Download Audiology Boot Camp: Compliance, Coding and

Compliance, Coding,
Reimbursement, and
Practice Management
for the Audiology
Practice
Kim Cavitt, AuD
Audiology Resources, Inc.
Live Streamed from Chicago, IL
February 23-24, 2017
Learning Outcomes
• Attendees will be able to:
• …list Federal regulations applicable to
audiology.
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....identify the FDA warning signs of
ear disease.
• …describe the differences between
bundling and unbundling.
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...list the CPT and HCPCS codes to be
used when fitting a hearing aid.
...define managed care terms.
2
A Bit of Housekeeping…
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We will be utilizing Poll Everywhere throughout the event.
The only attendees that are eligible for CEUs are those who
paid to attend this event.
The only attendees able to ask questions during and after the
event are the paid attendees themselves.
You will have until March 10 to complete the course
evaluation. This is required for CEUs to be processed.
•
This will come as a separate email on Monday.
3
Things to Know As We Start
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I will say things that are unpopular…
You decide what you do with the information presented over the next two
days.
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I try to document myself as much as possible though the inclusion of
links.
I try to keep politics out of this as much as possible but it is not always
possible.
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I want everyone to make informed decisions.
Healthcare reform is a moving target…what I tell you today may not apply
tomorrow.
I ALWAYS err on the conservative side of the laws and regulations.
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Many laws and regulations are too broadly written not to take this stance.
I am NOT an attorney and am not providing legal advice.
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I consulted a healthcare attorney in preparing this boot camp.
I strongly suggest every practice retain counsel for legal questions and
concerns.
4
HIPAA
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Health Insurance Accountability and Portability Act of
1996 (HIPAA)
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Civil and criminal penalties
https://www.hhs.gov/hipaa/for-professionals/index.html
Covers:
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Standard Transaction and Code Sets
National Provider Identifier
National Employer Identifier
HIPAA 5010
Security
HITECH (Breach Notification)
Privacy
• Marketing
• Business Associates
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HIPAA Audits
• HIPAA is now being audited by HHS.
• As a result, it is very important that you
follow the requirements set forth.
• http://www.hhs.gov/hipaa/forprofessionals/complianceenforcement/audit/
Standard Transaction and Code
Set
• This aspect of HIPAA requires
that the following code sets be
utilized for documenting and
billing all medical items and
services:
• CPT (Current Procedural Terminology)
• ICD 10 (International Classification of
Diseases-10th Revision)
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HCPCS (Healthcare Common
Procedure Coding System)
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National Provider Identifier (NPI)
• Requires that each individual provider utilize
their own distinct, unique individual provider
identification number for all payers.
• This number stays with the provider as they move
from employer to employer.
• National Provider Identifier (NPI)
• National Plan and Provider Enumeration System
(NPPES)
• https://nppes.cms.hhs.gov/NPPES/Welcome.do
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National Employer Identifier (EIN)
• Requires that each individual practice or facility
utilize their own distinct, unique practice or facility
identification number for all payers.
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This is required for every practice or facility except a sole
proprietorship.
The EIN is issued by the Internal Revenue Service (IRS).
Each practice also needs a facility or practice National
Provider Identifier (NPI).
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National Plan and Provider Enumeration System (NPPES)
• https://npiregistry.cms.hhs.gov/
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HIPAA 5010
• This was a systems update that went into effect
January 1, 2012 (enforcement began ion March 31,
2012) on that required systems updates to allow for
transition to ICD-10.
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Affected software vendors, payers, and clearinghouses
much more than providers.
https://www.cms.gov/Regulations-and-Guidance/HIPAAAdministrativeSimplification/Versions5010andD0/Version_5010.html
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837 Claims Format
• 837
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Claims submission format set forth in HIPAA 5010.
You should ask your office management vendor or EMR about this
format.
