95: Other disorders of ear
 Includes otalgia, otorrhea, deafness, hearing loss, transient ischemic deafness,
tinnitus, recruitment, diplacusis, hyperacusis, temporary threshold shift,
neuritis, intraoperative and postprocedural complications of ear and mastoid,
NEC
Diseases of Inner Ear (H80-H83)




(H80) Otosclerosis
(H81) Disorders of vestibular function
 (H81.0) Ménière's disease
 (H81.1) Benign paroxysmal vertigo
 (H81.2) Vestibular neuronitis
 (H81.3) Other peripheral vertigo
 (H81.4) Vertigo of central origin
 Central positional nystagmus
(H82) Vertiginous syndromes in diseases classified elsewhere
(H83) Other diseases of inner ear
 (H83.0) Labyrinthitis
 (H83.1) Labyrinthine fistula
 (H83.2) Labyrinthine dysfunction
 (H83.3) Noise effects on inner ear
ICD-10 codes (not an exhaustive list)
Diseases of inner ear: H80-H83

H81 Disorders of vestibular function
Excludes: vertigo: NOS (R42), epidemic (A88.1)
 H81.0 Ménière’s disease
Labyrinthine hydrops
Ménière’s syndrome or vertigo
 H81.1 Benign Paroxysmal vertigo
 H81.2 Vestibular neuronitis
 H81.3 Other peripheral vertigo
Lermoyez’ syndrome
Vertigo:
 Aural
 Otogenic
 Peripheral NOS (not otherwise specified)
ICD-10 codes (cont.)
 H81.4 Vertigo of central origin
Central positional nystagmus
 H81.8 Other disorders of vestibular function
 H81.9 Disorder of vestibular function,
unspecified
Vertiginous syndrome NOS
ICD-10 codes (cont.)





H82 Vertiginous syndromes in diseases classified elsewhere
H83 Other diseases of inner ear
H83.0 Labyrinthitis
H83.1 Labyrinthine fistula
H83.2 Labyrinthine dysfunction
Hypersensitivity
Hypofunction
} of labyrinth
Loss of function
ICD-10 codes (cont.)
 H83.3 Noise effects on inner ear
Acoustic trauma
Noise-induced hearing loss
 H83.8 Other specified diseases of inner ear
 H83.9 Disease of inner ear, unspecified
ICD-10 codes (cont.)
Other disorders of ear (H90-H95)
 H90 Conductive and sensorineural hearing loss
Includes: congenital deafness
Excludes: deaf mutism NEC (H91.3) (not elsewhere classified)
deafness NOS (H91.9)
hearing loss:
 NOS (H91.9)
 Noise-induced (H83.3)
 Ototoxic (H91.0)
 Sudden (idiopathic) (H91.2)
ICD-10 Codes-CHL
 H90.0 Bilateral conductive hearing loss
 H90.11 Conductive hearing loss, unilateral, right ear, with
unrestricted hearing on the contralateral side
 CHL right ear, no hearing loss in the left
 H90.12 Conductive hearing loss, unilateral, left ear, with
unrestricted hearing on the contralateral side
 CHL left ear, no hearing loss in the right
 H90.2 CHL, unspecified
New ICD-10-CM codes-10/1/16
 H90.A11 Conductive hearing loss,
unilateral, right ear with restricted hearing
on the contralateral side
 H90.A12 Conductive hearing loss,
unilateral, left ear with restricted hearing on
the contralateral side
ICD-10 Codes-SNHL
 H90.3 Sensorineural hearing loss, bilateral
 H90.41 SNHL, unilateral, right ear, with unrestricted
hearing on contralateral side
 H90.42 SNHL, unilateral, left ear, with unrestricted
hearing on contralateral side
New ICD-10-CM Codes (cont.)
 H90.A21 Sensorineural hearing loss, unilateral, right ear,
with restricted hearing on the contralateral side
 H90.A22 Sensorineural hearing loss, unilateral, left ear,
with restricted hearing on the contralateral side
ICD-10 codes (cont.)
 H90.5 Sensorineural hearing loss, unspecified
Congenital deafness NOS
Hearing loss:
Central
Neural
} NOS
Perceptive
Sensory
Sensorineural deafness NOS
ICD-10 Codes-Mixed HL
 H90.6 Mixed conductive and SNHL, bilateral
 H90.7 Mixed CHL and SNHL, unilateral with unrestricted
hearing on the contralateral side
 H90.71 Mixed CHL and SNHL, unilateral, right ear, with
unrestricted hearing on the contralateral side
 H90.72 Mixed CHL and SNHL, unilateral, left ear, with
unrestricted hearing on the contralateral side
 H90.8 Mixed CHL and SNHL, unspecified
New ICD-10-CM Codes (cont.)
 H90.A31 Mixed conductive and sensorineural hearing
loss, unilateral, right ear with restricted hearing on the
contralateral side
 H90.A32 Mixed conductive and sensorineural hearing,
unilateral, left ear with restricted hearing on the
contralateral side
ICD-10 codes (cont.)
 H91 Other hearing loss
Excludes: abnormal auditory perception (H93.2)
hearing loss as classified in H90.impacted cerumen (H61.2)
noise-induced hearing loss (H83.3)
psychogenic deafness (F44.6)
transient ischaemic deafness (H93.0)
 H91.0 Ototoxic hearing loss
Use additional external cause code, if desired, to identify toxic agent.
ICD-10 codes (cont.)
 H91.8 Other specified HL
 H91.8X Other specified HL
 H91.8X1 Other specified HL, right ear
 H91.8X2 Other specified HL, left ear
 H91.8X3 Other specified HL, bilateral
 H91.8X9 Other specified HL, unspecified ear
 Can use these for different ears, different types of hearing
loss
ICD-10 (cont.)
 H91.9 Hearing loss, unspecified
Deafness:
 NOS
 High frequency
 Low frequency
 H92 Otalgia and effusion of ear
ICD-10 codes (cont.)
 H93 Other disorders of ear, not elsewhere classified
 H93.0 Degenerative and vascular disorders of ear
Transient ischaemic deafness
ICD-10 Code -Tinnitus
H93.1 Tinnitus
 H93.11 Tinnitus, right ear
 H93.12 Tinnitus, left ear
 H93.13 Tinnitus, bilateral
 H93.19 Tinnitus, unspecified ear
New ICD-10-CM Codes (cont.)
 H93.A Pulsatile tinnitus
 H93.A1 Pulsatile tinnitus, right ear
 H93.A2 Pulsatile tinnitus, left ear
 H93.A3 Pulsatile tinnitus, bilateral
 H93.A9 Pulsatile tinnitus, unspecified ear
 Z0.58 Observation and evaluation of newborn for other
specified suspected condition ruled out
ICD-10 codes (cont.)
 H93.2 Other abnormal auditory perceptions
Auditory recruitment
Diplacusis
Hyperacusis
Temporary auditory threshold shift
Excludes: auditory hallucinations (R44.0)
(H93.2-H93.299)
ICD-10 Codes (cont.)
 H93.3 Disorders of acoustic nerve
Disorder of 8th cranial nerve
 H93.8 Other specified disorders of ear
 H93.9 Disorder of ear, unspecified
F: Mental, Behavioral and Neurodevelopmental Disorders
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F01-F03.91 Dementia
F04-F19.99 Amnesia; other mental, personality and mood disorders; alcohol, opiod, cannabis, sedatives, cocaine,
other stimulants, hallucinogens, nicotine, inhalants, other psychoactives use/abuse
F20-F48.9 Schizophrenia, manic episodes, bipolar disorder, major depressive disorder, phobic, panic, obsessivecompulsive, PTSD, dissociative/conversion, hypochondriacal, non-psychotic, and other anxiety disorders
F50-F59 Eating/sleeping/sexual disorders, behavior syndromes associated with non-psychoactive substance
abuse
F60-69 Disorders of adult personality and behavior
F70-F79 Intellectual disabilities
F80-F89 Pervasive and specific developmental disorders
 F80.0-F80.2 Phonological, expressive, mixed receptive-expressive disorder
F80.4 speech delay due to hearing loss (code also type of HL)
F80.8-F89 Other developmental disorders of speech and language, scholastic skills
F90-F98.9 Behavioral and emotional disorders with onset usually occurring in childhood and adolescence
F99 Mental disorder, NOS
Q: Congenital malformations, deformations and
Chromosomal Abnormalities
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Examples:
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Q16 Congenital malformations of ear causing impairment of hearing
Q16.0 Congenital absence of (ear) auricle
Q16.1 Congenital absence, atresia and stricture of auditory can (external)
Q16.3 Congenital malformation of ear ossicles
Q16.4 Other congenital malformations of middle ear
Q16.9 Congenital malformation of ear causing impairment of hearing,
unspecified
Q17.1 Macrotia
Q17.4 Misplaced ear (low-set ears)
R: Symptoms, Signs and Abnormal Clinical and Laboratory Findings
 The codebook states the R chapter includes signs,
symptoms, abnormal results and “ill-defined conditions
regarding which no diagnosis classifiable elsewhere is
recorded.”
 May need to use when there is no H code
 R42, dizziness and giddiness, is a great example
 R62.0 delayed milestones in childhood
Auditory Symptoms

R42 Dizziness and giddiness
 Light-headedness
 Vertigo NOS
• Excludes vertiginous syndromes (H81.-)
•
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R62.0 Delayed milestones in childhood
R94.12 Abnormal results of function studies of ear and other special senses
R94.120 Abnormal auditory function study
R94.121 Abnormal vestibular function study
R94.122 Abnormal results of other function studies of ear and other special
senses
T: Injury, Poisoning, and Certain Other Consequences of
External Causes
 Includes barotrauma, foreign bodies, burns, frostbite,
medications, gases, solvents, heavy metals, snake
venom, etc.
 Potential for ototoxicity utilization
 Includes complications with devices
T Codes
 T36.3 Poisoning by, adverse effect of and underdosing of
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macrolides
T36.3X Poisoning by, adverse effect of and underdosing of
macrolides
T36.3X5 Adverse effects of macrolides
T36.5 Poisoning by, adverse effect of and underdosing of
aminoglycosides
T36.5X Poisoning by, adverse effect of and underdosing of
aminoglycosides
T Codes (cont.)
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T36.5X4 Poisoning by aminoglycosides, undetermined
T36.5X5 Adverse effect of aminoglycosides
T39.0 Poisoning by, adverse effect of and underdosing of salicylates
T39.01 Poisoning by, adverse effect of and underdosing of aspirin
T39.015 Adverse effect of aspirin
T39.09 Poisoning by, adverse effect of and underdosing of other
salicylates
T39.095 Adverse effect of salicylates
T Codes (cont.)
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T39.3 Poisoning by, adverse effect of and underdosing of other non-steroidal
anti-inflammatory drugs (NSAID)
T39.31 Poisoning by, adverse effect of and underdosing of propionic acid
derivatives (includes fenoprofen, flurbiprofen, ibuprofen, ketoprofen, naproxen
oxaprozin)
T39.315 Adverse effect of proprionic acid derivatives
T39.39 Poisoning by, adverse effect of and underdosing of other non-steroidal
anti-inflammatory drugs (NSAID)
T39.395 Adverse effect of other non-steroidal anti-inflammatory drugs (NSAID)
T40.3 Poisoning by, adverse effect of and underdosing of methadone
T40.3X Poisoning by, adverse effect of and underdosing of methadone
T40.3X5 Adverse effect of methadone
T Codes (cont.)
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T45.1 Poisoning by, adverse effect of and underdosing of antineoplastic and immunosuppressive drugs
T45.1X Poisoning by, adverse effect of and underdosing of antineoplastic and immunosuppressive drugs
T45.1X5 Adverse effect of anti-neoplastic and immunosuppressive
drugs
T46.7X5 Adverse effect of peripheral vasolidators
T50.1X Poisoning by, adverse effect of and underdosing of loop
(high ceiling) diuretics
T50.1X5 Adverse effect of loop (high ceiling) diuretics
T Codes (cont.)
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T52 Toxic effect or organic solvents
T52.1 Toxic effect of benzene
T52.1X Toxic effects of benzene
T52.1X1 Toxic effect of benzene, accidental (unintentional)
T52.1X2 Toxic effect of benzene, intentional self-harm
T52.1X3 Toxic effect of benzene, assault
T52.1X4 Toxic effect of benzene, undetermined
T52.2 Toxic effects of homologues of benzene (toluene and xylene)
T52.2X Toxic effect of homologues of benzene
T52.2X1 Toxic effect of homologues of benzene, accidental (unintentional)
T52.2X2 Toxic effect of homologues of benzene, intentional self-harm
T52.2X3 Toxic effect of homologues of benzene, assault
T52.2X4 Toxic effect of homologues of benzene, undetermined
T codes (cont.)
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T52.8 Toxic effects of other organic solvents
T52.8X Toxic effects of other organic solvents
T52.8X1 Toxic effect of other organic solvents, accidental (unintentional)
T52.8X2 Toxic effect of other organic solvents, intentional self-harm
T52.8X3 Toxic effect of other organic solvents, assault
T52.8X4 Toxic effect of other organic solvents, undetermined
T52.9 Toxic effects of unspecified organic solvent
T52.91 Toxic effect of unspecified organic solvent, accidental (unintentional)
T52.92 Toxic effect of unspecified organic solvent, intentional self-harm
T52.93 Toxic effect of unspecified organic solvent, assault
T52.94 Toxic effect of unspecified organic solvent, undetermined
T Codes (cont.)
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T56 Toxic effect of metals
T56.0 Toxic effects of lead and its compounds
T56.0X Toxic effects of lead and its compounds
T56.0X1 Toxic effects of lead and its compounds, accidental (unintentional)
T56.0X2 Toxic effects of lead and its compounds intentional self-harm
T56.0X3 Toxic effects of lead and its compounds, assault
T56.0X4 Toxic effects of lead and its compounds, undetermined
T56.1 Toxic effects of mercury and its compounds
T56.1X Toxic effects of mercury and its compounds
T56.1X1 Toxic effects of mercury and its compounds, accidental (unintentional)
T56.1X2 Toxic effects of mercury and its compounds, intentional self-harm
T56.1X3 Toxic effect of mercury and its compounds, assault
T56.1X4 Toxic effect of mercury and its compounds, undetermined
T Codes (cont.)
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T56.8 Toxic effects of other metals
T56.89 Toxic effects of other metals
T56.891 Toxic effect of other metals, accidental (unintentional)
T56.892 Toxic effect of other metals, intentional self-harm
T56.893 Toxic effect of other metals, assault
T56.894 Toxic effect of other metals, undetermined
T56.9 Toxic effects of unspecified metal
T56.91 Toxic effect of unspecified metal, accidental (unintentional)
T56.92 Toxic effect of unspecified metal, intentional self-harm
T56.93 Toxic effect of unspecified metal, assault
T56.94 Toxic effects of unspecified metal, undetermined
T57.0 Toxic effect of arsenic and its compounds
T57.0X Toxic effect of arsenic and its compounds
T57.0X1 Toxic effect of arsenic and its compounds, accidental (unintentional)
T57.0X2 Toxic effect of arsenic and its compounds, intentional self-harm
T57.0X3 Toxic effect of arsenic and its compounds, assault
T57.0X4 Toxic effect of arsenic and its compounds, undetermined
T Codes (cont.)
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T57.2X Toxic effect of manganese and its compounds
T57.2X1 Toxic effect of manganese and its compounds, accidental (unintentional)
T57.2X2 Toxic effect of manganese and its compounds, intentional self-harm
T57.2X3 Toxic effect of manganese and its compounds, assault
T57.2X4 Toxic effect of manganese and its compounds, undetermined
T58 Toxic effect of carbon monoxide
T58.0 Toxic effect of carbon monoxide from motor vehicle exhaust
T58.01 Toxic effect of carbon monoxide from motor vehicle exhaust, accidental (unintentional)
T58.02 Toxic effect of carbon monoxide from motor vehicle exhaust, intentional self-harm
T58.03 Toxic effect of carbon monoxide from motor vehicle exhaust, assault
T58.04 Toxic effect of carbon monoxide from motor vehicle exhaust, undetermined
T58.1 Toxic effect of carbon monoxide from utility gas
T58.11 Toxic effect of carbon monoxide from utility gas, accidental (unintentional)
T58.12 Toxic effect of carbon monoxide from utility gas, intentional self-harm
T58.13 Toxic effect of carbon monoxide from utility gas, assault
T58.14 Toxic effect of carbon monoxide from utility gas, undetermined
T58.2 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels
T Codes (cont.)
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T58.2X Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels
T58.2X1 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, accidental (unintentional)
T58.2X2 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, intentional self-harm
T58.2X3 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, assault
T58.2X4 Toxic effect of carbon monoxide from incomplete combustion of other domestic fuels, undetermined
T58.8 Toxic effect of carbon monoxide from other source
T58.8X Toxic effect of carbon monoxide from other source
T58.8X1 Toxic effect of carbon monoxide from other source, accidental (unintentional)
T58.8X2 Toxic effect of carbon monoxide from other source, intentional self-harm
T58.8X3 Toxic effect of carbon monoxide from other source, assault
T58.8X4 Toxic effect of carbon monoxide from other source, undetermined
T58.9 Toxic effect of carbon monoxide from unspecified source
T58.91 Toxic effect of carbon monoxide from unspecified source, accidental (unintentional)
T58.92 Toxic effect of carbon monoxide from unspecified source, intentional self-harm
T58.93 Toxic effect of carbon monoxide from unspecified source, assault
T58.94 Toxic effect of carbon monoxide from unspecified source, undetermined
T59 Toxic effect of other gases, fumes and vapors (includes aerosol propellants)
Other Codes To Be Used With the H and T codes, If
Applicable
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A00-A09 Intestinal Infections Diseases
 A04.7 Clostridium difficile (C-diff)
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A40-A41.9 Streptococcal and other sepsis
A49-A49.9 Bacterial infection of unspecified site
B50-B54 Plasmodium falciparum malaria and other malaria codes
B95-B95.8 Streptococcus, Staphlococcus, and Enterococcus as the
cause of diseases classified elsewhere. Includes staphylococcus
aureus and MRSA
B99-B99.9 Other and unspecified infectious diseases
Other Codes (cont.)
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C00-C14.8 Malignant neoplasms
C30-C39 Malignant neoplasms of respiratory and intrathoracic organs, including head and neck and lung
C34-C34.92 Malignant neoplasms of bronchus and lung
C43.2-C43.4 Melanoma and other malignant neoplasms of skin
C4A.2-C4A.4 Merkel cell carcinoma of eye, external auricular canal, parts of face, scalp and neck
C44.2-C44.49 Other and unspecified malignant neoplasm of skin of ear and external auricular canal, face, scalp and neck
C47.0 Malignant neoplasm of head, face and neck
C49.0 Malignant neoplasm of connective and soft tissue of head, face and neck
C50-C50.929 Malignant neoplasm of breast
C51-C58 Malignant neoplasms of female genital organs
C60-C63.9 Malignant neoplasms of male genital organs
C64-C68.9 Malignant neoplasms of urinary tract
C71-C71.9 Malignant neoplasms of brain and other parts of central nervous system
C72.4-C72.59 Malignant neoplasm of acoustic nerve and unspecified cranial nerves
C79-C79.89 Secondary Malignant neoplasm of other and unspecified sites
Other Codes (cont.)
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D00-D00.1 Carcinoma in situ of oral cavity, esophagus and stomach
D02-D02.4 Carcinoma in situ of middle ear and respiratory system
D03-D03.4 Melanoma in situ of lip, eyelid, external ear canal and scalp and neck
D03.52 Melanoma in situ of breast (skin) (soft tissue)
D04.2-D04.22 Carcinoma in situ of skin of ear and external auricular canal
D05-D09.9 Carcinoma in situ of breast
D10-D11.9 Benign neoplasm of mouth and pharynx
D14-D14.4 Benign neoplasm of middle ear and respiratory system
D17-D17.0 Benign lipomatous neoplasm and of head, face and neck
D37.0-D37.09 Neoplasm of uncertain behavior of oral cavity and pharynx
D38-D38.0 Neoplasm of uncertain behavior of middle ear and respiratory and intrathoracic organs
D39-D41.9 Neoplasm of uncertain behavior of female genital organs, male organs and urinary organs
D42-D42.9 Neoplasm of uncertain behavior of meninges
D43-D43.9 Neoplasm of uncertain behavior of brain and central nervous system
D48.6-D48.62 Neoplasm of uncertain behavior of breast
D49.3-D49.6 Neoplasm of unspecified behavior of breast, bladder, outer genitourinary organs and brain
T Codes (cont.)
 T59 Toxic effect of other gases, fumes and vapors
(includes aerosol propellants)
 T70.0XXA Otic barotrauma, initial encounter
 T70.0XXD Otic barotrauma, subsequent encounter
 T70.0XXS Otic barotrauma, sequela
Z: Factors Influencing Health Status and Contact with Health
Services
 Supplemental codes
 Likely to be denied when utilized as the primary code
(replaces the ICD-9 V codes)
 Encounter for other special examination without complaint,
suspected or reported diagnosis; the reason for the encounter
 Examples:
 Z01.10 Encounter for examination and hearing
 Z01.11 Encounter for exam of ears and hearing with abnormal findings
Supplemental Codes
• Z01.110 Encounter for hearing examination following failed hearing
screening
• Z01.118 Encounter for examination of ears and hearing with other
abnormal findings
―Use additional code to identify abnormal findings
• Z01.12 Encounter for hearing conservation and treatment
Supplemental Codes
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•
•
•
•
•
Z45 Encounter for adjustment and management of implanted device
Z45.320 Encounter for adjustment and management of bone conduction
device
• Z45.321 Encounter for adjustment and management of cochlear device
• Z45.328 Encounter for adjustment and management of other implanted
hearing device
Z46.1 Encounter for fitting and adjustment of hearing aid
Z57.0 Occupational exposure to noise
Z71.2 Person consulting for explanation of examination or test findings
Z76.5 Malingerer (Person feigning illness with obvious motivation)
Z77.122 Contact with and (suspected) exposure to noise
Supplemental Codes
Z83.52 Family history of ear disorders
Z86.69 Personal history of other diseases of the nervous system
and sense organs
Z96.20 Presence of otological and audiological implant,
unspecified
Z96.21 Cochlear implant status
Z96.22 Myringotomy tube(s) status
Z96.29 Presence of other otological and audiological implants
Z97.4 Presence of external hearing-aid
A few others…
 G51.0 Bell’s Palsy
 M95.11 Cauliflower ear, right
 M95.12 Cauliflower ear, left
Other Changes…
 Tinnitus is no longer defined as subjective or objective
 Conductive HL codes are no longer specified as to
anatomy/physical location
 H90.0x
 SNHL is no longer categorized as sensory or neural
 H90.3 is SNHL
ICD-10-CM codes for Speech-Language Pathologists-Voice
 R49.9 Unspecified voice and resonance disorder
 R49.1 Aphonia
 R49.0 Dysphonia
 R49.21 Hypernasality
 R49.22 Hyponasality
 R49.8 Other voice and resonance disorders
ICD-10-CM Codes for SLPs (swallowing disorders)
 R13.0 Aphagia
 R13.10 Dysphagia, unspecified
 R13.11 Dysphagia, oral phase
 R13.12 Dysphagia, oropharyngeal phase
 R13.13 Dysphagia, pharyngeal phase
 R13.19 Other dysphagia
 R63.3 Feeding difficulties
I69.010-319, I69.810-918 for SLPs (ASHA)
 Other Developmental Disorders of Speech and
Language
 F80.82 Social pragmatic communication disorder
(Excludes1: Asperger's syndrome [F84.5], autistic
disorder [F84.0])
 ASHA Note: The "Excludes1" note means that F80.82
may not be reported in conjunction with F84.5 or F84.0.
More SLP ICD-10-CM Codes (ASHA)
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Sequelae of Cerebrovascular Disease
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Cognitive Deficits Following Nontraumatic Subarachnoid Hemorrhage
I69.010 Attention and concentration deficit following nontraumatic subarachnoid hemorrhage
I69.011 Memory deficit following nontraumatic subarachnoid hemorrhage
I69.012 Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage
I69.013 Psychomotor deficit following nontraumatic subarachnoid hemorrhage
I69.014 Frontal lobe and executive function deficit following nontraumatic subarachnoid
hemorrhage
I69.015 Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage
I69.018 Other symptoms and signs involving cognitive functions following nontraumatic
subarachnoid hemorrhage
I69.019 Unspecified symptoms and signs involving cognitive functions following nontraumatic
subarachnoid hemorrhage
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SLP ICD-10’s (cont.) ASHA
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Cognitive Deficits Following Nontraumatic Intracerebral hemorrhage
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I69.110 Attention and concentration deficit following nontraumatic intracerebral hemorrhage
I69.111 Memory deficit following nontraumatic intracerebral hemorrhage
I69.112 Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage
I69.113 Psychomotor deficit following nontraumatic intracerebral hemorrhage
I69.114 Frontal lobe and executive function deficit following nontraumatic intracerebral
hemorrhage
I69.115 Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage
I69.118 Other symptoms and signs involving cognitive functions following nontraumatic
intracerebral hemorrhage
I69.119 Unspecified symptoms and signs involving cognitive functions following nontraumatic
intracerebral hemorrhage
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SLPs ICD-10 Codes (cont.) ASHA
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Cognitive Deficits Following Other Nontraumatic Intracranial Hemorrhage
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I69.210 Attention and concentration deficit following other nontraumatic intracranial hemorrhage
I69.211 Memory deficit following other nontraumatic intracranial hemorrhage
I69.212 Visuospatial deficit and spatial neglect following other nontraumatic intracranial
hemorrhage
I69.213 Psychomotor deficit following other nontraumatic intracranial hemorrhage
I69.214 Frontal lobe and executive function deficit following other nontraumatic intracranial
hemorrhage
I69.215 Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage
I69.218 Other symptoms and signs involving cognitive functions following other nontraumatic
intracranial hemorrhage
I69.219 Unspecified symptoms and signs involving cognitive functions following other
nontraumatic intracranial hemorrhage
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SLP ICD-10 Codes (cont.) ASHA
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Cognitive Deficits Following Cerebral Infarction
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I69.310 Attention and concentration deficit following cerebral infarction
I69.311 Memory deficit following cerebral infarction
I69.312 Visuospatial deficit and spatial neglect following cerebral infarction
I69.313 Psychomotor deficit following cerebral infarction
I69.314 Frontal lobe and executive function deficit following cerebral infarction
I69.315 Cognitive social or emotional deficit following cerebral infarction
I69.318 Other symptoms and signs involving cognitive functions following
cerebral infarction
I69.319 Unspecified symptoms and signs involving cognitive functions following
cerebral infarction
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SLP ICD-10 Codes (cont.) ASHA
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Cognitive Deficits Following Other Cerebrovascular Disease
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I69.810 Attention and concentration deficit following other cerebrovascular disease
I69.811 Memory deficit following other cerebrovascular disease
I69.812 Visuospatial deficit and spatial neglect following other cerebrovascular disease
I69.813 Psychomotor deficit following other cerebrovascular disease
I69.814 Frontal lobe and executive function deficit following other cerebrovascular disease
I69.815 Cognitive social or emotional deficit following other cerebrovascular disease
I69.818 Other symptoms and signs involving cognitive functions following other
cerebrovascular disease
I69.819 Unspecified symptoms and signs involving cognitive functions following other
cerebrovascular disease
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SLP ICD-10 Codes (cont.) ASHA
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Cognitive Deficits Following Unspecified Cerebrovascular Disease
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I69.91 Cognitive deficits following unspecified cerebrovascular disease
I69.910 Attention and concentration deficit following unspecified cerebrovascular disease
I69.911 Memory deficit following unspecified cerebrovascular disease
I69.912 Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease
I69.913 Psychomotor deficit following unspecified cerebrovascular disease
I69.914 Frontal lobe and executive function deficit following unspecified cerebrovascular disease
I69.915 Cognitive social or emotional deficit following unspecified cerebrovascular disease
I69.918 Other symptoms and signs involving cognitive functions following unspecified
cerebrovascular disease
I69.919 Unspecified symptoms and signs involving cognitive functions following unspecified
cerebrovascular disease
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Revised SLP ICD-10 Codes (ASHA)
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Specific Developmental Disorders of Speech and Language
No change F80.0 Phonological disorder
Add
Speech-sound disorder
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Pervasive Developmental Disorders
No change F84.0 Autistic disorder
Add
Autism spectrum disorder
No change F88 Other disorders of psychological development
No change
Developmental agnosia
Add
Global developmental delay
Add
Other specified neurodevelopmental disorder
No change F89 Unspecified disorder of psychological development
Add
Neurodevelopmental disorder NOS


ASHA Note: These revisions do not change the intent of the codes, but add new language to include descriptive
information or examples related to disorders captured under each code.
Now What?






Continue to monitor claims for denials
Review EOBs carefully
Provider speed is slower in choosing a code
Specificity “moratorium” ended on 10/1/16
Hopefully will be new codes in the near future
Staff should continue to meet to identify problem areas
 Implement correction plans
 May include changing documentation processes
 May need to include additional codes into systems or delete ones never
utilized
 Retrain current staff and train new staff
References
http://www.audiology.org/practice/coding/ICD-10-CM/Pages/default.aspx
http://www.cdc.gov/nchs/icd/icd10cm.htm
http://www.cdc.gov/nchs/data/icd9/icd10cm_guidelines_2014.pdf
http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/icd10
Essential Resources



ICD-10-CM codebook for non-hospital based audiologists
ICD-10-PCS codebook for hospital based audiologists
https://commerce.amaassn.org/store/catalog/subCategoryDetail.jsp?category_id=cat1150010&nav
Action=push
Essential Resources (cont.)
 https://www.optumcoding.com/Category/100091/100276/
 www.cdc.gov/nchs/about/otheract/icd9/icd10cm.htm
http://www.who.int/classifications/icd/en/
Other Resources (with caution):
 http://www.icd10data.com/Convert
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Medicare Requirements for
Audiologists
The most stringent of all payers
Medicare Requirements
 Many commercial payers’ guidance is based on that of




Medicare’s
Audiologists and SLPs can not opt out of Medicare
Must enroll if providing diagnostic services and billing for them
If a Medicare beneficiary requests you file the claim, you must
due to the mandatory claim statute
Medicare requires a physician order and the audiologic and/or
vestibular evaluations are to be based on medical necessity
What is Medical Necessity?
 Title XVIII of the Social Security Act, section 1862 (a)(1)(a):
 Notwithstanding any other provisions of this tile, no
payment may be made under Part A or Part B for any
expenses incurred for items or services, which are not
reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the
functioning of a malformed body member
For those things that are statutorily excluded:


Anything not medically necessary
What is medical necessity?
 “…necessary for the diagnosis or treatment of illness or injury or
to improve the functioning of a malformed body member.”
 May be located in the Local Coverage Determination policy
 Needed for the diagnosis or treatment of a medical condition
 Provided for the diagnosis, direct care and treatment of the patient’s
medical condition
 Meets the standard of good health practice
 Is not for the convenience of the patient or health care practitioner
 Williams, Burton and Abel, Audiology Today. Vol. 20 (6)
Medicare Enrollment
 Audiology services are in the “other diagnostic test” category
for Medicare
 “Other diagnostic tests” are not (or ever) to be billed “incident
to”
 In April, 2008 the Centers for Medicare and Medicaid Services
issued Transmittal 84
 Recognition by CMS
 Clarification of widely accepted incorrect billing practices of audiologic
diagnostic services
 https://www.cms.gov/PhysicianFeeSched/50_Audiology.asp
Medicare Requirements for Audiologists
 Audiology statute allows reimbursement only for
diagnostic procedures:
 Sec. 1861. [42 U.S.C. 1395x] of the Social Security
Act
 The term “audiology services” means 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 be covered if furnished by a physician
Medicare (cont.)



(B) The term “qualified audiologist” means an individual with a master's
or doctoral degree in audiology who—
(i) is licensed as an audiologist by the State in which the individual
furnishes such services, or
(ii) in the case of an individual who furnishes services in a State which
does not license audiologists, has successfully completed 350 clock
hours of supervised clinical practicum (or is in the process of
accumulating such supervised clinical experience), performed not less
than 9 months of supervised full-time audiology services after obtaining
a master's or doctoral degree in audiology or a related field, and
successfully completed a national examination in audiology approved
by the Secretary.
Medicare (cont.)
 Audiologists and SLPs are not on the list of
providers who may opt out of Medicare
 You must be enrolled unless all services for all patients is at no charge
 Learn the rules for your contractor and monitor the
Local Coverage Determination policies:
 http://www.cms.gov/medicare-coverage-database/indexes/lcd-
list.aspx?Cntrctr=198&ContrVer=1&CntrctrSelected=198*1&name=First+Coast+Service+Options%2C+I
nc.+%2809202%2C+MAC+-+Part+B%29&s=46&DocType=All&bc=AggAAAAAAAAAAA%3D%3D&
SlidesCarnival icons are editable shapes.
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Examples:
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/SE1311.pdf
Tidbits
 A Medicare patient cannot pay more for the same service than another
patient (OIG)
 All patients must be charged the same amount for services
 For those Medicare patients on whom you cannot collect, if you show
a “good faith effort” in collecting, on a case-by-case basis, fees can
then be written off
 For all patients, have a financial agreement to collect the required co-pay
 Due to the Medicare Access and CHIP Reauthorization Act of 2015,
we will continue to enjoy a 0.5% payment update through 2019
 Afterwards, payments will be frozen until 2025
Payment Impact on SLPs
 Conversion Factor for 2016 is $35.8279
 Conversion Factor for 2015 was $35.9335
 MACRA eliminated the Sustainable Growth Rate
 Multiple Procedure Payment Reductions (MPPR)
 Reimbursement is decreased when multiple codes are performed
on the same date of service in the same facility
 Applies to some speech-language pathology codes AND includes
physical AND occupational therapies
SLPs and The Therapy Cap
 Increased therapy cap $20 from 2015 to 2016: from
$1940 to $1960 for SLP and PT services
 Until 12/31/17, can use KX modifier for services
exceeding the cap
 Medical review process provided at or above $3700 is in
effect until 12/31/17
SLPs and “Incident to”
 SLPs are currently allowed to have services billed to
Medicare via the NPI of a physician as part “of services
that are integral to the care provided by the ordering
physician.”
 Direct supervision is required by physician:
 Must be in the office and available
 Is essentially for technicians
 Audiologists are not to have their services billed via the
NPI of the physician
Other Tidbits
If required by a third party payer, referring provider must be
on the CMS 1500 claim form
 Medicare provider orders:
 On the physician’s letterhead or prescription pad
 May want to avoid referral pads with your practice name to avoid
solicitation
 Check with Noridian (Medicare contractor)
Medicare (cont.)
 Chapter 15-Covered Medical and Other Health
Services, Medicare Benefits Policy Manual
-80 Requirements for Diagnostic X-ray, Diagnostic
Laboratory, and Other Diagnostic Tests
 80.3 Audiological Diagnostic Testing
 A. Benefit. Hearing and balance assessment services are
generally covered as "other diagnostic tests" under
section 1861(s)(3) of the Social Security Act. Hearing and
balance assessment services furnished to an outpatient of a
hospital are covered as "diagnostic services" under section
1861(s)(2)(C).
Medicare (cont.)
 Audiological diagnostic tests are not covered under the
benefit for services ‘incident to’ a physician’s service
(described in Pub. 100-02, chapter 15, section 60),
because they have their own benefit as “other diagnostic
tests”. See Pub. 100-04, chapter 13 for general
diagnostic test policies.
Medicare (cont.)
 Medicare considers us to be only diagnosticians by virtue of
the “other diagnostic tests” category
 Requires a physician order for a medically necessary reason
 Medicare services are predicated on “medical necessity”
 http://www.audiology.org/resources/audiologytoday/Documents/AudiologyTo
day/2008ATNovDec.pdf
 Direct Access will remove the order requirement, but medical
necessity will remain in effect and will be required
 Medical necessity is not just a Medicare requirement
 Required by all payers
Medicare (cont.)
 “When a qualified physician or qualified
nonphysician practitioner orders a specific
audiological test using the CPT descriptor for the
test, only that test may be performed for that order.
 Further orders are necessary if the ordered test
indicates that other tests are necessary to evaluate,
for example, the type or cause of the condition.
Orders for specific tests are required for
technicians.” (MBPM Chapter 15)
Medicare (cont.)
 “When the qualified physician or qualified nonphysician
practitioner orders diagnostic audiological tests by an
audiologist without naming specific tests, the audiologist
may select the appropriate battery of tests.” (MBPM,
Chapter 15)
Medicare (cont.)
 “Coverage and Payment for Audiological Services.
Diagnostic services performed by a qualified
audiologist and meeting the requirements at
§1861(ll)(3)(B) are payable as “other diagnostic
tests.”
 Audiological diagnostic tests are not covered as
services incident to physician’s services or as
services incident to audiologist’s services.” (MBPM,
Chapter 15)
Medicare (cont.)
 “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.”
(MBPM, Chapter 15)
Medicare (cont.)
 “If a beneficiary undergoes diagnostic testing performed
by an audiologist without a physician order, the tests are
not covered even if the audiologist discovers a
pathologic condition.” (MBPM Chapter 15)
Medicare (cont.)
 “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.” (MBPM, Chapter
15)
Medicare (cont.)
 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.” (MBPM, Chapter 15)
Medicare (cont.)
 “If a physician refers a beneficiary to an audiologist for
testing related to signs or symptoms associated with
hearing loss, balance disorder, tinnitus, ear disease, or
ear injury, the audiologist’s diagnostic testing services
should be covered even if the only outcome is the
prescription of a hearing aid.” (MPBM, Chapter 15)
Medicare (cont.)