• CMS 1500
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Paper claim form
• http://www.cms.gov/outreach-and-education/medicarelearning-network-mln/mlnproducts/downloads/837p-cms1500.pdf
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Protected Health Information
(PHI)
• Names
• Street number and name, city, and last two digits
of the zip code
• Dates directly related to the individual (birth date)
• Phone number
• Fax number
• Email address
• Social security number
• Medical record number
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Protected Health Information
(PHI)
• Health insurance member number
• Account numbers
• Certificate or license numbers
• Vehicle identifiers and serial numbers
• Device identifiers and serial numbers
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Hearing aid serial numbers
• URLs
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Protected Health Information
(PHI)
• IP addresses
• Biometric indicators
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Finger, retinal, and voice prints
• Photos
• Any unique identifying number, characteristic or
code
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Security
• The Security Rule is an extension of the Privacy
Policy.
• Went into effect April 20, 2005.
• Applies to electronic formats.
• Providers need to have:
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Administrative Safeguards.
Physical Safeguards.
Technical Safeguards.
• You also need policies and procedures related to
operations and documentation.
• http://www.hhs.gov/hipaa/forprofessionals/security/index.html
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Security Rule
• Covered entities must:
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“Ensure the confidentiality, integrity, and availability of all
e-PHI they create, receive, maintain or transmit.
Identify and protect against reasonably anticipated
threats to the security or integrity of the information.
Protect against reasonably anticipated, impermissible
uses or disclosures.
Ensure compliance by their workforce.”
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Security Rule: Risk Assessment
• “A risk analysis process includes, but is not limited
to, the following activities:
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Evaluate the likelihood and impact of potential risks to ePHI.
Implement appropriate security measures to address the
risks identified in the risk analysis.
Document the chosen security measures and, where
required, the rationale for adopting those measures.
Maintain continuous, reasonable, and appropriate
security protections.”
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Security Rule: Risk Assessment
• What do audiologists need to think about?
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Computers
Phones
Tablets
Fax Machines
Answering Machines
Audiometers
Test Suites
OMS/EMR
NOAH
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Security Rule:
Administrative Safeguards
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Security Measures
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To reduce risks of breaching protected health information.
Need a Security Officer
Information Access Management
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Regulate who has access to protected health information.
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Minimum necessary access
Training and Accountability
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Authorize access to PHI.
Train staff on policies and procedures.
Sanction staff who do not comply.
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Security Rule:
Physical Safeguards
• Facility access and control
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Limiting and controlling physical access.
• Workstation and device security
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Proper use and access to workstations and electronic
devices.
Policies and procedures related to:
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Transfer.
Removal.
Disposal.
Re-use.
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Security Rule:
Technical Safeguards
• Control of access
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Passwords to protect access.
• Audit
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Safeguards to record and examine access.
• Integrity control
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Ensure that PHI is not improperly altered or destroyed.
• Transmission security
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Protections against “hacking.”
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Security Rule:
Policies, Procedures and Documentation
• You must develop policies and procedures to comply
with the security rule.
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If need guidance, consult an IT consultant who specializes in
HIPAA.
• Must have written policies and procedures.
• Need to document staff training, actions, activities, and
risk assessments.
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Business Associate
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“A business associate is a person or organization, other
than a member of a covered entity's workforce, that
performs certain functions or activities on behalf of, or
provides certain services to, a covered entity that involve
the use or disclosure of individually identifiable health
information. Business associate functions or activities on
behalf of a covered entity include claims processing, data
analysis, utilization review, and billing.”
“Business associate services to a covered entity are limited
to legal, actuarial, accounting, consulting, data
aggregation, management, administrative, accreditation, or
financial services.”
Providers are responsible for the actions of their business
associates.
http://www.hhs.gov/hipaa/forprofessionals/privacy/guidance/business-associates/index.html
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Common Audiology Business Associates
• Hearing aid manufacturers
• Earmold manufacturers
• Accountant
• Lawyer
• OMS vendor
• IT consultant
• Buying/management group
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HITECH-Breach Notification
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Effective date of February 17, 2010.