“The technical components of certain audiological diagnostic tests i.e.,
tympanometry (92567) and vestibular function tests (e.g., 92541) that
do not require the skills of an audiologist may be performed by a
qualified technician or by an audiologist, physician or nonphysician
practitioner acting within their scope of practice.
If performed by a technician, the service must be provided under the
direct supervision [42 CFR §410.32(3)] of a physician or qualified
nonphysician practitioner who is responsible for all clinical judgment
and for the appropriate provision of the service. The physician or
qualified nonphysician practitioner bills the directly supervised service
as a diagnostic test.” (MBPM, Chapter 15)
Audiology Codes That Have a Technical and Professional Component
 Vestibular CPT codes (92537-92546, 92548)
 92547 (vertical electrodes) does not have the TC/PC
split
 Florida’s Local Coverage Determination Medicare policy specifies this
code for use for ENG and VNG
 Comprehensive ABR CPT code (92585)
 OAE CPT codes (92587, 92588)
TC/PC split
 If a technician performs the test, that can be billed
“incident to” the physician, if they directly supervised
the test (e.g., 92585-TC)
 The interpretation and report can be billed by an
audiologist or physician (e.g., 92585-26)
 If the audiologist performs both the test and does
the interpretation and report, it is billed with the
global code (92585)
 TC + PC = Same reimbursement for global code
Medicare (cont.)
 “The “other diagnostic tests” benefit requires an order
from a physician, or, where allowed by State and local
law, by a non-physician practitioner.” (MBPM, Chapter
15)
Specialties who can order/refer for beneficiary services, Part B and DMEPOS,
if allowed by state licensure
 Doctor of Medicine or Osteopathy,
 Physician Assistant
 Doctor of Dental Medicine
 Certified Clinical Nurse
 Doctor of Dental Surgery
 Doctor of Podiatric Medicine
 Doctor of Optometry
 Doctor of Chiropractic Medicine




Specialist
Nurse Practitioner
Clinical Psychologist
Certified Nurse Midwife
Clinical Social Worker
(CMS Medlearn Fact Sheet: ICN 906223 April 2011)
What else?
 Who is the referring professional if required by a third
party payer?
 Medicare physician referrals:
 On the physician’s letterhead or prescription pad
 Not to have the appearance that it was solicited by you
 May want to avoid referral pads with your practice name
 Check with your Medicare contractor (First Coast)
Medicare (cont.)
 “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” (MBPM, Chapter 15)
Medicare (cont.)
 “The medical record shall identify the name and
professional identity of the person who ordered 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.” (MBPM, Chapter 15)
Medicare (cont.)
 Audiology transmittals (84, 127, 1975, 2007, 2044)
 Diagnostic services performed by an audiologist are to
be billed with the NPI of the audiologist
 “Contractors shall not pay for services performed by
audiologists and billed under the NPI of a physician.”
 “Contractors shall not pay for audiological services
incident to the service of a physician or nonphysician
practitioner.”
http://www.cms.gov/PhysicianFeeSched/50_Audiology.asp
Medicare Requirements
 Audiologists can not opt out of Medicare
 Must enroll if providing diagnostic services and billing for them
 If not enrolled, they are to be free to every patient
 If a Medicare beneficiary requests you file the claim, you must
as it is required by the mandatory claim statute
 Many commercial payers’ guidance is based on that of
Medicare’s
Medicare Requirements for Audiologists
 Audiology statute allows reimbursement only for
diagnostic procedures:
 Sec. 1861. [42 U.S.C. 1395x] of the Social Security Act
 The term “audiology services” means 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 be covered if furnished by a physician
Medicare (cont.)
 “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” (MBPM, Chapter 15)
Medicare (cont.)
 “The medical record shall identify the name and
professional identity of the person who ordered 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.” (MBPM, Chapter 15)
Medicare (cont.)
 “Audiological Treatment. There is no provision in the
law for Medicare to pay audiologists for therapeutic
services. For example, vestibular treatment, auditory
rehabilitation and auditory processing treatment,
while they are within the scope of practice of
audiologists, are not diagnostic tests, and therefore,
shall not be billed by audiologists to Medicare.”
(MBPM, Chapter 15)
Medicare (cont.)
 Audiology transmittals (84, 127, 1975, 2007, 2044)
 “Diagnostic services performed by an audiologist are to be
billed with the NPI of the audiologist.”
 “Contractors shall not pay for services performed by
audiologists and billed under the NPI of a physician.”
 “Contractors shall not pay for audiological services incident
to the service of a physician or nonphysician practitioner.”
http://www.cms.gov/PhysicianFeeSched/50_Audiology.asp
Medicare Audiology Transmittals
 “Contractors shall not pay for the technical component of
audiological diagnostic tests performed by a qualified
technician unless the physician or nonphysician
supervisor who provides the direct supervision
documents clinical decision making and active
participation in delivery of the service.”
Medicare Audiology Transmittals
 “Contractors shall not pay for services that require
the skills of an audiologists when furnished by an
AuD 4th year student or others who are not qualified
according to section 1861(II)(3) of the Act.”
 “Although AuD 4th year students, and other audiology
students, do not meet the current requirements in statute to
provide audiology services, they may meet standards
equivalent to audiology technicians.”
Medicare Audiology Transmittals
 Audiology services must be personally furnished by an
audiologist, or nonphysician practitioner (NPP).
Physicians may personally furnish audiology services,
and technicians or other qualified staff may furnish those
parts of a service that do not require professional skills
under the direct supervision of physicians.
Medicare Audiology Transmittals
 “Orders are required for audiology services in all
settings.
 Coverage and, therefore, payment for audiological
diagnostic tests is determined by the reason the
tests were performed, rather than by the diagnosis
or the patient's condition.”
http://www.cms.gov/PhysicianFeeSched/50_Audiology.asp
Medicare
“Medicare will not pay for services performed by audiologists
and billed under the NPI of a physician. In denying such claims,
Medicare will use:
 CARC 170 (Payment is denied when performed/billed by this type of
provider. Note: Refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment Information REF), if present.);
and
 Remittance Advice Remark Code (RARC) N290
(Missing/incomplete/invalid rendering provider primary identifier.)”

Medicare Audiology Transmittals
 Audiology services must be personally furnished by an
audiologist, or nonphysician practitioner (NPP).
Physicians may personally furnish audiology services,
and technicians or other qualified staff may furnish those
parts of a service that do not require professional skills
under the direct supervision of physicians.
Medicare Audiology Transmittals
 “Orders are required for audiology services in all
settings.
 Coverage and, therefore, payment for audiological
diagnostic tests is determined by the reason the
tests were performed, rather than by the diagnosis
or the patient's condition.”
http://www.cms.gov/PhysicianFeeSched/50_Audiology.asp
Medicare Guidance

Revisions and Re-Issuance of Audiology Policies
 https://www.cms.gov/mlnmattersarticles/downloads/MM6447.pdf

per Section 1861 (ll) (3) of the Social Security Act, “audiology
services” are defined 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. 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.”
Revisions and Re-Issuance (cont.)
 “Qualifications
 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.”
Revisions and re-issuance (cont.)
 “The opt out law does not define “physician” or
“practitioner” to include audiologists; therefore, they may
not opt out of Medicare and provide services under
private contracts.”
 http://www.cms.gov/Transmittals/downloads/R132BP.pdf
Revisions and Re-issuance (cont.)
 “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.”
Revisions and Re-issuance (cont.)
 “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.”
Revisions and re-issuance (cont.)
 “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.”
Revisions and re-issuance (cont.)
 “For claims with dates of service on or after October 1,
2008 audiologists are required to be enrolled in the
Medicare program and use their National Provider
Identifier (NPI) on all claims for services they render in
office settings.”
Revisions and re-issuance (cont.)

“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 Medicare contractor 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.”
Revisions and re-issuance (cont.)
 “Audiology services may be furnished and billed by
audiologists and, when these services are furnished by
an audiologist, no physician supervision is required.”
Revisions and re-issuance
 “When a physician or supplier furnishes a service that
is covered by Medicare, then it is subject to the
mandatory claim submission provisions of section
1848(g)(4) of the Social Security Act. Therefore, if an
audiologist charges or attempts to charge a beneficiary
any remuneration for a service that is covered by
Medicare, then the audiologist must submit a claim to
Medicare.”
Revisions and re-issuance (cont.)
• “Medicare will not pay for an audiological test under the
MPFS if the test was performed by a technician under the
direct supervision of a physician if the test requires
professional skills. Such claims will be denied using Claim
Adjustment Reason Code (CARC) 170 (Payment is denied
when performed/billed by this type of provider. Note: Refer
to the 835 Healthcare Policy Identification Segment (loop
2110 Service Payment Information REF), if present.).”
Revisions and re-issuance (cont.)
• “Medicare will not pay for audiological tests furnished by
technicians unless the service is furnished under the direct
supervision of a physician. In denying claims under this
provision, Medicare will use:
 CARC 185 (The rendering provider is not eligible to perform the
service billed. Note: Refer to the 835 Healthcare Policy Identification
Segment (loop 2110 Service Payment Information REF), if present.);
and
 RARC M136 (Missing/incomplete/invalid indication that the service
was supervised or evaluated by a physician.)”
Revisions and re-issuance (cont.)
 “Medicare will pay physicians and NPPs for treatment
services furnished by audiologists incident to physicians’
services when the services are not on the list of audiology
services at
http://www.cms.gov/PhysicianFeeSched/50_Audiology.as
p and are not “always” therapy services and the audiologist is
qualified to perform the service.”
 http://www.cms.gov/Medicare/Billing/TherapyServices/AnnualTherapy
Update.html
Revisions and re-issuance (cont.)
 “All audiological diagnostic tests must be
documented with sufficient information so that
Medicare contractors may determine that the
services do qualify as an audiological diagnostic
test.”
Revisions and re-issuance (cont.)

“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 (PC), if the
audiology service has a professional component/technical
component split.”
Revisions and re-issuance (cont.)
 “When Medicare contractors review medical records of
audiological diagnostic tests for payment under the
MPFS, they will review the technician’s qualifications to
determine whether, under the unique circumstances of
that test, a technician is qualified to furnish the test under
the direct supervision of a physician.”
Revisions and re-issuance (cont.)
 “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.”
Revisions and re-issuance (cont.)
 “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.”
Revisions and re-issuance (cont.)
 “Tests that have no appropriate CPT code may be
reported under CPT code 92700 (Unlisted
otorhinolaryngological service or procedure).”
Summary of Medicare Audiology Service Provision
Medicare only reimburses licensed audiologists for
diagnostic procedures, with a physician order, for a
medically necessary reason, by way of a claim with a date
of service not older than one calendar year of filing, from
the same physician fee schedule as physicians, with the
audiologist’s NPI.
SLPs and Medicare
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Medicare Part C (Advantage Plans)
 Requires fraud and abuse training annually
 Provide services above what traditional Medicare does
not
 May include routine annual testing
 May include a partial payment for hearing aid(s)
Status within Medicare
 Participating provider
 Non-participating provider
 Limiting Charge provider
2016 Medicare Physician Fee Schedule for
Montana
CPT code
Participating
Non-par
Limiting Charge
92557
38.20
36.29
41.73
92567
14.76
14.02
16.12
92550
21.64
20.56
23.64
Resource:
http://cms.gov/Outrea
ch-andEducation/MedicareLearning-NetworkMLN/MLNProducts/D
ownloads/How_to_M
PFS_Booklet_ICN901
344.pdf
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Medicare Beneficiary “Rights”
 Social Security Act (§ 1848(g)(4) “requires that
claims be submitted for all Medicare patients for
services rendered on or after September 1, 1990.”
 Applies to all providers who provide covered services to
Medicare beneficiaries
 “The requirement to submit Medicare claims does not mean
physicians or suppliers must accept assignment”
(CMS MLN Matters Number SE0908)
ABNs
 Mandatory ABN:
 “When Medicare is expected to deny payment (entirely or in
part) for the item or service because it is not reasonable and
necessary under Medicare Program standards.”
 Voluntary ABN:
 “…not required for care that is statutorily excluded or for
services for which no Medicare benefit category exists.”
 “Example of Medicare Program exclusions are:
 Hearing aids and hearing examinations”
Advanced Beneficiary Notice
 Required (mandatory)
 Provider believes Medicare may deny the service due to not
meeting medical necessity
 Provider uncertain if Medicare does cover for some diagnoses, may
not be for this particular instance
 Voluntary
 Non-covered, statutorily excluded, services such as treatment or
rehabilitation




Vestibular rehabilitation
Cerumen management
Tinnitus management
Other applications
Covered vs. Non-Covered

Covered services:
 Patient notices a change in their hearing, equilibrium, tinnitus
 Medical necessity
 Physician order
 Non-covered services:
 Hearing aids
 Annual routine hearing evaluations
 Patient who comes in without a physician order
 Rehab/treatment
 In our scope of practice
 Patients pay privately
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Resource:
 http://www.cms.gov/Outreach-and-Education/Medicare-
Learning-NetworkMLN/MLNProducts/downloads/abn_booklet_icn006266.p
df
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Three options on the ABN:
1. Bill Medicare
 By signing and utilizing option 1, you can bill Medicare and bill the patient if
the claim is denied
2. Don’t bill Medicare
3. Patient declines procedure
 Itemizes:
 Patient’s name
 Date of service
 Procedure(s) performed
 Costs to be incurred
Medicare Modifiers
GY‐Item or service is statutorily excluded or does not meet the definition of any Medicare benefit
– Often used when a secondary insurance has a hearing aid benefit and requires a Medicare denial
GA‐“Waiver of Liability Statement Issued as Required by Payer Policy”
– To be used when a denial is expected and an ABN is on file
– No ABN, no billing the patient
GX‐ “Notice of Liability Issued, Voluntary Under Payor Policy”
– For services that are non‐covered, statutorily excluded
GZ‐“Item or service expected to be denied as not reasonable and necessary”
– To be used when there is no ABN on file; likely to be utilized in an emergency situation; patient is not
responsible for payment
Also for SLPs (ASHA):
Medicare Enrollment
 Provider Enrollment Chain, Ownership System
(PECOS)




Online system for initial enrollment and revalidation
Update current information
Check enrollment status
Must report changes to contractor no later than 90 days after
the change unless
 A change in ownership or managing interest (within 30 days)
 DMEPOS must notify the National Supplier Clearinghouse of changes in
enrollment (within 30 days)
https://pecos.cms.hhs.gov/pecos/login.do
Medicare Enrollment
 Independent, contracting audiologists should have an
855R for all facilities where they provide services
 Each one needs to be itemized on the 855I
 Addresses, names of facilities need to match
 Site visits are being conducted to ensure the legitimacy of the facility
Medicare Enrollment


Medicare 101 – Par, Non-Par, Limiting Charge
Medicare Participation
 Participating Provider
 You bill Medicare, they pay you
 Patient pays their co-insurance to you
 Non-participating Provider
 You bill Medicare, they pay patient
 Patient pays you
 Results in 5% less than par
 Limiting Charge Provider
 You bill Medicare, they pay patient
 Patient pays you
 Results in the highest level of Medicare reimbursement: 10% over participating
Medicare 101
 Medicare Participating Provider
 Patient pays you their 20% co-insurance
 You bill Medicare
 Medicare pays you the 80% of the allowable amount per the
Medicare Physician Fee Schedule
Medicare 101
 Medicare Non-Participating Provider
 Patient pays you their 80% allowable
 You bill Medicare
 Medicare pays the patient 80% of the allowable amount per the
Medicare Physician Fee Schedule and their co-insurance
 Challenging in an economically depressed area
Medicare 101 (cont.)
 Medicare Limiting Charge Provider
 Patient pays you their 80% allowable and co-insurance
 You bill Medicare
 Medicare pays the patient 80% of the allowable amount per
the Medicare Physician Fee Schedule and their co-insurance
 You receive 10% more of the MPFS than a participating
provider
 Challenging in an economically depressed area
Medicare Enrollment

May apply and receive the required Provider
Transaction Access Number (PTAN) via one of two
ways:
 On-line:
 Provider Enrollment, Chain and Ownership System
(PECOS) online

https://pecos.cms.hhs.gov/pecos/login.do
Medicare Enrollment
 CMS 855I paper application (Dated 7/11)
 Hard copy https://www.cms.gov/cmsforms/downloads/cms855i.pdf
 Submit an 855I for an individual provider
 If a sole practitioner or Incorporated Independent
 CMS 460 (For participation)
 CMS 580 (Electronic funds transfer)
Medicare Enrollment
 May also need to file the 855R, to re-assign the benefits
to employer or to contractor:
https://www.cms.gov/cmsforms/downloads/cms855r.pdf
 Most recent form is dated 11/12
 Submit an 855S if providing (DME)
 Cochlear implants
 Osseo-integrated devices (Bahas, Pontos)
 Providers who submit the 855A or 855S must pay a fee
Medicare Enrollment (Group)
•
•
Submit an 855B if group (2 or more providers)
If already enrolled in Medicare via an 855I:



Must file an CMS 855B
Must file an CMS 855R
Must file an CMS 580


If enrolling first time, submit:






CMS 460 if participating
CMS 855I
CMS 855B
CMS 855R
CMS 580
CMS 460 if participating
MUST BE ENROLLED IN PECOS
Medicare Enrollment (cont.)
 All providers enrolling must also submit a CMS-588
Electronic Funds Transfer (EFT)
 Direct deposit
 Contractor will not be able to withdraw funds for any overpayments
 MLN Matters Number SE1126 Revised
What will you need to use PECOS?
 National Provider Identifier (NPI)
 Other identifying information:
 Legal business name/TIN of the provider or organization
 Bank account information
 Practice address(es)
 Business license(s)
 Information about any final adverse actions
Medicare Enrollment
 Submit Certification Statement ASAP after submitting internet
enrollment, ideally no more than one week after submitting
the application if hard copy and via USPS
 Processing is not permitted until the Certification Statement is received
 Must be signed and dated
 Must include documentation (state license, terminal degree)
 Effective date of filing is the date the Certification Statement is received by
contractor, if PECOS submission was successful
 Original signature
 (Blue) ink
Medicare Enrollment
 “Submission Receipt” e-mail confirms the application has
been submitted successfully
 May print a copy for your records
 Do not submit the printed copy to Contractor
 Data cannot be edited after submission unless the
contractor requests additional information
Medicare Enrollment
 After 15 days, can check status:
 “Received by the Medicare Enrollment Contractor”
 “Reviewed by the Medicare Enrollment Contractor”
 “Returned for Additional Information”
 Respond within 30 days of the request
 If not, may cause delay or application may be rejected
 “Approved or rejected”
 Final status
Medicare Enrollment
 PECOS enrollment:
 CMS requires 90% of the applications be processed within 45 days
of receipt of the signed/dated Certification Statement
 Paper enrollment
 CMS requires 80% of the applications be processed within 60 days
for initial enrollment
 80% of paper changes within 45 days
Medicare Enrollment

Change of information must be reported within 30 days of any of these
changes except for the last item:
 Move to a new/different facility/organization*
 Change in practice location*
 Change in practice ownership*
 Adverse legal action*
 DMEPOS must notify National Supplier Clearinghouses of changes*
 Change billing services
 Report immediately!
 Medicare Easy Remit free software
Medicare Enrollment
 No later than 90 days, report:
 Change in business structure
 Sole proprietorship to incorporated structure
 Change in organization’s legal business name/tax identification
number (TIN)
 Change in practice status
 Move
 Retirement
 Close of practice
Medicare Enrollment

Deactivation
 If you have not submitted claims for 12 months
 Begins on the 1st day of the 1st month of no claims submissions through the last day of the 12th
month
 May not reactivate until ready to submit a new claim
 Change of information on enrollment form not updated within 90 calendar days of when the change
occurred
 Change of ownership not reported within 30 calendar days

Must submit complete 855’s
 If you have never completed an 855 I or B
 If you have not completed an 855 I since 2003
 Need to update 855 R’s with each place you offer services
 Your practice, if applicable
 Those with whom you contract
Medicare Beneficiary “Rights”
 Social Security Act (§ 1848(g)(4) “requires that claims be
submitted for all Medicare patients for services rendered
on or after September 1, 1990.”
 Have to be enrolled in order to file a claim to Medicare
 Applies to all providers who provide covered services to Medicare
beneficiaries
 “The requirement to submit Medicare claims does not mean
physicians or suppliers must accept assignment”
(CMS MLN Matters Number SE0908)
8550





Enrollment form
 https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/cms855o.pdf
To be completed by certain physicians and non-physician practitioners to enroll in the Medicare
program for the sole purpose of ordering and referring items or services for Medicare
beneficiaries.
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7723.pdf
These providers do not and will not send claims to a Medicare contractor for the services they
furnish
Application to audiology: referring physicians who are not enrolled, or who have opted out of
Medicare.
 Claims with those referring providers who are not enrolled via the 8550 will result in denied
claims
 Patient can’t be billed for these denials
 Ensure that all your Medicare referring/ordering providers are enrolled
 PECOS
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Physician Quality Reporting System
For Audiologists and Speech-Language
Pathologists
10 audiology organizations have been working on
audiology quality measure development since 2008





American Academy of Audiology
Academy of Doctors of Audiology
American Speech-Language-Hearing
Association
Academy of Rehabilitative Audiology
American Academy of Private Practice
in Speech Pathology and Audiology





Association of VA Audiologists
Directors of Speech and Hearing
Programs in State Health and
Welfare Agencies
Educational Audiology Association
Military Audiology Association
National Hearing Conservation
Association
PQRS

Designed to improve quality of care to Medicare beneficiaries
 Maximize efficiency; minimize burden for reporting
 Applies only to Medicare enrolled Part B eligible providers (EP)
 Not Part A hospital or Skilled Nursing Facilities
 Must report in 2016 or face a 2% penalty on ALL 2018 Medicare
claims
 Just add the appropriate G or CPT II code on the claim!
Why Physician Quality Reporting System?
 Care coordination
 Track Medicare enrolled quality services
 Physician Compare
 Consumer website to locate Medicare providers based on practice
information and quality reporting
2016 PQRS Measures Reporting

No changes to 3 current measures for audiologists except the depression
screening is required when performing CPT code 92625 (tinnitus evaluation)
 Cross-cutting measures (#130, #134, #226)

Three new measures:
 Falls risk assessment (#154)
 CPT codes 92540, 92541, 92542 and/or 92548
 Falls Plan of Care (#155)
 CPT codes 92540, 92541, 92542 and/or 92548
 Smoking cessation (#226)
 CPT codes 92540, 92557 and/or 92625
 No ICD-10-CM codes in these new measures
 Avoid negative reporting, doesn’t count towards avoiding the penalty

For SLPs: Measures #130, #131, #226
 #130 and #131 are for each visit
Required Domains
 The 9 measures needed to cover 3 National Quality
Forum domains:
 Patient safety (#130, #154 and #155)
 Person and Caregiver-Centered Experience and Outcomes
 Communication and Care Coordination (#131 and #261)
 Effective Clinical Care
 Community/Population Health (#134, #226)
 Efficiency and Cost Reduction
2016 Eligible PQRS Measures for Audiologists-The
Ones From 2015

#261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
AND

#130-Documentation and Verification of Current Medications in the Medical Record
AND

#134-Screening for Clinical Depression and Follow-Up Plan


We continue to have these three 2015 measures in 2016 and three additional
potential opportunities (measures) for reporting
Of the ones above, #130 and #134 are cross-cutting measures
No changes to 3 current measures except the depression screening is
required when performing CPT code 92625 (tinnitus evaluation))s required
when performing CPT code 92625 (tinnitus evaluation)
No Three
new
changes
to 3measures:
current measures except the depression screening is
•
No ICD-10-CM codes in these new
 Falls risk assessment (#154)
required
when performing CPT code 92625
(tinnitus evaluation)
measures
 CPT codes 92540, 92541, 92542 and/or
92548
Cross-cutting measures (#130,• #134
and now #226)
If indicated, report once/year
 Falls Plan of Care (#155)
 CPT codes 92540, 92541, 92542 and/or 92548

Preventative Care and Screening:
Tobacco Use (#226)
 CPT codes 92540, 92557 and/or 92625
 Cross cutting measure
•
Avoid negative reporting as it doesn’t count
towards avoiding the penalty
PQRS Measure #130
 Documentation and Verification of Current
Medications in the Medical Record
 This measure is to be reported at each visit occurring
during the reporting period for all patients aged 18 years
and older
 To determine if documentation of a current medication
list occurred
#130 for 2016
 Description: “Eligible professional attests to
documenting, updating or reviewing a patient’s current
medications using all immediate resources available on
the date of encounter.”
 “This list must include ALL known prescriptions, overthe-counters, herbals and vitamin/mineral/dietary
(nutritional) supplements and must contain the
medications’ name, dosages, frequency and route of
administration.”
Audiology CPT Codes For PQRS #130:
 CPT Codes:
 92541
 92542
 92543
 92544
 92545
 92547
 92548
 CPT Codes:
 92557
 92567
 92568
 92570
 92585
 92588
 92626
CPT Codes For SLPs and #130:
 92507, 92508, 92526, 92626, 97532
Clinical Example #130 (cont.)
 Report on #130 (and #226) if you performed these CPT
codes:
 92557
 92570
 92588
 No ICD-10 codes required for this measure
Clinical Example #130
 With two of these example CPT codes included in the
measure and since an ICD-10 code is not specified, can
report on this measure with G8427 if the following are
documented to the best of your ability:
 The name of the drug, OTC, herbal, vitamin/dietary
[nutritional] supplements
 The dosage of the drug
 The frequency that it is taken
 The route of administration (pathway of how it is taken)
 Topical? IV? Sub-lingual? etc.
For 2016 (#130)

G8427: Eligible professional attests to documenting in the medical record they
obtained, updated, or reviewed the patient’s current medications
 Also report if not taking any medications

G8430: Eligible professional attests to documenting in the medical record the patient
is not eligible for a current list of medications being obtained, upgraded, or reviewed
by the eligible professional
THIS WILL RESULT IN NEGATIVE REPORTING AND
WILL NOT AVOID THE PENALTY:

G8428: Current list of medications not documented as obtained,
updated, or reviewed by the eligible professional, reason not given
PQRS Measure #134
 Screening for Clinical Depression and Follow-up
 This measure is to be reported a minimum of once per
reporting period for all patients aged 12 years and older
 Description
 Percentage of patients aged 12 years and older
screened for clinical depression using an age
appropriate standardized tool AND if positive, a followup plan is documented on the date of the screen
Measure #134 (cont.)

CPT code: 92625

ICD-10-CM codes: None specified for this measure

G8431: Screening for clinical depression is documented as being positive AND a follow-up
plan is documented
G8510: Screening for clinical depression is documented as negative, a follow-up plan is
not required
G8433: Screening for clinical depression not documented, documentation stating the
patient is not eligible



THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE PENALTY:

G8940: Screening for clinical depression documented as positive, a follow-up plan not
documented, documentation stating the patient is not eligible
PQRS Measure #134 (cont.)
 If you choose to report on this measure, check with your
state licensure law to ensure that it is within the scope of
practice for audiologists in your state
 If you select this measure for reporting, you will report:
 Whether or not the patient was screened for depression
using a standardized tool (PHQ9, BDI or BDI-II, CES-D,
DEPS, DADS, GDS, PRIME MD-PHQ2, PHQ-A, and
BDI-PC) AND a follow-up plan was suggested
Depression Screening Tools Include But Are Not
Limited To:








Patient Health Questionnaire (PHQ-9)
 http://patient.info/doctor/patient-health-questionnaire-phq-9
Beck Depression Inventory (BDI or BDI-II)
 http://mhinnovation.net/sites/default/files/downloads/innovation/research/BDI%20with%20interpretation.pdf
Center for Epidemiologic Studies Depression Scale (CES-D)
 http://www.actonmedical.com/documents/cesd_long.pdf
Depression Scale (DEPS)
 http://zadz.ch/en/sicknesses/test/depression-self-test-deps/
Duke Anxiety-Depression Scale (DADS)
 http://healthmeasures.mc.duke.edu/images/DukeAD.pdf
Geriatric Depression Scale (GDS)
 http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf
Cornell Scale Screening
 http://geropsychiatriceducation.vch.ca/docs/edu-downloads/depression/cornell_scale_depression.pdf
PRIME MD-PHQ2
 http://www.oacbdd.org/clientuploads/Docs/2010/Spring%20Handouts/Session%20220j.pdf
Clinical Example for #134






67 year old male referred by PCP for an audiologic and tinnitus
assessment
Chief complaint is tinnitus x 6 months
Depression screening performed routinely by this practice
CPT codes performed: 92557, 92570 and 92625
ICD-9 code: H93.13 (bilateral tinnitus)
G code: G8431 (screening for clinical depression is documented as
being positive AND a follow-up plan is documented)
New for 2016!

Measure #154 Falls: Risk Assessment
 Part of a two part measure (#155)
 Report once/calendar year if you perform
 CPT codes 92540, 92541, 92542, and/or 92548
 To report on those patients who have had 2 or more falls in the past year or any fall
resulting in an injury in the past year
 Numerator:
 Patients who had a risk assessment for falls completed within 12 months
 “Fall: A sudden, unintentional change in position causing an individual to land at a
lower level, on an object, the floor or the ground, other than as a consequence of
sudden onset of paralysis, epileptic seizure, or overwhelming external force.”
 Injury: an event that results in the need for medical attention
Facts
 Falls are the leading cause of injury and deaths among
older people, likely to grow
 In every second of every day, an older American falls
 In 2014, 29 million falls, 7 million injuries
 Fractures, head injuries, lacerations
 CDC says Medicare costs for falls: $31 billion
PQRS Measure #154: Falls Risk Assessment






“Comprised of balance/gait AND one or more of the following:
Balance/gait assessment:
 Get Up and Go
 Tanetti
Demo videos are on the AQC website (R. Gans, PhD)
 Berg
http://audiologyquality.org/measures
Postural blood pressure (supine, standing)
Vision assessment (Snellen or referral for assessment)
Home fall hazards assessment (can include referral for evaluation)
Medications assessment (whether current meds may or may not contribute to falls)
And documentation on whether medications are a contributing factor or not to falls within the past 12 months”
PQRS Measure #154 (cont.)
 Patient reports no falls or only 1 fall without injury in the past
year
 You perform 92540, 92541, 92542 and/or 92548
 You must report CPT code 1101F
 Patient screened for future fall risk; documentation of no
falls in the past year or only one fall without injury in the
past year
Measure #154 (cont.)


If patient reports 2 or more falls in the past 12 months or 1 fall with an
injury AND risk assessment not performed for medical reasons (patient
is not ambulatory, bedridden, immobile, confined to wheelchair) and
you’ve performed 92540, 92541, 92542 and/or 92548:
Code 3288F with 1P AND 1100F
 3288F with 1P is falls risk assessment documented
 1P is also used to report documented circumstances that exclude patients (not
ambulatory, bed ridden, etc.)
AND
 1100F is patient screened for future falls risk and documentation of 2 or more falls or
any fall with injury in the past year

Must also perform and report #155, Falls Risk Plan of Care
Measure #154 (cont.)

If patient has 2 or more falls in the past 12 months OR 1 fall with an
injury:
 And you performed 92540, 92541, 92542 and/or 92548
 Perform standardized scale, review and document whether current medications may
or may not be contributing to falls, dizziness, imbalance or vertigo

When warranted, refer for:






Postural blood pressure (supine, standing)
Vision assessment (Snellen or referral for assessment)
Home fall hazards assessment (can include referral for evaluation)and/or
Medication review
Code 3288F and 1100F
Perform and report on Measure #155, falls risk plan of care
Measure #154 (cont.)
 3288F with 1P is falls risk assessment documented
 1P is also used to report documented circumstances that
exclude patients (not ambulatory, bed ridden, etc.)
AND
• 1100F is patient screened for future falls risk and
documentation of 2 or more falls or any fall with injury in
the past year
Measure #154 (cont.)

THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT
AVOID THE PENALTY:
 If falls status is not documented and you performed CPT
codes 92540, 92541, 92542 and/or 92548
 CPT code 1101F with 8P (no documentation of falls status)
Measure #154 (cont.)

THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT
AVOID THE PENALTY:
 Risk assessment for falls not complete, reason not otherwise
specified

3288F-8P AND 1100F
PQRS Measure #155: Falls: Plan of Care

“This measure should be reported if 1100F is submitted for Measure #154.”

Also report even if a falls risk assessment was not performed if you performed
CPT codes 92540, 92541, 92542 and/or 92548.

1100F: “Patient screened for future falls risk; documentation of two or more falls
in the past year or any fall with injury in the past year”

Reported once/reporting period for those age > 65 years on date of encounter
AND when 1100F is reported for #154
Plan of Care (#155)
 Must be reported with 0518F: Falls plan of care
documented
 Plan of care must include:
 Consideration of Vitamin D supplementation was advised or considered
or documentation that patient was referred to his/her physician for
vitamin D supplementation advice
 Balance, strength and gait training
 Document that these were provided OR a referral was made to an exercise
program that includes at least one of these components OR referral to
physical therapy; can include referral for VRT and/or providing it in your
practice
Plan of Care (cont.)
OR

0518F with 1P: Documentation of medical reason(s) for no plan of care for falls (ie, patient
is not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on
helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair)
(meets exclusion criteria)
OR
THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT
AVOID THE PENALTY:

0518F with 8P: Plan of care not documented, reason not otherwise specified
Example of a patient reporting dizziness

Perform appropriate vestibular tests
 Report on the following measures:
 #130 (medications) (92540 not included)
 #154 (falls risk screening)
 #155 (falls risk plan of care)
 #226 (tobacco use and intervention) (if you did 92540)
 #261 (acute or chronic dizziness if ICD-10-CM codes are R42, H81.10, H81.11,
H81.12 or H81.13)
 The claim form may have up to 5 different G or CPT II codes with these CPT test
codes
PQRS Measure #226: Care and Screening: Tobacco Use: Screening and Cessation
Intervention

Percentage of patients aged 18 years and older who were screened for
tobacco use one or more times within 24 months AND who received
cessation counseling information if identified as a tobacco user

Once/reporting period


CPT codes: 92540, 92557, and/or 92625 for audiologists
CPT codes: 92521-92524 for SLPs

No ICD-10-CMs are included
Measure #226 (cont.)
 Patients who were screened for tobacco use at least once
within 24 months AND who received tobacco cessation
intervention if identified as a tobacco user
 Tobacco use includes any type of tobacco
 Tobacco cessation intervention includes brief counseling (3
minutes or less) and/or pharma-cotherapy
Measure #226 (cont.)

4004F: Patient screened for tobacco use AND received tobacco cessation intervention (counseling,
pharmacotherapy, or both), if identified as a tobacco user
OR

1036F: Current tobacco non-user (meets exclusion criteria)
OR

4004F with 1P: Documentation of medical reason(s) for not screening for tobacco use (eg, limited life
expectancy, other medical reasons)
THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE PENALTY:
OR

4004F with 8P: Tobacco screening OR tobacco cessation intervention not performed, reason not
otherwise specified (patient is identified as a user, did not receive tobacco cessation counseling report)
Measure #226 (cont.)
“All patients should be asked if they use tobacco and should have
their tobacco use status documented on a regular basis.”
 “Evidence has shown that clinic screening systems, such as
expanding the vital signs to include tobacco use status or the use of
other reminder systems such as chart stickers or computer prompts,
significantly increase rates of clinical intervention.”
 “Minimal interventions lasting less than 3 minutes increase overall
tobacco abstinence rates. Every tobacco user should be offered at
least a minimal intervention, whether or not he or she is referred to
an intensive intervention.”