Applies to paper and electronic formats.
Breach:
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An “impermissible” or unauthorized use or disclosure of PHI.
Must do a risk assessment.
Breach notification:
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Must occur within 60 days.
Providers and business associates have burden of proof that notifications have been
made.
Business Associates must notify the covered entity.
Notify the individual.
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Notify the Media:
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Oftentimes provide identity theft protections.
If breach is of more than 500 individuals.
Notify Secretary of Health and Human Services:
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If breach is of more than 500 individuals.
http://www.hhs.gov/hipaa/for-professionals/breach-notification/index.html
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Privacy Rule
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Protections of patient’s health information and PHI.
Effects both paper and electronic records.
Effective April 14, 2003 and updated in January 2013.
Protects “Individually identifiable health information” is
information, including demographic data, that relates to:
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The individual’s past, present or future physical or mental health or
condition,
The provision of health care to the individual,
The past, present, or future payment for the provision of health
care to the individual, and that identifies the individual or for which
there is a reasonable basis to believe it can be used to identify the
individual.
Individually identifiable health information includes many common
identifiers (e.g., name, address, birth date, Social Security
Number).
http://www.hhs.gov/hipaa/for-professionals/privacy/index.html
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Privacy: Disclosures That Do Not Require
Authorization
• Treatment
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Ordering/referring physician.
Physician/provider you are referring to.
Coordination of care.
• Payment
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Insurance carrier.
• Health Care Operations
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“Certain administrative, financial, legal, and quality improvement
activities of a covered entity that are necessary to run its business”
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Privacy Rule Specifics:
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Keep disclosures to “minimum necessary.”
Need a Privacy Officer.
Need training on privacy and that training must be
documented.
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New hires.
Annually
Must have a complaint process.
Must have record safeguards:
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Storage.
Disposal.
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HIPAA: 7 years
Need though to consult state and payer record retention requirements
as they can exceed HIPAA.
Access.
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Privacy Rule Specifics:
• Email
• Texting
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Both can be done with patients through
encrypted/secured service providers.
http://www.hipaajournal.com/texting-violation-hipaa/
https://www.fusemail.com/resource-center/whitepapers/ensure-email-ephi-hipaa-compliant/
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Use and Disclosure
• The HIPAA version of a medical release.
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Could also list who can be disclosed to on intake form.
• This is a specific, HIPAA form.
• Allows the patient to list who can be disclosed to and what
can be disclosed.
• Can also restrict disclosures here.
31
Privacy Rule: Marketing
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The Privacy Rule defines “marketing” as making “a
communication about a product or service that
encourages recipients of the communication to purchase
or use the product or service.”
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Applies to marketing sent to your database only.
“An arrangement between a covered entity and any
other entity whereby the covered entity discloses
protected health information to the other entity, in
exchange for direct or indirect remuneration, for the
other entity or its affiliate to make a communication about
its own product or service that encourages recipients of
the communication to purchase or use that product or
service.”
http://www.hhs.gov/hipaa/forprofessionals/privacy/guidance/marketing/
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Marketing versus Education
• Marketing
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Requires authorization
Is a third-party paying for the communication?
Are you trying to get a patient to purchase an item or service?
Are you “marketing”:
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Price
Product
Promotion
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Marketing versus Education
• Education
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Does not require authorization.
Talks about technology, not product
No mention of specific products or price.
No promotions.
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Privacy Rule:
Marketing Decision Matrix Poll
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Do you co-op marketing with a third-party?
Are you an equity member of a buying group whose
products you market?
Do you have a lease or loan from a third-party vendor?
Do you have a business development fund for products
you market?
Do you go on vendor-funded trips?
Do you offer discounts, promotions, offers, or discounts?
Do you participate in Medicaid, Medicare, Worker’s
Compensation, or TriCare?
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Long Form vs. Short Form Marketing
Authorization
• Short form
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No remuneration, in cash or in kind, exchanges hands in any form
for products you market.
You pay for all of your own marketing communications, in full,
that are sent to your database.
Example:
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By initialing this section and signing below, I authorize
_________________________ to send me educational and/or
marketing information on the products and services offered by
____________________________. No remuneration is involved in
this communication. I understand that I may revoke this
authorization, in writing, at any time.
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Long Form vs. Short Form Marketing
Authorization
• Long form
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Remuneration, in cash or in kind, occurs regarding a product or
service you are marketing.
The vendor is paying in whole or in part for the communication.
One page document.
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Omnibus Rule
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Effective September 23, 2013.
Business associates (any entity that creates, receives,
maintains, or transmits PHI on behalf of a provider who
supplied this information to them) and their contractors
and subcontractors, are required to comply to the
updated HIPAA Privacy and Security Rules, including
breach notification.
Patients have the right to request that a copy of their
electronic medical record be supplied to them in an
electronic format.
http://www.hhs.gov/hipaa/for-professionals/privacy/lawsregulations/combined-regulation-text/omnibus-hipaarulemaking/
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Omnibus Rule
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Patients who are paying privately for an item or
service have the right to restrict any disclosure about
this item or service to their health plan.
“Marketing” has been redefined as any patient
communication where the provider receives financial
remuneration from a third-party whose products or
services are being marketed. When “marketing” is
being performed using PHI, a patient authorization
must be in place prior to sending this marketing
communication.
The sale of PHI is prohibited.
There must be a defined breach notification process
where a situation is presumed to be a breach until the
provider, business associate, contractor, or
subcontractor determines that there is a low probability
that the patient’s privacy has been compromised. A
risk assessment must be performed anytime there is a
breach of PHI.
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Omnibus Rule
• Allows for broader use of PHI for fundraising
opportunities.
• Allows for a streamlined authorization process for
use of PHI for research purposes.
• Penalties have increased to up to $1.5 million
maximum per calendar (many fines range
between $100 and $50,000 per violation and
degree of culpability) and up to 10 years in jail.
41
What Every Practice Needs:
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2013 or newer revised Notice of Privacy Practices
2013 or newer revised Business Associate Agreement
2013 or newer revised Breach Notification Policy
2013 or newer revised Marketing Authorization
Providers with individual NPIs
Facility NPI
Use and Disclosure form
Acknowledgement of Receipt of Notice of Privacy
Practices
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Can be added to your intake form.
Security Policy and Process
Breach Notification Policy and Process
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What Every Practice Needs:
• Risk Assessment Process for breaches.
• Independent Contractor Agreement that includes
HIPAA Language
• Documentation of Staff Training
• Employee Confidentiality Form
43
Office of the Inspector General
• Also known as OIG.
• They are the “policemen” and “auditors” of Medicare and
Medicaid.
• http://oig.hhs.gov
45
We Are NOT Immune….
• http://oig.hhs.gov/newsroom/mediamaterials/2016/takedown.asp
• http://oig.hhs.gov/fraud/docs/alertsandbulletins/sfanursing
facilities.pdf
• https://www.justice.gov/sites/default/files/opa/legacy/2014
/05/13/lovelace-et-al.pdf
The Importance of Codes of
Ethics
• Please be aware of :
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The ethical guidelines outlined in your State licensure law.
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Failure to comply can result in the loss of your license.
Ignorance is not a defense.
The Codes of Ethics of organizations which you are a
member.
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Failure to comply can result in you being removed from this
organization and/or losing your credentialed status.
Also, some of the aspects of a Code of Ethics can also protect
you from violating legal statutes, laws, rules, or regulations.
47
Professional Codes of Ethics
• AAA
•
http://www.audiology.org/resources/documentlibrary/Pages/co
deofethics.aspx
• ASHA
•
http://www.asha.org/Code-of-Ethics/
48
Ethical Quandary?
• Would you feel comfortable telling your patient about
your:
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Vendor funded trip?
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Business Development Fund?
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May have OIG implications.
May have OIG implications.
Vendor Payment Arrangement?