Measure #226 (cont.)
 “The combination of counseling and medication is more
effective for smoking cessation than either medication or
counseling alone. Therefore, whenever feasible and
appropriate, both counseling and medication should be
provided to patients trying to quit smoking.”
PQRS Measure #261--Referral for Otologic Evaluation for
Patients with Acute or Chronic Dizziness
 Denominator
 Patients aged birth and older AND
 CPT codes:
 92540, 92541-92548, 92550, 92557, 92567, 92568, 92570, 92575
 ICD-10 codes:
 R42(dizziness and giddiness)
 H81.10, H81.11, H81.12, H81.13 (BPPV codes)
 Report once per calendar year
PQRS Measure #261 (cont.)

G8856: Referral to a physician for an otologic evaluation performed
OR
 G8857: Patient is not eligible for the referral for otologic evaluation
measure (e.g., pts who are already under the care of a physician for
acute or chronic dizziness) (meets exclusion criteria)
THIS WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE
PENALTY:

G8858: Referral to a physician for an otologic evaluation not
performed, reason not specified
PQRS CPT Codes for Speech-Language Pathologists
 #130 (medications): 92507, 92508, 92526, 92626, 97532
 #131(pain): 92507, 92508, 92526, 92626, 97532
 #226 (tobacco cessation): 92521, 92522, 92523, 92524
PQRS Measure #131 Pain Assessment and Follow-Up
SLPs only
 Percentage of patients aged 18 and older with documentation




of a pain assessment using a standardized tool(s) on each
visit AND documentation of a follow-up plan when pain is
present
Report for each visit along with #130
No ICD-10-CM specificity
CPT codes: 92507, 92508, and 92526
Report only if state licensure scope of practice allows for
standardized screenings and referrals for pain
Pain Standardized Tool



Required to determine presence or absence of pain
May include location, intensity, description and onset/duration
Can include:











Brief Pain Inventory (BPI)
Faces Pain Scale (FPS
McGill Pain Questionnaire (MPQ)
Multidimensional Pain Inventory (MPI)
Neuropathic Pain Scale (NPS)
Numeric Rating Scale (NRS)
Oswestry Disability Index (ODI)
Roland Morris Disability Questionnaire (RMDQ)
Verbal Descriptor Scale (VDS)
Verbal Numeric Rating Scale (VNRS)
Visual Analog Scale (VAS)
Follow-Up Plan
 Documented outline of care for a positive pain
assessment is required
 Must include:
 A planned f/u appointment or referral
 Notification to other care providers as applicable OR
 Indicate the initial treatment plan is still in effect
 May include pharmocologic and/or educational interventions
Not eligible if…
 Severe mental and/or physical incapacity where the
person is unable to express themselves in a manner
understood by others
 Patient is in an urgent or emergent situation and a delay
in treatment would jeopardize the patient’s health status
G Codes to use, with tool documented in chart
 G 8730 Pain assessment documented as positive using a
standardized tool AND a follow-up plan is documented
OR
 G8731 Pain assessment using a standardized tool is
documented as negative, no follow-up plan required
OR
Exclusions:
 G8442 Pain assessment NOT documented as being
performed, documentation the patient is not eligible for a
pain assessment using a standardized tool
OR
 G8939 Pain assessment documented as positive, followup plan not documented, documentation the patient is
not eligible
OR
Performance Not Met:
 G8732 No documentation of pain assessment, reason
not given
 G8509 Pain assessment documented as positive using a
standardized too, follow-up plan not documented, reason
not given
THESE WILL RESULT IN NEGATIVE REPORTING AND WILL NOT AVOID THE
PENALTY:
Other Codes for SLPs
 G codes for functional limitation and status for:
 Swallowing
 Motor speech
 Spoken language comprehension
 Spoken language expression
 Attention
 Memory
 Voice
 Other SLP Functional Limitation
Codes for functional limitation, current status at the time of the
initial therapy/episode outset and reporting intervals
 Swallowing: G8996
 Motor speech: G8999
 Spoken language comprehension: G9159
 Spoken language expression: G9162
 Attention: G9165
 Memory: G9168
 Voice: G9171
 Other SLP functional limitations: G9174
Codes for functional limitation, projected goal
status at initial therapy treatment/onset and at
discharge from therapy
 Swallowing: G8997
 Motor speech: G9186
 Spoken language comprehension: G9160
 Spoken language expression: G9163
 Attention: G9166
 Memory: G9169
 Voice: G9172
 Other SLP functional limitations: G9175
Codes For Functional Limitation, Discharge Status At
Discharge from therapy/end of reporting on limitation
 Swallowing: G8998
 Motor speech: G9158
 Spoken language comprehension: G9161
 Spoken language expression: G9164
 Attention: G9167
 Memory: G9170
 Voice: G9173
 Other SLP functional limitations: G9176
Tips:
 Use all 3 when there will not be an ongoing process
 Use 1 when it is an ongoing process
 Modifiers are required by the Centers for Medicare and
Medicaid Services (CMS) with the use of all G-codes
 Can report National Outcomes Measurement System
(NOMS), not required by CMS
 Severity rating scale (1-7)
Impairment Limitation Restriction Modifiers (ASHA)
What Do You Get From CMS?
 Monitor your Remittance Advice (EOB) summaries
 N620: “This procedure code is not payable. It is for
reporting/information purposes only.”
 Indicates that the PQRS codes were received
 Does not guarantee that reporting was correct
 Check your quarterly reports
 https://portal.cms.gov/wps/portal/unauthportal/home/
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CMS PQRS Resource- QualityNet Help Desk
Available Monday – Friday; 7:00 AM–7:00 PM CT
• General CMS Physician Quality Reporting System and eRx Incentive
Program information
• Portal password issues
• Feedback report availability and access
• PQRI-IACS registration questions
• PQRI-IACS login issues
Phone: 1-866-288-8912
TTY: 1-877-715-6222
Email: [email protected]
CMS PQRS Webpages
https://pqrs.cms.gov/#/home
https://www.cms.gov/Medicare/Quality-InitiativesPatient-Assessment-Instruments/PQRS/index.html
Physician Compare






“To allow consumers to search for physicians and other health care
professionals enrolled in the Medicare program (ACA).”
“The purpose of Physician Compare is to help consumers make
informed choices about healthcare they receive through Medicare”
and to incentivize “physicians to maximize performance”
Consumers can select providers based on “robust and reliable
quality of care data”
THIS INCLUDES YOUR PQRS REPORTING
All those enrolled in PECOS are to be listed
Check your own listing:
https://pecos.cms.hhs.gov/pecos/login.do#headingLv1
Physician Compare (cont.)
 Information currently provided:
 Medicare enrolled providers’ names, addresses, phone
numbers, specialties, training, gender
 Languages spoken other than English
 If provider is accepting new Medicare patients and if
they accept assignment
 Hospital affiliations
 Outcome measures reporting
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2017 PQRS Measures
?
MACRA, MIPS and APMs
 Medicare Access and CHIP Reauthorization Act of 2015
(MACRA)
 Different than the Affordable Care Act (2010)
 Ended the Sustainable Growth Rate (SGR)
 Historically was more than a dozen temporary fixes
 New framework for rewarding health care providers for giving better
care, not just more care
 Combing existing quality reporting programs into one
https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRAMIPS-and-APMs.html
MIPS and APMs
 Merit-Based Incentive Payment System (MIPS) OR
Alternative Payment Models (APM)
 Will combine PQRS, merit based programs and EHR
 Measured on quality, resource use, clinical practice improvement,
management of certified EHR technology
 Moving away from fee-for-service and to positive, negative or neutral
adjustments in payment
 Moving toward low-cost, high quality patient care
MIPS
 Payment to be based on:
 Quality
 Clinical practice improvement
 Incentives for care coordination, patient opportunities for greater access
 Advancing care information
 Electronic Healthcare Records
 Resource use
 Performance measurement for specific measures
 Point system-highest points for higher quality care
What We Do Know…
 Awaiting final rule, no known date of release
 On or around November 1st with the MPFS?
 Impact to audiologists likely won’t be until at least 2019 as we
are one of several professions excluded for 2019
 Were SLPs omitted from the list?? PT and OT are noted
 PQRS as we now know it will likely be sunsetted in 2017
 Continue to do what you are doing! It’s good patient care and
best practices
 Medications (both), tobacco(both), balance and tinnitus patients
CMS 1500 form

The National Uniform Claim Committee (NUCC)
 Voluntary organization, chaired by the AMA
 CMS partners with NUCC
 Revision due to changes:
 Meets requirements of several initiatives
 ICD-10 changes
 Need more room for longer codes
 Added 8 additional lines (total of 12 diagnosis codes)
 Changed from numeric to alphabetic (A-L)
 Removed the period within the code lines
 Need to indicate referring (DN), ordering (DK) or supervising (DQ) provider
in box 17
CMS 1500 form (cont.)

Changed form date from 08/05 to 02/12
 1500 rectangular symbol now has a QR (Quick Response Code)

Other form changes:
 TRICARE CHAMPUS changed to TRICARE
 Social Security Number changed to ID#
 Box 19 changed to “additional claim information”
 Other changes
 Balance due is “Rsvd for NUCC Use”
CMS 1500 form timeline

As of April 1, 2014: Payers receive and process paper claims
submitted ONLY on the revised version (02/12) claim form
 Consult with your practice management system vendor
 Forms may be ordered here:
 [email protected] (1.800.482.9367, ext. 58029)
 http://bookstore.gpo.gov/catalog/government-forms-phonedirectories (1.866.512.1800)
Claim Form
 Lists the CPT(s), ICD(s) and HCPCS codes and
demonstrates their interaction:
 What you performed (CPT)
 Diagnosis results (ICD)
 Resulting recommendations if product (HCPCS)
 Ties the coding systems together
What Goes Where?
 Boxes 1-16 Patient information
 Box 17 Referring Provider
 Include their NPI
 Include DN (referring provider) or DK (ordering provider)
 Box 19 Can include “need denial from Medicare for
secondary to pay”
 Box 21 ICD-10-CM codes
What Goes Where (cont.)
 Box 24 (A-J)
 A: Date of service
 B: Place of service
 11 Office
 12 Home
 31 Skilled Nursing Facility
 32 Nursing Facility
 34 Hospice
What Goes Where (cont.)
 D: CPT/HCPCS/PQRS codes and modifiers
 E: Diagnosis pointers
 Corresponds to A-L in the ICD-10-CM boxes
 F: Fees
 G: Units (most will be 1 with the exception of time based
codes, earmolds, earmold impressions)
 J: Your National Provider Identifier (NPI)
What Goes Where (cont.)
 Box 25: Federal Tax Identification Number (TIN)
 Box 26: Patient account number, if one is assigned
 Box 27: Accept assignment
 Yes or no
 Box 28: Total charge
 Box 29: Amount patient paid
 Box 32: Facility name, location, NPI number
 Box 33: Provider name, address, phone, NPI
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Standardized Billing Form:
The CMS 1500
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Standardized Billing Form:
The CMS 1500
Interactive CMS 1500 Instructions
http://www.palmettogba.com/Internet/cms1500.nsf/CMS1500.htm
l#
http://www.hmsa.com/PORTAL/PROVIDER/zav_QU.03.010.htm
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Medicare Claims Submission
 Claims must be submitted electronically
 Submit an Electronic Data Interchange (EDI) form
 A few exceptions include:
 A physician, practitioner, or supplier that has fewer than 10 Full-Time
Equivalent (FTE) employees.
 Claims filed later than one calendar year after date of service
will be denied
 No appeal process
 Patient cannot be billed
Medicare Claims Submission (cont.)
 When you furnish covered services to Medicare beneficiaries,
you are required to submit claims for your services and
cannot charge beneficiaries for completing or filing Medicare
claim.”
 -https://www.cms.gov/Outreach-and-Education/Medicare-
Learning-NetworkMLN/MLNProducts/Downloads/MedicareClaimSubmissionGui
delines-ICN906764.pdf
Effective 1/1/15, to replace -59:




XE—Separate Encounter: A service that is performed under the same billing
provider NPI on the same date of service, but is distinct because it is a separate
encounter for the patient.
XS—Separate Structure: A service that is performed under the same billing
provider NPI on the same date of service, but on a different structure or organ.
XP—Separate Practitioner: A service that is performed under the same billing
provider NPI on the same date of service, but is distinct because it is performed
by a different individual provider.
XU—Unusual Non-Overlapping Service: A service that is performed under the
same billing provider NPI on the same date of service, but the procedure does
not overlap the usual components of the main service performed.
Medicare Modifiers (cont.)
 None truly are applicable
 CMS guidance is to continue to use the -59 modifier
 Use when you file a claim for 1-3 of the codes that are included in
92540 (basic vestibular evaluation):
 92541
 92542
 92544
 92545
Medicaid
 The individual state agency that provides services for low
income residents
 Federal government matches state funds
 Differs in coverage from state to state
 Hearing and audiology services included
 Early and Periodic Screening, Diagnosis and Treatment
(EPSDT) regulations allow for mandatory coverage of health
care services, including hearing services, birth to age 21
Medicaid
 Prior to enrolling in your state’s Medicaid program, need to
know:
 If you can sustain your practice with providing services to this
population
 Lowest reimbursement of any payer
 Can’t ration services-you are either in or out
 Know coverage and billing processes
 They are unlike any other payer
 Rates and requirements
 Diagnostics and hearing aid dispensing
Break!
Documentation-Why Is It Important?
 A chart is a legal document
 Provides continuity of care between health care
professionals
 Requirement of third party payers
 Peer Review
 Need to explain and interpret test results
 Not all readers will be audiologists
Documentation
 Essential in daily practice
 Audits
 Electronic Health Care records (EHR)
 More vital for ICD-10’s
 Is addressed in the Academy’s COE (5e)
 “Individuals shall maintain accurate documentation of
services rendered according to accepted medical, legal
and professional standards and requirements.”
What should be included?
 Demographic information
 Patient’s name
 Date of birth
 Contact information
 Insurance card
 Photocopy front and back (need address)
 Driver’s license
 Medical Identity Theft
 Collections
What else?
 If required by a third party payer, include the referring
provider
 If not referred, note that the patient self-referred
 Medicare physician orders:
 On the physician’s letterhead or prescription pad
 May want to avoid referral pads with your practice name so as not
to appear that the order was solicited
 Check with Noridian for their guidance on the use of referral pads
Documentation (cont.)
 Sign and date the audiogram and chart notes
 Must provide user instructional brochure for hearing aids
and note it in the record
 Must obtain medical clearance for hearing aids or
provide waiver
 “If I can’t code your encounter form from your
documentation, then your documentation is inadequate.”
 Kyle Dennis, personal e-mail
Chart Notes:
 “If it isn’t in the chart, it didn’t happen…”
 Need to document all that patient relays to you
 SOAP “outline”
 Need to explain and interpret test results
 Don’t assume anyone other than an audiologist understands what it
means
SOAP
 Subjective findings
 History
 Objective finding
 Physical exam
 Testing
 Assessment
 Creating a differential diagnosis or diagnoses
 Plan
 Recommendations for patient based on the above
 Referrals to others
Hard Copy Guidance
 No sticky notes!
 Everything needs to be secured with the patient’s name and date…
 If err, strike through with one single line
 No scribbling or liquid paper
 All Personal Health Information (PHI) should be
shredded
 Sticky notes too if they have PHI
Documentation
Documentation
 A chart is a legal document
 Can be subpoenaed
 Provides continuity of care between health care
professionals
 Quality Assessment
 Payer requirement
 Need to explain and interpret tests results
 Don’t assume a non-audiologist provider understands
anything about any diagnostic test or treatment
What should be included?
 Demographic information
 Patient’s name
 Address
 Date of birth
 Contact information
 Insurance card
 Photocopy front and back (need address)
 Driver’s license
 Medical Identity Theft
And?
 Reason for the visit
 Case history
 Surgeries
 Medications, past and present
 Herbals, over-the-counter meds
 Occupational noise exposure
 Recreational noise exposure
More…
 HIPAA forms
 Notice of Privacy Practices (NPP)
 Case history
 Adult
 Familial hearing loss
 Age of onset, syndromes?
 Treatment plan
 Surgeries
 Amplification
 Other
More…
 Pediatric:
 History:
 Prenatal
 Delivery
 Familial hearing loss
 Developmental milestones
What else?
 Who is the referring professional if required by a third
party payer?
 Medicare physician referrals:
 On the physician’s letterhead or prescription pad
 Not to have the appearance that it was solicited by you
 May want to avoid referral pads with your practice name
 Contact your Medicare Administrative Contractor (MAC) for guidance
 Get it in writing
And?
 Reason for the visit
 Include other diseases that may impact hearing and balance
 Case history
 Family history of ear disease, hearing loss and other hereditary
diseases/syndromes
 Surgeries
 Medications, past and present
 Prescriptions, herbals, over-the-counter meds
 Occupational noise exposure
 Recreational noise exposure
Case History (cont.)
 Case history
 Adult
 Familial hearing loss
 Age of onset, syndromes?
 Treatment plan
Surgeries? Amplification?
 Notice of Privacy Practices (NPP)
 Review of systems…
More…
 Pediatric:
History:
Prenatal
Delivery
Family
Chart Notes:
 “If it isn’t in the chart, it didn’t happen…”
 Need to document what the patient communicates to you
 Many utilize the SOAP “outline”
 Subjective, objective, assessment and plan
SOAP

Subjective findings
 History

Objective finding
 Physical exam
 Otoscopy
 Otoscopy pre and post earmold impression with notes
 Testing

Assessment
 Puzzle piecing

Plan
 Recommendations for patient based on the above
 Referrals to others
Hard Copy Guidance
 If err, strike through with one single line
 Initial with your three initials
 Do not use white out
 Do not scribble
Electronic Health Care Records (EHR/EMR)

Enter all applicable information for that particular date of service
 Date and possibly time stamped
 Some systems disallow re-entry for that time period
 May have to add an addendum

Some systems have templates for:





Audiograms
Tympanometry
Real ear measures
Outcome measures
If there are no templates, they’ll need to be scanned into the
patient’s record
Bundling vs. Itemization:
 Bundling vs. itemization
 Likely to optimize reimbursement with third party payers
 Gives the insurance company the choice to bundle
 Transparency (HLAA)
Bundling vs. Itemization (cont.)

Bundling
 One payment, one code
 Does not decipher what is service and what is product

Itemization (detaches service from product)
 Separate itemization of all fees:
 Hearing aid(s)
 Dispensing fee(s)
 Orientation fee
 Conformity evaluation
 Earmold(s)
 Earmold impression(s)
 Batteries
 Extended service or warranty packages
 Office visits?
Question: I currently bundle my fees
 Yes
 No
Tidbits







Must know your hourly rate
 HAVE TO KNOW WHAT YOUR EXPENSES ARE
Need to know with each separate contract what you can (or can’t
afford) to loose
Don’t make decisions out of fear, but out of a thorough evaluation of
what your practice needs to survive
May need to restrict product offerings
May need to refer elsewhere
Are insurance waivers allowed
Denial and termination processes
Durable Medical Equipment (DME)
 Hearing aids are not considered DME by Medicare
 Hearing aids may be considered DME by third party
payers and/or your state’s Medicaid agency
DME
 As long as it is not contractually excluded, a patient
should expect to pay for services
 If you are not contracted for DME/hearing aids that you
are not held to the payer’s fee schedule for DME/hearing
aids
Next steps (cont.)
 Medical necessity vs. patient care protocols
 Purchase agreement
 State licensure law requirements
 Itemization may not be allowed by state licensure
 Specific tests (e.g., MCLs, UCLs, bone conduction at 250 Hz) may be
required in state licensure law(s) when dispensing amplification
Waivers
 Patient’s acknowledgement of their financial
responsibility for fees not paid by their insurance
benefit, if not contractually excluded
 Have patient sign at the time of providing services
 Time of patient education
 Itemize CPT/HCPCS codes to be utilized and patient out of pocket
cost estimate
 Original retained in chart, copy to patient
 Not the same as the ABN (Medicare only)
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Examples:
Waivers (cont.)
 Do your payers provide their own?
 Will they allow one that your office creates?
 Should include:
 Patient’s name
 Date
 How much is their responsibility and for what
 They must understand this is beyond their benefit and their EOB may
have the benefit stating they owe zero
Itemizing for Third Party Payers



Know your hourly rate
Don’t make decisions out of fear
Need to know with each separate contract what you can (or can’t afford) to
loose
 Some will pay 50% or 60% of what is billed
 Need to charge your usual and customary fees to everyone in order to sustain this rate; can offer
cash discounts to private pay patients with caution and a policy
 Some won’t allow you to bill the patient for the difference between the allowable and the
payment amount



May need to restrict product offerings (AGX 3 instead of an AGX 9)
Ask if insurance waivers are allowed if patient wants to go beyond their benefit
Be aware of the denial and termination processes
Establishing Hourly Rate
 How many hours/week? (30?)
 Direct patient care time only
 Weeks/year that services are provided (49?)
 Number of providers in the practice (2?)
 Multiply the hours/week/year by the number of providers
(49 x 2 = 98) x 30 = 2940
Hourly Rate Calculation (cont.)
Includes:
Does not include:
 Salary/benefits
 Overhead
 Rent, equipment,
utilities, marketing, etc.
Hourly rate = Annual
expenses ÷ 2940
 Cost of goods (COG):
 Hearing aids
 Ear molds
 Batteries
 ALDs
 Hearing aid accessories
To Determine Break-Even Hourly Rate and Profit
Margin
 Total annual expenses – COG ÷ annual contact hours
(break-even point)
$XXX.xx – COG ÷ 2940 = YYY.yy
 Total annual expenses – COG + desired profit ÷ annual
contact hours
$XXX.xx – COG + DP ÷ 2940 = YYY.yy
Next Steps:
 Assign fees for each professional service procedure
based on your hourly rate/profit goal
 Load payer allowables into your management system
 Compare amounts paid with contracted fees
 Don’t assume the payer’s amount is correct
Next Steps:
 Purchase agreement
 State licensure law requirements
 Itemization may not be allowed by state licensure
 Specific tests (e.g., MCLs, UCLs, bone conduction at 250 Hz) may be
required in state licensure law(s) when dispensing amplification
Healthcare Common Procedure Coding System (HCPCS)
 Some services
 Hearing aid devices and supplies
 Cochlear implant codes (non-stimulation and mapping)
 Osseo-integrated codes
HCPCS Codes
 Services
 V5008 Hearing screening
 V5010 (Assessment for hearing aid)
 May be required by Medicaid
 V5011 (Fitting/orientation/checking of hearing




aid)
V5014 (Repair/modification of a hearing aid)
V5020 (Conformity evaluation)
 Real ear measures
S0618 (Audiometry for hearing aid evaluation to
determine the level and degree of hearing loss)
Dispensing fees applicable to the type of device
 Supplies:
 Hearing aids
 Earmold impressions
and earmolds
 Batteries
 Assistive Listening
Devices
Cochlear Implant Codes (cont.)

L8622 Alkaline battery for use with CI device, any size, replacement,
each





L8623 Lithium ion battery for use w/ CI device speech processor;
other than ear level, replacement, each
L8624 Lithium ion battery for use with CI device speech processor,
ear level, replacement, each
L8627 CI, external speech processor, component, replacement
L8628 CI, external controller component, replacement
L8629 Transmitting coil and cable, integrated, for use with CI
device, replacement
Osseointegrated Device Codes






L8690 Auditory osseointegrated device, includes all internal and external
components
L8691 Auditory osseointegrated device, external sound processor replacement
L8692 Auditory osseointegrated device, external sound processor, used without
osseointegration, body worn, includes headband or other means of external
attachment
L8693 Auditory osseointegrated device abutment, any length, replacement only
L9900 Orthotic and prosthetic supply, accessory, and/or service component of
another
Fitting:
 V5299 Hearing service, miscellaneous OR
 L8699 Auditory osseointegrated device, includes all internal and external components
Hearing Aid Modifiers
 May be payer dependent
 RT indicates right side (ear)
 LT indicates left side (ear)
 May need to bill each service and device with monaural
codes with modifier for each ear separately instead of
binaural codes
Waivers
 Serves as the patient’s acknowledgement of their personal
financial responsibility that will not be paid by their insurance
benefit
 Patient should sign at the time of service
 Time of patient education
 Itemize CPT/HCPCS codes to be utilized
 Retain the original, give a copy to patient
 Not the same as the ABN
 Does the payer recognize S1001, Deluxe item, patient
notified?
Waivers (cont.)
 Do your payers provide their own?
 Will they allow one that your office creates?
 Should include:
 Patient’s name
 Date
 How much is their responsibility and for what
 They must understand this is beyond their benefit and their EOB may
have the benefit stating they owe zero
Hearing Aid Evaluation options:
 S0618 Audiometry for hearing aid evaluation to
determine the level and degree of hearing loss
OR
 V5010 Assessment for hearing aid
OR
 92590 Hearing aid examination and selection, monaural
OR
 92591 Hearing aid examination and selection, binaural
SlidesCarnival icons are editable shapes.
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●
Resize them without losing quality.
●
Change fill color and opacity.
●
Change line color, width and style.
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Examples:
Example: Monaural BTE

HAE








V5011 Fitting/orientation/checking of hearing aid
V5020 Conformity Evaluation
V5241 Dispensing fee, monaural hearing aid, any type
V5257 Hearing aid, digital, monaural, BTE
V5264 Earmold/insert, not disposable, any type (1 unit)
V5266 Battery
V5275 Earmold impression, each
V5299 Hearing service, miscellaneous (extended warranty packages, for example)
 Typically not reimbursed by third party payers
Monaural BTE (example)









92590 (Hearing aid examination and selection, monaural), or V5010
(Assessment for hearing aid). Your choice of the code may be payer dependent.
V5011 Fitting/orientation/checking of hearing aid
V5020 Conformity Evaluation
V5241 Dispensing fee, monaural hearing aid, any type
V5257 Hearing aid, digital, monaural, BTE
V5264 Earmold/insert, not disposable, any type (1 unit)
V5266 Battery
V5275 Earmold impression, each
V5299 Hearing service, miscellaneous (extended warranty packages, for
example)
Example: Binaural RICs







HAE option
V5011 Fitting/orientation/checking of hearing aid
V5020 Conformity Evaluation
V5160 Dispensing fee, binaural
V5261 Hearing aid, digital, binaural, BTE
V5266 Battery
V5299 Hearing service, miscellaneous (extended warranty
packages, for example)
 For receiver in the canal (RIC) technology, the receiver could
be billed as V5267, hearing aid supplies/accessories.
Binaural BTEs With Two Earmolds

HAE option








V5011 Fitting/orientation/checking of hearing aid
V5020 Conformity Evaluation
V5160 Dispensing fee, binaural
V5261 Hearing aid, digital, binaural, BTE
V5264 Ear mold/insert, not disposable, any type
V5266 Battery
V5275 Ear impression, each
V5299 Hearing service, miscellaneous (extended warranty packages, for
example)
Binaural Hearing Aids When Payer Requires LT/RT modifiers

HAE option
V5011-RT Fitting/orientation/checking of hearing aid
V5011-LT Fitting/orientation/checking of hearing aid
V5020-RT Conformity evaluation
V5020-LT Conformity evaluation
V5257-RT Hearing aid, digital, monaural, BTE
V5257-LT Hearing aid, digital, monaural, BTE
V5241-RT Dispensing fee, monaural hearing aid, any type
V5241-LT Dispensing fee, monaural hearing aid, any type
V5264-RT Earmold/insert, not disposable, any
type
V5264-LT Earmold/insert, not disposable, any
type
V5275-RT Earmold impression, each
V5275-LT Earmold impression, each
V5267-RT Hearing aid supplies/accessories, if
indicated
V5267-LT Hearing aid supplies/accessories, if
indicated
V5266-RT Battery for use In hearing device
V5266-LT Battery for use In hearing device
BICROS Billing:
 When billing for CROS or BICROS devices:
 Check with the payer as some don’t recognize what a (BI)CROS
device is
 May want to obtain prior authorization to ensure that you will be
paid for the entire device and for corresponding services
 Bill the (BI)CROS codes and if not paid fairly, then appeal with an
explanation
BICROS (example)

HAE






V5011 Fitting/orientation/checking of hearing aid
V5020 Conformity Evaluation
V5220 Hearing aid, BICROS, behind the ear
V5240 Dispensing fee, BICROS
V5266 Battery for use In hearing device
V5264 Earmold/insert, not disposable, any type (This would be filed with the number of earmolds
utilized)
V5275 Earmold impression, each (This will need to be filed with the number of EMIs taken)
V5299 Hearing service, miscellaneous (extended warranty packages, for example)


Another option for BICROS:










HAE
V5011 Fitting/orientation/checking of hearing aid
V5020 Conformity Evaluation
V5241 Dispensing fee, monaural hearing aid, any type
V5257 Hearing aid, digital, monaural, BTE
V5264 Earmold/insert, not disposable, any type (1 unit) (This will need to be filed with 2 units for 2
earmolds)
V5266 Battery
V5267 Hearing aid supplies/accessories (for offside microphone)
V5275 Earmold impression, each (This will need to be filed with 2 units for 2 earmold impresssions)
V5299 Hearing service, miscellaneous (extended warranty packages, for example)
 Typically not reimbursed by third party payers
SlidesCarnival icons are editable shapes.
This means that you can:
●
Resize them without losing quality.
●
Change fill color and opacity.
●
Change line color, width and style.
Isn’t that nice? :)
Examples:
Itemizing binaural hearing aids
 S0618 Audiometry for hearing aid evaluation to
determine the level and degree of hearing loss
 V5010 Assessment for hearing aid
 92590 Hearing aid examination and selection,
monaural
 92591 Hearing aid examination and selection,
binaural
Binaural BTEs, with earmolds









92591 (Hearing aid examination and selection, binaural), or V5010 (Assessment for hearing aid). Your
choice of the code may be payer dependent.
V5011 Fitting/orientation/checking of hearing aid
V5020 Conformity Evaluation
V5160 Dispensing fee, binaural
V5261 Hearing aid, digital, binaural, BTE
V5264 Earmold/insert, not disposable, any type (This will need to be filed with 2 units for 2 earmolds)
V5266 Battery for use In hearing device
V5275 Earmold impression, each (This will need to be filed with 2 units for 2 earmold impressions)
V5299 Hearing service, miscellaneous (extended warranty packages, for example)
 *For receiver in the canal (RIC) technology, the receiver could be billed as V5267, hearing aid
supplies/accessories.
Question:
 I bill a BICROS hearing aid:
 1. With the BICROS code(s)
 2. With the BICROS and hearing aid code(s)
 3. Depends
Resources (cont.)
 http://www.audiology.org/practice/reimbursement/medicare/Pa
ges/Medicare_FAQ.aspx
 http://www.cms.gov
 http://www.audiology.org/practice/reimbursement/medicare/Do
cuments/201105_CMS_1500_Form_At_A_Glance.pdf
 http://www.audiology.org/practice/reimbursement/medicare/Do
cuments/enrollmentOptions4medicare.pdf
SlidesCarnival icons are editable shapes.
This means that you can:
●
Resize them without losing quality.
●
Change fill color and opacity.
●
Change line color, width and style.
Isn’t that nice? :)
Examples:
SlidesCarnival icons are editable shapes.
This means that you can:
●
Resize them without losing quality.
●
Change fill color and opacity.
●
Change line color, width and style.
Isn’t that nice? :)
Examples:
Contracting Tidbits

Obtain legal counsel to review contracts
 Well-versed in applicable federal and state health care regulations

Must be in compliance with:
 Federal Statutes
 Anti-Kickback Statutes
 Safe Harbors
 Stark Laws
 Medicare requirements
 Health Information Portability Accountability Act (HIPAA)
 Occupational Safety and Health Act (OSHA)
 American Disabilities Act (ADA)
 State Statutes
 Some may be more stringent that the federal regulations
Contracting Questions:
 Balance billing definition
 Many think it is the difference between what was billed and
what was paid
 It is the difference between what was billed and what is
allowed
 What are the allowed charges?
 Co-pays? (specific dollar amount)
Are required to be collected
 Co-insurance? (percentage)
 Deductibles are required to be collected
Contracting Questions (cont.)
 Request fee schedule
 Monitor it annually
 Review prior to signing contract
 In network vs out of network
 Be aware of the:
 Credentialing process (Audigy does this for you!)
 Denial process
 Termination process
Contracting Questions (cont.)


Need to know your expenses/costs
Some of these plans actually can cost YOU money
 Low reimbursement, write offs

Can the patient upgrade beyond their benefit to greater levels of
technology?
 Non-covered benefit

Review contracts and fees every 6-12 months
 Can make changes without notification (evergreening)

Compare Explanation of Benefits (EOBs) to payments
 Payers do make errors
 Don’t want to write off more than what you have to
Contracting
 Need to know if you can afford to be a provider:
 Overhead costs, practice expenses?
 Number of patients you can expect?
 Do you have to give something(s) away?
 What may be a beneficial arrangement for the practice down
the street may not be for you
 Contracting must be data-driven, not fear driven
More Considerations
 Negotiated rate
 Differences between payers
 Verification process
 A requirement with EVERY patient
 Complete before hearing aid evaluation
 Ability of patient cost sharing?
 The MOST important question
 Under what circumstances?
Furthermore…
 Fee schedule
 Obtain one before signing on the dotted line!
 Ask for updates on a minimum of an annual basis
 Do not submit an invoice unless hearing aid benefit is invoice +
cost
More tidbits
 When must claim be filed?
 When must payment be made?
 Prompt payment state regulations
 Does the discount you offer for diagnostics apply to
hearing aids/assistive listening devices?
Even More Considerations
 How much professional liability are you required to
carry?
 $1million/$3 million
 What are you required to meet with hearing
instruments:




Free hearing evaluations?
Free batteries? Free rechecks? If so, for how long?
Level of technology?
Required number of visits?
Steps to Contracting
 Request Information
 Complete Application and Credentialing Process
 Will need a License, NPI and Tax ID
 http://www.caqh.org/pdf/CAQH_Provider_Applicationv5_2006-10-31.pdf
Provider Insurance Credentialing
 Provider Enrollment
 Process of applying for inclusion to a health insurance’s provider
network
 Two step process for commercial insurances:
 Credentialing
 Contracting
 Credentialing can be completed multiple ways
 On-line (CAQH, OneHealthPort, etc.)
 State specific application???
 Insurance carrier specific application
Provider Insurance Credentialing
 Information needed for credentialing:
 Personal Demographics
 State license info
 Service, billing and correspondence addresses
 Education information
 Employment history
 Professional liability
 Peer reference (at least 3)
Provider Insurance Credentialing
 Necessary documents:
 State license
 Diploma for highest level of education
 Professional liability face sheet
 W-9
 Driver’s license
Provider Insurance Credentialing
 On-line credentialing
 CAQH (Council for Affordable Quality Healthcare)
 http://www.caqh.org/
 All your information is entered and stored for commercial insurances to
access
 Need to update documents and re-attest every quarter to keep
information up to date
 Failure to update documents or re-attest will cause you to be terminated from
any insurance that accesses CAQH
Provider Insurance Credentialing
 Paper application submission
 Re-credentialing happens every 2-3 years
 Review, updating and adding/deleting information
 Updated documents
 Failure to re-credential will result in termination
 If terminated, you will need to go through the initial credentialing
process again and a new effective date will be issued.
Provider Insurance Credentialing
 Initial credentialing
 Can take 60-120 days to complete
 Once complete, contracting can take an additional 30-45 days
 Most commercial insurances do not “back-date” effective dates
 Effective dates are issued once both steps are completed
Denial/Appeal
 When to appeal?
 When your reimbursement was not as patient’s contract stipulated
 Need to monitor
 There is a contract with the patient and their insurance company
 There is a contract with the patient’s payer and you
How to File an Appeal
 Letter of appeal
 Include patient name, date of birth, copy of insurance card and a copy
of the Explanation of Benefits (EOB)
 Letter addressing the reason for appeal
 Didn’t meet the patient’s benefit?
 Insurance companies do make errors
Insurance Networks

Tru Hearing
 Blue Cross/Blue Shield
 Promotes that they have “more than 3800 qualified TruHearing
Providers”
 Select or Choice plans
 Dispensing fee is typically $375/ear or $600/ear, depending on
technology, 3 visits in the first year at no charge; need to verify
 Batteries first year, 45 day trial period
 If contracted with with TruHearing, you are reimbursed $75 for an
evaluation fee, they pay devices, $50 after first year per visit
 If not contracted directly with TruHearing, you can proceed as you
choose, but contact your local BC/BS representative when verifying
benefits
Insurance Networks (cont.)