Gifts from vendors?
49
Ethical Practice Guidelines on Financial Incentives
from Hearing Instrument Manufacturers
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Created by AAA and ADA in 2003 and updated by
AAA in July 2011.
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http://audiologyweb.s3.amazonaws.com/migrated/20140114_EPC_I
ndustryGuideline.pdf_5382ed0f4cb195.24348078.pd
f
Arrangements you must avoid:
• Prid Pro Quo
• An exchange of goods or services where one transfer is
contingent on another.
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Ethical Practice Guidelines on Financial
Incentives from Hearing Instrument
Manufacturers
• Conflicts of Interest
• Ownership interests in company’s whose products you dispense.
• Disclosure of any commercial interests to patients.
• Disclosure of consulting relationship to patients.
• Acceptance of gifts of any value from manufacturers.
• Disclosure of remuneration for research.
• Incentive trips (rewarded for conducting business).
• Business Development Funds.
• Lease arrangements.
• Cash rebates.
• Sales quotas with manufacturer in order to receive an incentive.
52
•
When Ethics Violations Can
Turn Into Legal Problems
Anti-Kickback legislation:
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http://oig.hhs.gov/compliance/physicianeducation/roadmap_web_version.pdf
Criminal penalties.
It is a felony to knowingly and willfully solicit or receive any
remuneration, directly, or indirectly, overtly or covertly, in cash or in
kind, in return for purchasing, leasing, or(or recommending the
purchase, lease, or ordering ) of any item or service reimbursable
in whole or in part under a federal health care program.
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Medicare
Medicaid
Tricare
They create an incentive to overutilize particular goods and
services, impinge upon the patient care process, and create an
unfair competitive environment to those who refuse to provide
remuneration.
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When Ethics Violations Turn Into
Legal Problems
• Some examples from Audiology
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An audiologist furnishes hearing tests to a physician’s patients at
less than fair market value (or free) in exchange for hearing aid
referrals where some of these referrals may be for instruments
covered under a Federal health program.
When an audiologist purchases X number of products and gets X
free from a manufacturer and bills a federal payer for any of these
products once they have been provided to the patient and does not
disclose the “buy one, get one” deal
54
What Can I Give Patients?
• Anything that is less than $10 in value per item or less than
$50 per year.
• https://oig.hhs.gov/fraud/docs/alertsandbulletins/SABGifts
andInducements.pdf
• http://www.hawleytroxell.com/2011/11/gifts-to-patientsand-potential-referral-sources/
• http://www.hhhealthlawblog.com/2013/11/gifts-toreferral-sources-and-patients.html
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What Can I Give Physicians?
• Gifts of “nominal value” (although they do not define
this).
• It is better to give nothing!
• http://www.hhhealthlawblog.com/2013/11/gifts-toreferral-sources-and-patients.html
• http://www.hawleytroxell.com/2011/11/gifts-to-patientsand-potential-referral-sources/
56
What Gifts Can I Receive from Industry?
• Nominal value only.
• Education is allowed.
• http://journalofethics.ama-assn.org/2014/04/coet21404.html
• http://www.hhhealthlawblog.com/2013/11/gifts-toreferral-sources-and-patients.html
57
Relationships to Vendors
• Sunshine Act: The Sunshine Act requires manufacturers of
pharmaceuticals, medical devices, biological and medical
supplies covered by Medicare, Medicaid or SCHIP to
collect, track and report all financial relationships with
physicians and teaching hospitals to CMS.
•
http://www.theatlantic.com/health/archive/2013/02/what-thesunshine-act-means-for-health-care-transparency/272926/
• There, as a result, is precedent in health care.
Relationships to Vendors
• Is your relationship with the vendor benefiting:
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The patient or consumer?
Your business or practice?
You, personally?
The vendor?
We all need to be more careful and aware of these relationships
and have them vetted by our own, personal legal counsel.