American Hearing Benefits (AHB)
 Part of AudioNet America which includes AHB, HearUSA and Hearing
Life/AHAA
 Starkey devices via AudioNet America for UAW Ford and GM plans
 After 6 months, office visits can be filed for $20/visit

EPIC
 “Hearing healthcare benefit plan”
 Partners with Phonak (and Lyric), Unitron, GN Resound, Starkey,
Widex, Siemens, Oticon
 Contractor for services (e.g., UHC)
Insurance Networks (cont.)
 Amplifon (formerly HearPO)
 Cigna
 Approximately a $2800 “benefit”
 Dispensing fees, testing, free batteries for 2 years, 3
year repair, loss and damage warranty
 60 day trial period
Federal Regulations Impacting Audiology and SpeechLanguage Pathology
Anti-Kickback Statutes (42 U.S.C. §1320a-7b(b))
 Applies to Medicare, Medicaid and other federal payers who
“knowingly and willfully solicits or receives any remuneration,
directly or indirectly, overtly or covertly, in cash or in kind, in
return for purchasing, leasing, or ordering (or recommending
the purchase, lease, or ordering) of any item or service
reimbursable in whole or in part under a federal health care
program.”
AKS (cont.)
 Kickbacks in health care result in:
 Overutilization
 Increased costs to Medicare
 Unfair competition for those unwilling to pay kickbacks
 Corruption of medical decision-making
AKS (cont.)
 Steep penalties, enforced by the Office of the Inspector
General
 Criminal (felony):
 Up to 5 years in prison AND
 Fines up to $25,000/violation and treble charges (3 times the amount of
remuneration offered, paid, solicited or received)
 Civil:
 Up to $50,000 and 3 times the kickback (treble damages)
 Exclusion from participation in federal health care programs
Penalties
AKS (cont.)

Applies to:
 Medicare
 Any procedures
 Cochlear Implants
 Osseo-integrated devices





Medicaid
Tricare
Federal Employees Health Benefit Policy (FEHBP)
Vocational Rehabilitation
Veterans’ Affairs (VA)
 Outsourcing services to public sector providers
AKS (cont.)
• Forgiving a co-pay may be a violation, if a routine
practice

Need to attempt to collect co-pays and deductibles unless you have
proof of the patient’s inability to pay
 “Good faith effort”
 Legal to provide discounted services to uninsured
people

Professional discounts may be a violation
AKS (cont.)
 Illegal to submit claims you know are
false/fraudulent
 “No specific intent to defraud is required”


http://oig.hhs.gov/compliance/physician-education/01laws.asp
Government does not need to prove patient harm or financial loss to the
programs to show that a provider violated the AKS

Even if medical necessity has been met
AKS (cont.)
 Actual knowledge of an AKS violation or specific intent to
commit a violation is not necessary for conviction under
the statute
 Government must still prove intention of law violation,
but no longer has to prove the intent to violate the AKS
itself
 PPACA, Pub. L. No. 111-148, §6402(f)(2), 124 Stat 119 (2010)
Stark Law (42 U.S.C. § 1395nn)
 Stark prohibits self-referrals for the provision of Designated
Health Services (DHS) and all claims for federal
reimbursement for such services furnished pursuant to a
referral, if a physician has a financial relationship, either
ownership or a compensation arrangement, with the entity
 A physician may not refer Medicare patients for designated
health services to an entity with which the physician or
immediate family member has a financial relationship
 Limited applicability to audiologists
Stark Law
 Civil, not criminal
 Denial of reimbursement, mandatory refunds, civil monetary
penalties, exclusion from federal and state health care programs
 Potential $15,000 Civil Monetary Penalty/service
 Up to three times the amount claimed
 Some states have their own Stark Laws and may be
broader than the federal law
Office of the Inspector General
 Oversees the AKS
 Oversees fraud and abuse within Medicare/Medicaid
 More extensive auditing occurring
 Offers opinions on specific scenarios
 Published that you cannot charge a Medicare
patient more than what you charge another patient
for the same service
 States also have AKS laws for Medicaid
A Roadmap……

http://oig.hhs.gov/compli
ance/physicianeducation/roadmap_we
b_version.pdf
False Claims
 What is considered a False Claim?
False Claim (cont.)
 Criminal offense to submit a false claim to the
government (Medicare and Medicaid)
 Offenses:






Submitting a claim for services not rendered
Submitting a claim for services not medically necessary
Not billing with the appropriate provider number
Falsifying a diagnosis
Upcoding
Unbundling a bundled code (92557, 92540, 92550 and 92570)
False Claims (cont.)

Can include:
 Overbilling
 Providing inferior products
 Falsifying claims and medical records to certify patients for benefits
 Billing for phantom services
 Duplicate billing
 Patterns of furnishing/billing for excessive or non-covered services
 Doug Lewis, JD, Ph.D., Au.D., MBA, Audiology Today JulAug 2012
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And then…
 “Ear Nose and Throat Associates of Corpus Christi, LLC
entered into a settlement agreement with the Office of
Inspector General (OIG) for the U.S. Department of Health
and Human Services, effective December 3, 2014
 The $200,630 settlement resolves allegations that for nearly
three years the practice improperly submitted claims to
Medicare and Texas Medicaid for hearing assessment
services performed by unqualified technicians”
 http://oig.hhs.gov/fraud/enforcement/cmp/cmp-ae.asp
False Claims Act (cont.)
 In May, 2013, 89 physicians, nurses, and other health
care providers in 8 cities were arrested for $223 million
in false claims
 A total of 600 providers for $2 billion in fraud
SLPs and the OIG
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aud_and_Abuse.pdf
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Examples:
OIG Guidance
 Office of the Inspector General issued the Special Fraud Alert
on December 19, 1994 stating may be considered “indicators
of potentially unlawful activity” for “failure to collect
copayments or deductibles for a specific group of Medicare
patients for reasons unrelated to indigency (e.g., a supplier
waives coinsurance or deductible for all patients from a
particular hospital, in order to get referrals).”
 http://oig.hhs.gov/fraud/docs/alertsandbulletins/121994.h
tml
False Claim (cont.)
 Civil penalties:
 $5,000-$11,000/claim
 Can be tripled depending on severity/prosecution costs
 No specific intent to defraud is required
 Criminal penalties:
 Up to 5 years in prison and/or
 Up to $10,000 in fines
False Claims and the Affordable Care Act
(2010)
 Report and return of overpayments made by Medicare




and Medicaid
Must be reported within 60 days of the discovery of the
overpayment
Overpayment may be considered a false claim
State False Claim laws may also apply
Whistleblower laws:
 15-30% of total recovery
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Health Insurance Portability and Accountability Act of 1996 (HIPAA)





Allows for portability and continuity of health
care for those who changed or lost their jobs
Combat fraud, abuse and waste in health
insurance and health care delivery
Improve access to long term care services
and coverage
Simplify the administration of health
insurance
Promote the use of medical savings accounts
https://www.gpo.gov/fdsys/pkg/PLAW-104publ191/html/PLAW-104publ191.htm
HIPAA (cont.)
 Must have policies and procedures that include:
 Notice of Privacy Practices (NPP)
 How Personal Health Information (PHI) is treated
 Encryption to prevent lost or stolen information
 E-mails
 Patient’s current, past and future health care information
 How a violation of PHI will be dealt with if lost, stolen or disclosed
 Perform annual documented HIPAA staff trainings and risk analyses
 Appoint an privacy officer
 http://www.hhs.gov/hipaa/for-professionals/index.html
HIPAA (cont.)
 Transaction and Code Sets (10/16/03)
 Privacy (4/14/03) Protecting personal health information
 Notice of Privacy Practices- 9/23/13
 Marketing/Remuneration and fund-raising changes
 How patients want their PHI to be handled
 Update patient info/signature annually
 Business Agreements (BA)
 Revise-BAs are now subject to HIPAA penalties (9/23/13)
Business Associate/Agreement


What Is a “Business Associate?” A
“business associate” is a person or entity that
performs certain functions or activities that involve the use or disclosure
of protected health information on behalf of, or provides services to, a
covered entity. A member of the covered entity’s workforce is not a business associate. A covered health
care provider, health plan, or health care clearinghouse can be a business associate of another covered
entity. The Privacy Rule lists some of the functions or activities, as well as the particular services, that make a
person or entity a business associate, if the activity or service involves the use or disclosure of protected health
information. The types of functions or activities that may make a person or entity a business associate include
payment or health care operations activities, as well as other functions or activities regulated by the Administrative
Simplification Rules.
Business associate functions and activities include: claims processing or administration; data analysis, processing
or administration; utilization review; quality assurance; billing; benefit management; practice management; and
repricing. Business associate services are: legal; actuarial; accounting; consulting; data aggregation;
management; administrative; accreditation; and financial. See the definition of “business associate” at 45 CFR
160.103.
-www.hhs.gov/hipaa/for-professionals/privacy/guidance/business-associates/
HIPAA Privacy
 To protect Personal Health Information (PHI):
 Patient’s names
 Patient demographic information and contact information
 Social security number
 Insurance information and plan numbers
 Patient’s state driver’s license and VINs
 Photo on driver’s license
 NOAH must be password protected
 Contains PHI, audiometric data and hearing aid serial numbers
HIPAA (cont.)

Security (4/21/05) To protect data integrity, confidentiality
 Physical safeguards, technical data and technical security services
 Passwords-for all systems and stand alone software
 Biometrics
 Electronic signatures
 Work PC
 NOAH
 Thumb drives, e-mail, CDs
 Disaster recovery
 Theft, fire, intrusion, other environmental hazards
 Data breaches
HIPAA (cont.)
 “Minimum necessary”
 Each facility/practice needs to have a HIPAA compliant
program in place
 Appoint a privacy officer
 Policy must be available in waiting area and a copy
offered to patients
 Patient signs the Notice of Privacy Practices (NPP)
 Encryption-computers, fax, copiers
Health Care Providers -Audiologists




Every health care provider, regardless of size, who electronically
transmits health information in connection with certain transactions, is a
covered entity
All “providers of services” (e.g., institutional providers such as
hospitals) and “providers of medical or health services” (e.g., noninstitutional providers such as physicians, dentists and other
practitioners) as defined by Medicare, and any other person or
organization that furnishes, bills, or is paid for health care
Transactions include claims, benefit eligibility inquiries, referral
authorization requests, or other transactions for which HHS has
established standards under the HIPAA Transactions Rule
The Privacy Rule covers a health care provider whether it
electronically transmits these transactions directly or uses a
billing service or other third party to do so on its behalf
Source: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html
Security Rule
 “…established a national set of security standards for
protecting certain health information that is held or transferred
in electronic form.”
 A major goal of the Security Rule is to protect the privacy of
individuals’ health information while allowing covered
entities to adopt new technologies to improve the quality
and efficiency of patient care
 Safeguards must be put in place to secure individuals’
“electronic protected health information” (“ePHI”)
Source: http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html
Risk Assessment for Security


Anytime a breach of PHI occurs, a risk assessment must be completed
Should include the following possibilities for risk as a result of these factors and the measures in
place to address them:
 Natural: Floods, earthquakes, tornadoes, landslides, avalanches, electrical storms, and other
such events.
 Human: Events that are either enabled by or caused by human beings, such as unintentional
acts (inadvertent data entry) or deliberate actions (network based attacks, malicious software
upload, unauthorized access to confidential information).
 Environmental: Long-term power failure, pollution, chemicals, and liquid leakage.

http://www.hhs.gov/hipaa/for-professionals/faq/2022/what-are-some-examples-of-threats-that-covered-entitiesshould-address/
HIPAA (cont.)


“Minimum necessary”
Each facility/practice needs to have a HIPAA compliant program in
place

Need to have a privacy policy for your office
 Must be accessible and offered to all patients
 They need to sign a Notice of Privacy Policy (NPP) attesting to how they want their PHI handled
 Includes mailings, voice mail messages
 Policy must be available in waiting area and a copy offered to patients
 Annual training for staff


Office of the Civil Rights (OCR) has responsibility for enforcement
Audits
 Practices are being currently being audited
HIPAA (cont.)
 If billing electronically, you are a covered entity (CE)
 As a CE, you need to have business agreements (BA)
with those companies with whom you exchange PHI
 Hearing aid vendors
 Earmold vendors
 Others
 Need plans in place to protect personal health
information
HIPAA Requirements:
 Written procedures with recovery plan
 Passwords
 Physical safeguards
 Locked cabinets if patient health information is contained therein
 Backed up information stored offsite
 Secure a HIPAA IT specialist
 Plan if breaches occur
 Need to determine low level of probability
HIPAA (cont.)
 Civil and criminal penalties
 Civil: $100-$25,000 per calendar year
 Correction within 30 days may lessen the penalty
 Monetary penalties only
 Criminal:
 Up to $50,000 and imprisonment for up to one year
Health Information Technology for Economic and Clinical Health
Act (HITECH) (ARRA 2009) 11/30/09; 1/11/11; 1/1/12
 Notification if there is a breach (2/17/10)
 Acquisition, access, use or disclosure of PHI not permitted by Privacy rules
 First class mail notification within 60 days of discovery of breach
 Dependent on how many are affected
 Must report to those who were affected and to the
Department of Health and Human Services (HHS) within
60 days of discovery if over 500 patients are identified
 If over 500 patients affected, must contact local media
 Business Associates need to implement their own HIPAA
compliant programs
HIPAA/HITECH Changes
 Effective September 23, 2013:
 Update your Notice of Privacy Practices (NPPs)
 New requirements for marketing and fundraising
 Required to redistribute to patient and displayed prominently
 Update security policy with breach notification specified
 Business Associates (BAs) having subcontractors must also
have BAs if they handle Personal Health Information (PHI)
 Must notify CEs if there is a breech
 Check with manufacturers, clearinghouses, other vendors
who handle PHI
524
HIPAA/HITECH Changes (cont.)
 Patients can request that a claim for their services not be
submitted to their payer if they pay privately
 Patients may request their electronic record and it must
be supplied to them in this manner, if possible
HIPAA HITECH (cont.)
 Marketing
 New rules apply when “a communication about a product or service
that encourages recipients of the communication to purchase or
use the product or service.”
 http://www.hhs.gov/hipaa/for-
professionals/privacy/guidance/marketing/index.html
 Applies to your patient’s data
 Manufacturer implications
HIPAA HITECH (cont.)
 Implications include:
 Manufacturer sponsored open houses
 Manufacturer sponsored marketing
 Business development funds for marketed products
 Discounts or promotions
HIPAA/HITECH (cont.)

Fines will rise to up to $1.5 million maximum per calendar year and up to 10
years imprisonment
 Patients’ rights to receive electronic copies of their health records
 Encryption
 If can’t deliver records electronically, must be able to provide in another
manner
 Patients may restrict disclosures to health plan if they pay privately, in full
 Data breaches with anything other than a low probability of compromise must be
reported to the affected patients and the federal government
 Risk assessments should be conducted, must be if a breach
 Process must be explained to patients, posted on practice websites
528
Breach Notification






Definition of Breach
A breach is, generally, an impermissible use or disclosure under the Privacy Rule that
compromises the security or privacy of the protected health information. An
impermissible use or disclosure of protected health information is presumed to be a breach
unless the covered entity or business associate, as applicable, demonstrates that there is a
low probability that the protected health information has been compromised based on a
risk assessment of at least the following factors:
The nature and extent of the protected health information involved, including the types of
identifiers and the likelihood of re-identification;
The unauthorized person who used the protected health information or to whom the
disclosure was made;
Whether the protected health information was actually acquired or viewed; and
The extent to which the risk to the protected health information has been mitigated.
 http://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html
Breach Notification (cont.)
“Covered entities that experience a breach affecting more
than 500 residents of a State or jurisdiction are, in addition
to notifying the affected individuals, required to provide
notice to prominent media outlets serving the State or
jurisdiction.”
http://www.hhs.gov/hipaa/for-professionals/breachnotification/index.html
“These individual notifications must be provided without
unreasonable delay and in no case later than 60 days
following the discovery of a breach and must include, to
the extent possible, a brief description of the breach, a
description of the types of information that were involved in the
breach, the steps affected individuals should take to protect
themselves from potential harm, a brief description of what the
covered entity is doing to investigate the breach, mitigate the
harm, and prevent further breaches, as well as contact
information for the covered entity (or business associate, as
applicable).”
http://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html
Breach Notification (cont.)
“If a breach affects 500 or more individuals, covered
entities must notify the Secretary without unreasonable
delay and in no case later than 60 days following a breach.”
Examples of Data Breaches:
 Cignet Health in Maryland--$4.3 million civil monetary penalty
($1.5 million CMP/willful violation)-patient requests for records
denied
 Massachusetts General Hospital--$1 million
 Several hundred patient records left on the subway
 Some were HIV patients
 Carelessness results in most breaches; many have been theft
Recent HIPAA Breaches:
 New York Presbyterian and Columbia University-PHI
publicly available, lack of policies/protections: $4.8
million
 Concentra-theft of unencrypted laptop: $1.7 million (QCA
Health Plan: $250,000)
 Skagit County, WA-PHI on a server, publicly available
$215,000
 Ober-Kaler presentation
Examples (cont.)