When Ethics Violations Can Turn
Into Legal Problems
• As a result you want to avoid:
• Free hearing tests
•
•
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Providing free hearing tests when you are a Medicare
provider appears to be a clear violation of Medicare rules
and regulations. Medicare prohibits offering free services
such as hearing testing as an inducement to generate other
services such as diagnostic audiologic services.
http://www.asha.org/Practice/reimbursement/medicare/audi
ology-medicare-prohibitions-FAQs/
You need your own legal counsel to help you work through the
ramifications of providing free testing given your specific
situation.
60
When Ethics Violations Can Turn
Into Legal Problems
• Use of referral pads.
• Write-offs of co-pays and deductibles.
• Unless meets established, documented indigent
policy.
• Reminder mailing for annual hearing tests
where you are seeking third-party
coverage.
• All could be construed as a solicitation of a
Medicare covered service.
61
Anti-Kickback
•
•
“Section 1128B(b) of the Social Security Act (42 U.S.C.
1320a-7b(b)), previously codified at sections 1877 and
1909 of the Act, provides criminal penalties for individuals
or entities that knowingly and willfully offer, pay, solicit or
receive remuneration in order to induce business
reimbursed under the Medicare or State health care
programs. The offense is classified as a felony, and is
punishable by fines of up to $25,000 and imprisonment for
up to 5 years.”
This provision is extremely broad. The types of
remuneration covered specifically include kickbacks,
bribes, and rebates made directly or indirectly, overtly or
covertly, or in cash or in kind. In addition, prohibited
conduct includes not only remuneration intended to
induce referrals of patients, but remuneration also
intended to induce the purchasing, leasing, ordering, or
arranging for any good, facility, service, or item paid for by
Medicare or State health care programs.
62
When Ethics Violations Turn Into Legal
Problems
• False Claims Act
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•
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Criminal penalties.
https://downloads.cms.gov/cmsgov/archiveddownloads/SMDL/downloads/SMD032207Att2.pdf
Do not submit fraudulent claims to any entity.
•
Claims for services not performed.
• Including hearing aids that have not yet been dispensed.
•
Billing under someone else’s provider number.
63
False Claims Act
•
Upcoding
• Billing for a comprehensive test when all you did was air conduction.
• Billing for a comprehensive test and not adding a modifier when you
only tested one ear.
• All codes but 92601-92604 imply two ears were tested.
• 52 modifier
•
Billing for services known to not be covered and not adding the
appropriate modifier.
• Hearing aids.
• Aural rehabilitation.
• Evaluation and Management codes.
• GY Modifier
64
False Claims Act
• Submitting claims for services which were not
medically necessary and not adding the
appropriate modifier.
• Annual hearing tests.
• Tests solely for the sale of a hearing aid.
• Presence of a physician order does not guarantee medical
necessity.
•
GY Modifier
65
FDA Requirements
• Requirements:
•
•
•
•
https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCF
R/CFRSearch.cfm?fr=801.420
http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/C
FRSearch.cfm?FR=801.421
Receive a User Brochure
Medical Clearance or Medical Waiver
•
•
Needed for each fitting of a child under the age of 18
years of age.
If over 18 years of age, may sign a medical waiver.
• The FDA will NOT be policing the lack of use of a medical waiver.
•
Either needs to be in FDA language.
66
FDA Requirements
• “The U.S. Food and Drug Administration today (December 7, 2016)
announced important steps to better support consumer access to
hearing aids. The agency issued a guidance document explaining that it
does not intend to enforce the requirement that individuals 18 and up
receive a medical evaluation or sign a waiver prior to purchasing most
hearing aids. This guidance is effective immediately. Today, the FDA is
also announcing its commitment to consider creating a category of
over-the-counter (OTC) hearing aids that could deliver new, innovative
and lower-cost products to millions of consumers”.
• http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/uc
m532005.htm
67
FDA Requirements
• Many state laws reference the
FDA Referral Red Flags:
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Active drainage within previous 90 days.
History of sudden or rapidly progressive hearing loss.