HealthNet in CA-$1.9 million subscribers on missing hard drives
HealthNet in CT-data security breach
UCLA-former employee’s computer stolen during a home burglary
 Contained PHI on 16,288 pts, no SS #s
 Paper containing password was missing
 Data encrypted
 First jailed HIPAA violator (4 months)-cardiothoracic
surgeon/researcher
 Viewed patient records, including his supervisor’s, co-workers’, celebrities;
did not have authorization for review
HIPAA Violations
(cont.)
 Nearly 300,000 Kaiser Permanente hospital records
were stored in a warehouse shared with a party rental
business and a car
HIPAA (cont.)
 August 2015, Excellus Blue Cross/Blue Shield had a
cyber attack that affected 10 million individuals
Occupational Safety and Health Act (OSHA)
 On both sides of the regulations:
 Must provide information and be in compliance regarding
sterilization of equipment and other instrumentation
 Label alcohol, disinfectants, etc.
 Testing for manufacturers
 Hearing loss incurred due to noise, solvents, gases or a combination
 Subject matter expert
 Forensic audiology
Infection Control Resources (Occupational Safety and Health Act)


Employee Training
Employers must ensure that their employees who have the risk of
occupational exposure participate in the training program that is
provided during the employee's normal working hours. The
program's structure must include training at the time of initial
assignment and then at least annually thereafter. The standard
specifies that the annual training must be provided within one year
of the previous training date.4
 http://www.infectioncontroltoday.com/articles/2000/08/osha-the-bloodborne-
pathogens-standard-and-you.aspx
Occupational Safety and Health Act In An Audiology
Practice

http://www.audiology.org/publications-resources/document-library/infectioncontrol-audiological-practice

https://www.osha.gov/dte/outreach/intro_osha/intro_to_osha_guide.html

https://www.osha.gov/Publications/2254.html

http://www.cdc.gov/oralhealth/infectioncontrol/faq/hand.htm

Some states require it as part of licensure (NY, FL)
Occupational Safety and Health Act In A Speech-Language
Pathology Practice
 http://www.asha.org/slp/infectioncontrol/https://www.osha.gov/
dte/outreach/intro_osha/intro_to_osha_guide.html
 https://www.osha.gov/Publications/2254.html
 http://www.cdc.gov/oralhealth/infectioncontrol/faq/hand.htm
 Some states require it as part of licensure (NY, FL)
Federal Drug Administration
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SLPs and the FDA
Classification of Speech Training Aids
 http://www.fda.gov/downloads/AdvisoryCommittees/Com
mitteesMeetingMaterials/MedicalDevices/MedicalDevice
sAdvisoryCommittee/EarNoseandThroatDevicesPanel/U
CM445493.pdf
From
http://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/Ho
meHealthandConsumer/ConsumerProducts/HearingAids/ucm181484.h
tm

Get a check up. Go to a doctor, preferably an ear, nose, and throat physician (also known
as an otolaryngologist) to get a medical exam. The medical exam will rule out any medical
reason for your hearing loss which would require medical or surgical treatment. You will
receive documentation of your medical exam and a statement that says you are a
candidate for hearing aids. Your doctor can also give you a referral to an audiologist or a
hearing aid dispenser if your health plan requires a doctor’s referral for services.
Note: You have the option to sign a waiver saying you do not want a medical exam to rule
out any medical reason for your hearing loss. However, FDA believes that it is in your
best health interest to have the medical exam by a licensed physician before buying
hearing aids. Consider going to an audiologist. An audiologist will perform an
audiological exam to determine the type and amount of your hearing loss, and will counsel
you as to your non-medical options to improve your hearing loss. Buy your hearing aid
from a licensed hearing healthcare professional. This will typically be an audiologist, a
hearing aid dispenser, or an ear, nose, and throat physician . Provide your documentation
that you received from your doctor that states you are a hearing aid candidate. Ask your
hearing healthcare professional to help you determine what features you will need.
FDA Red Flags








Visible congenital or traumatic deformity of the ear.
History of active drainage from the ear in the previous 90 days.
History of sudden or rapidly progressive hearing loss within the previous 90
days.
Acute or chronic dizziness.
Unilateral hearing loss of sudden or recent onset within the previous 90
days.
Audiometric air-bone gap equal to or greater than 15 decibels at 500 Hz,
1,000 Hz, and 2,000 Hz.
Visible evidence of significant cerumen accumulation or a foreign body in
the ear canal.
Pain or discomfort in the ear.
American Disabilities Act (ADA)

Promulgated in 1990
 “An Act to establish a clear and comprehensive prohibition of
discrimination on the basis of disability.”
 Audiologists may be on both sides of this:
 You are required to make your office as accessible as possible
 Physical accessibility as well as providing interpreters for the hearing impaired
 Can’t charge the patient for this service
 You may be requested to offer subject matter expert assistance if someone
challenges their lack of accessibility regarding hearing loss and amplification
accommodations
http://www.eeoc.gov/laws/statutes/ada.cfm
Reimbursement Resources
 http://www.audiology.org/practice/reimbursement/me
dicare/Pages/Medicare_FAQ.aspx
 http:www.cms.gov
 http://www.audiology.org/practice/reimbursement/me
dicare/Documents/201105_CMS_1500_Form_At_A
_Glance.pdf
 http://www.audiology.org/practice/reimbursement/me
dicare/Documents/enrollmentOptions4medicare.pdf
Scenario #1:
 My patient and I both want to know what the insurance
payment will be for his binaural hearing aids.
 Since that insurance company won’t give us the amount,
I submit the claim to see what his out of pocket
expenses will be so that we all know what he will be
responsible for and will then dispense his hearing aids.
Scenario #1 Response:
•
•
Criminal offense to submit a false claim to the
government (Medicare and Medicaid)
Offenses:
•
•
•
•
•
•
Submitting a claim for services not rendered
Submitting a claim for services not medically necessary
Not billing with the appropriate provider number
Falsifying a diagnosis
Up coding
Unbundling a bundled code (92557, 92540, 92550 and 92570)
Scenario #2
 My insurance company’s fee schedule offers $6000 for
binaural hearing aids. A month after the premium devices
were dispensed, they sent me a letter requesting $3000
back due to an error in payment.
 The patient must return the devices and we will have to
give her lesser technology.
Scenario #2 Response
•
Submit an appeal to the insurance company
•
Secure guidance from your state’s insurance department
•
Secure an opinion from your state licensure board
•
Secure an opinion from your professional organizations’
ethical practice committees
Scenario #2 Response (cont.)
•
You are providing what you and the patient agreed upon
and did so in good faith with the payer
•
Waivers may be beneficial in this instance so the patient
understands there may be a reconfiguration of their
benefit for which they should alert their Human
Resource department
Scenario #3
 I perform pure tone air conduction, speech reception
thresholds and word recognition
 I bill CPT code 92557
 Thoughts?
Scenario #3 Response
 CPT code 92557 requires pure tone aid AND bone
conduction, speech reception thresholds and word
recognition
 If you don’t complete all of the components of what is
required, use the -52 modifier for reduced services
 It may not be recognized by the payer, but it must be
appended
Scenario #4
 I perform tympanometry and ipsilateral acoustic reflex
thresholds bilaterally.
 I file the claim for 92550
 Thoughts?
Scenario #4 Response
 CPT code 92550 includes ipsilateral and contralateral
frequencies for a total of 14 reflexes
 4 Contra right and left ears (8)
 500, 1000, 2000 and 4000 Hz
 3 Ipsilateral right and left ears (6)
 500, 1000 and 2000 Hz
Scenario #5
 I perform tympanometry but can’t get a seal
 Can I bill for this procedure?
Scenario #5 Response
 If you attempt a procedure and have that documented,
suggest billing it with: -52
 Per the AMA’s Coding with Modifiers 5th edition:
 “Modifier 52 is appended when a service or procedure is
partially reduced or eliminated at the physician’s
discretion ie., started but discontinued.”
Scenario #6
 I perform a Dix Hallpike maneuver
 How do I bill for this?
Scenario #6 Response
 It is included as a position--CPT code 92542
Your Turn!
Changing Landscape
 Outcome measures
 Best practices
 Online hearing aids
 Providing services to patients who purchased online?
 Office policy for hearing aids not purchased in your office
 Specify services/fees for devices purchased from an audiologist or hearing aid
dispenser
 Specify services/fees for online purchased devices
Changing Landscape (cont.)
 You may be in violation of existing contracts if you refuse to service
these patients with these devices
 Itemize
 Charge for the services you are providing
 Hearing Loss Association of America promotes itemization for
transparency in costs and services
Changing Landscape (cont.)
 The marriage of one hearing aid company and one third
party payer is likely just the beginning
 “There’s an app for that”
 iPhone applications for testing and for the dispensing of hearing
aids and other wearables
Audiology Relevancy
 Consider providing other niche services:
 Vestibular services
 Tinnitus services
 Central auditory processing diagnostics and treatment
 Assistive listening devices
 Looping services
 Support staff
 Audiology aides/assistance, if recognized by state licensure
Areas of interest and potential in offering
hearing and balance services in this
dynamic environment
“It’s not about the widget…”
For your consideration….
Changing Landscape

Outcome measures similar à la PQRS
 Methodology for Medicare reimbursement in 4-6 years??
 Best practices will prevail in payment paradigms

Online hearing aids and PSAPs
 Providing services to patients who purchased online?
 Office policy for hearing aids not purchased in your office
 Specify services/fees for devices purchased from an audiologist or hearing aid dispenser
 Specify services/fees for online purchased devices
 Providing services to patients who want the “cheat(p)er” level of technology
 Office policy
Changing Landscape (cont.)
 You may be in violation of existing contracts if you refuse to provide
services to these patients with these devices
 Itemize
 Charge for the services you are providing
 Hearing Loss Association of America promotes itemization for
transparency in costs and services
Changing Landscape (cont.)

The marriage of one hearing aid company and one third party payer
 hiHealth Innovations and United Health Care
 Others

Big box retail
 Costco
 Sam’s
 Walmart

Online
 Hearing Planet
 Hearing aids
Changing Landscape (cont.)
 “There’s an app for that”
 iPhone applications for testing and for the dispensing of hearing
aids and other wearables
 Starkey’s Halo, Muse, Soundlens
 Soundhawk
 Eargo
 Audicus
 Others
Federal Drug Administration (FDA)
 Class I
Hearing aids
 Class II Tinnitus devices/auditory trainers
 Class III Cochlear implants
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SlidesCarnival icons are editable shapes.
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SlidesCarnival icons are editable shapes.
This means that you can:
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Change line color, width and style.
Isn’t that nice? :)
Examples:
Starkey
Eargo
SlidesCarnival icons are editable shapes.
This means that you can:
●
Resize them without losing quality.
●
Change fill color and opacity.
●
Change line color, width and style.
Isn’t that nice? :)
Examples:
SlidesCarnival icons are editable shapes.
This means that you can:
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Resize them without losing quality.
●
Change fill color and opacity.
●
Change line color, width and style.
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Examples:
Other Disruptions:
Audiology Relevancy
 Consider providing other niche services:
 Vestibular services
 Tinnitus services
 Central auditory processing diagnostics and treatment
 Assistive listening devices
 Wearables
 Looping services
 Support staff
 Audiology aides/assistance, if recognized by state licensure
Codes for Tinnitus Evaluation and Treatment
 CPT code:
 92625 Assessment of tinnitus (includes pitch, loudness
matching, and masking)
 Other tests performed
 ICD-10 code: H93.1
 H93.11
Tinnitus, right ear
 H93.12
Tinnitus, left ear
 H93.13
Tinnitus, bilateral
 H93.19
Tinnitus, unspecified ear
Codes for Central Auditory Processing Disorders
 CPT codes:
 92620 Evaluation of central auditory function, with report; initial 60
minutes
 92621 Evaluation of central auditory function, with report; each
additional 15 minutes
CAPD (cont.)
 ICD-10 codes: H93.2 Other abnormal auditory
perceptions
 H93.25 Central auditory processing disorder
 H93.29 Other abnormal auditory perceptions
 H93.291 Other abnormal auditory perceptions, right ear
 H93.292 Other abnormal auditory perceptions, left ear
 H93.293 Other abnormal auditory perceptions, bilateral
 H93.299 Other abnormal auditory perceptions, unspecified ear
Codes for Vestibular Evaluation




92540 Basic vestibular evaluation
92541 Spontaneous nystagmus test, including gaze and fixation
nystagmus, with recording
92542 Positional nystagmus test, minimum of 4 positions, with
recording
92537 Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm
and one cool irrigation in each ear for a total of four irrigations)
OR

92538 Monothermal, (i.e., one irrigation in each ear for a total of two irrigations)
Codes for Vestibular Evaluation (cont.)
 92544 Optokinetic nystagmus test, bidirectional,




foveal or peripheral stimulation, with recording
92545 Oscillating tracking test, with recording
92546 Sinusoidal vertical axis rotational testing
92547 Use of vertical electrodes (list separately in
addition to code for primary procedure)
92548 Computerized dynamic posturography
Codes for Vestibular Treatment
 CPT codes:
 95992 Canalith Repositioning Procedure
 Check with payers; Medicare and others will not recognize
audiologists for this procedure
 ICD-10 codes:
 R42
Dizziness and giddiness
 H81.1 BPPV
 H81.0-H83.2X Other dizzy related codes
Codes for Cochlear Implant Services

CPT codes:
 92601 Diagnostic analysis of cochlear implant, patient under 7
years of age; with programming
 92602 Diagnostic analysis of cochlear implant, patient under 7
years of age; subsequent reprogramming
 92603 Diagnostic analysis of cochlear implant, age 7 years or older
with programming
 92604 Diagnostic analysis of cochlear implant, age 7 years or older
with reprogramming
 92626/7 Evaluation of auditory rehabilitation status, first hour/each
additional 15 minutes
Codes for Cochlear Implant Services (cont.)
 ICD-10 codes:
 H90.3 SNHL, bilateral
 H90.41 SNHL, right ear
 H90.42 SNHL, left ear
 H90.5 Unspecified HL (several listed as NOS, not otherwise
specified)
IONM and Nerve Conduction Study CPT Codes (1/1/13)

CPT code 95940:
 Continuous intraoperative neurophysiology monitoring in the operating
room, one on one monitoring requiring personal attendance, each 15
minutes
 Must bill with 92585
 CPT code 95941:
 Continuous intraoperative neurophysiology monitoring from outside the
operating room (remote or nearby) or for monitoring of more than one case
while in the operating room, per hour
 Must bill with 92585
 Can’t bill outside of OR to Medicare
IONM and Nerve Conduction Study CPT Codes (cont.)
 G0453 Continuous IONM from outside the operating
room (remote or nearby), per patient, (attention directed
exclusively to one patient) each 15 minutes
 List with 92585
 Billed in units of 15 minutes
IONM and Nerve Conduction Study CPT Codes (cont.)



CPT codes 95905-95913
CPT code 95905
 Motor and/or sensory nerve conduction, using preconfigured electrode array(s), amplitude and latency/velocity
study, each limb, includes F-wave study when performed, with interpretation and report
Code chosen is dependent on the number of completed studies:
 CPT code 95905: Report only once per limb studied
 CPT code 95907: Nerve conduction studies 1-2 studies
 CPT code 95908: 3-4 studies
 CPT code 95909: 5-6 studies
 CPT code 95910: 7-8 studies
 CPT code 95911: 9-10 studies
 CPT code 95912: 11-12 studies
 CPT code 92913: 13 or more studies
IONM ICD codes
 ICD-10 Code for the reason for the test, type of hearing
loss or other audiologic/pre-diagnosed findings
Codes for Auditory Rehabilitation
 CPT codes:
 92626 Assessment of auditory rehabilitation status; first
hour
 92627 each additional 15 minutes
 92630 Auditory rehabilitation; prelingual hearing loss
 92633 Auditory rehabilitation; postlingual hearing loss
Codes for Auditory Rehabilitation (cont.)

ICD-10 codes:
 H93.299 Other abnormal auditory perceptions, unspecified ear
 H90.3 SNHL, bilateral
 H90.41SNHL, uni, right ear, with unrestricted hearing contralateral side
 H90.42 SNHL, uni, left ear, with unrestricted hearing contralateral side
 H90.3 SNHL, bilateral
 H90.8, H90.71, H90.72, H90.6 Mixed hearing loss family
 H90.5 Unspecified SNHL
 R94.120 Abnormal auditory function study
Common Audiology Coding Errors
 I perform pure tone air, speech reception thresholds and
word recognition testing bilaterally
 The patient has normal hearing acuity, so I don’t perform
bone conduction
 I bill 92557
Modifiers (cont.)
 -52 Reduced services
 Procedure is partially reduced or eliminated
 Discontinued at provider’s discretion after the procedure commenced
 Can be used to indicate monaural vs. binaural testing
 Can be appended to indicate that not all requirements of the code
were completed
 Not recognized by all carriers
 Example: 92557-52
Common Audiology Coding Errors
 I don’t get reimbursed enough for 92557 for all that I do
(case history, otoscopy, testing, counseling) but I do it
anyway
 The patient wants to proceed with hearing aids and
returns for a hearing aid evaluation
 I perform CPT code 92626, Evaluation of Auditory
Rehabilitation Status to discuss hearing aid options
 I bill 92626 to Medicare
Guidance on CPT code 92626
 Evaluation of auditory rehabilitation status, first hour
 92627, Evaluation of auditory rehabilitation status; each
additional 15 minutes
AAA, ADA, ASHA guidance
 Use to report the function of a patient pre and/or post
them receiving unilateral or bilateral hearing devices
including:
 Hearing aid(s)
 Auditory osseo-integrated implant(s)
 Middle ear implant(s)
 Cochlear implant(s)
 Auditory brainstem implant
Guidance (cont.)

AMA’s CPT Assistant, July 2014 states:
 “the evaluation will determine the need for auditory rehabilitation following the
fitting and verification of hearing devices and may also be used to monitor the
progress of therapeutic intervention.”
 To determine the need for rehabilitation


Check with patient’s third party payer
In the example, should use one of the hearing aid evaluation codes:
 92591 (monaural) or
 92592 (binaural) or
 V5010
 Choice will likely be payer dependent
 Check your fee schedules
Finally…
 Do not bill this scenario to Medicare
 Hearing aids are not a covered service
 Should use for:
 Cochlear implant(s)
 Osseo-integrated device(s)
 Auditory brainstem implant
 Include what and why you performed what you did in
your documentation
Medical Necessity Scenario
 Our office policy is for the initial visit, the patient must
have comprehensive audiometry (92557), tympanometry
and reflexes (92550) and otoacoustic emissions (92587)
 They have a symmetric 60 dB HL SNHL AU with goodexcellent WRS, tympanograms within normal limits and
reflexes present at all frequencies tested
 Does performing tympanometry, reflexes and OAEs
meet medical necessity?
Medical Necessity Definition
 Title XVIII of the Social Security Act, section 1862 (a)(1)(a):
Notwithstanding any other provisions of this tile, no
payment may be made under Part A or Part B for any
expenses incurred for items or services, which are not
reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the
functioning of a malformed body member
One more…
 I perform tympanometry and acoustic reflex thresholds
ipsilaterally
 I bill 92550
 Is this correct?
92550 Code Descriptor
 Procedure is to be ipsilateral and contralateral, bilaterally
for more than 2 reflexes
No…
 Should use the -52 modifier for reduced services since
you are not performing all the requirements listed for the
code
 Some payers may not recognize it, but must append it
SlidesCarnival icons are editable shapes.
This means that you can:
●
Resize them without losing quality.
●
Change fill color and opacity.
●
Change line color, width and style.
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Examples:
Questions?
Debbie Abel, AuD
Manager, Coding and Contract Services
360.558.5658
[email protected]