Unilateral hearing loss.
Conductive hearing loss or air-bone gap.
Impacted cerumen or foreign body in the ear canal.
Pain or discomfort.
Visibly congenital or traumatic deformity of the ear.
Acute or chronic dizziness.
68
FDA and State Dispensing Laws
• Just because the FDA has indicated that they will not
enforce the medical waiver or medical clearance
requirement does NOT mean that your state will
immediately remove it from your state dispensing laws.
• It is IMPORTANT that, before you discontinue use of the
medical clearance and medical waiver for adults, that you
contact your state dispensing and/or audiology licensure
boards and determine if the requirement remains in your
state.
When in Doubt…
• Hire legal counsel which specializes in health care
and/or Medicare law.
•
•
Do not enter into contractual relationships with others parties,
including physicians, healthcare facilities, buying groups, or
management services, without legal advice.
Can find an attorney via your state bar association or Google.
70
The Role of State Licensure
• It is this that dictates your scope of practice.
•
•
•
•
National Associations do not dictate this.
Payers do not dictate this.
Payers do not have to cover all items and services in your
scope of practice.
YOU cannot interpret this alone.
• It is very important that you are aware of the
requirements of both the hearing aid and/or
audiology licensure boards in your state and the
scope of practice limitations.
71
The Role of State Licensure
• Audiology Assistants, Technicians, and Support
Staff.
•
•
Cannot perform testing on Medicare beneficiaries and
legitimately receive payment.
Be careful of:
•
•
Scope of practice issues.
Lack of licensure.
• You may be allowing them to practice audiology without a license.
72
Managed Care Terms
• Accountable Care Organization (ACO): A healthcare
payment model that seeks to tie provider reimbursements
to quality metrics and reductions in the total cost of care for
an assigned population of patients; care is typically directed
and managed by the PCP, similar to that of an HMO.
• Allowed Charge (approved charge, allowable): Payment for
an item or service under the customary and current system
outlined on the payer fee schedule; inclusive of the
payment from the primary payer, secondary payer,
deductible, co-pay and co-insurance.
73
Managed Care Terms
• Alternative Payment Model (APM): APMs give Medicare
and Medicaid new ways to pay health care providers for the
care they give Medicare beneficiaries. The programs are
based upon cost savings, patient outcomes, and quality.
•
Accountable Care Organizations (ACOs), Patient Centered Medical
Homes, and bundled payment models are some examples of
APMs.
• Appeal: A request for a health insurer or plan to review a
coverage decision or payment again.
74
Managed Care Terms
• Assignment of Benefits: A procedure where the
•
•
•
member/beneficiary authorizes the payer to make
payment of allowable benefits directly to the rendering
provider.
Bad Debt: The amount that a practice must write off
due to a patient’s failure to meet their financial
responsibilities.
Balance Billing: Billing the patient for any amount in
excess of the allowed by the payer; billing the
difference between what the payer allows and your
usual and customary rate to the patient.
Beneficiary: A person eligible to receive benefits under
a health plan; the insured.
75
Managed Care Terms
• Benefits: The health care items or services covered under a
health insurance plan.
• Billed Charges: The amount the provider bills to the payer
for a specific item or service; same as “submitted charges.”
• Bundled Payments: payers compensate providers with a
single payment for an episode of care, which is defined as a
set of services delivered to a patient over a specific time
period. This model aims to incentivize providers to improve
care coordination, limit costly and unnecessary services,
and reduce variations in care not tied to patient care quality
and outcomes. By providing one single payment for various
providers, bundled payments seek to promote a teambased approach to care.
76
Managed Care Terms
•
•
•
•
•
•
Bundling: Billing for multiple, distinct items or services to a payer under a
singular code.
Care Coordination: The organization of your treatment across several health
care providers. HMOs and ACOs are common ways to coordinate care
through a PCP.
Carrier: The insurance company which writes and administers the health
insurance policy; the payer.
Claim: A demand to the payer, by the patient, for payment of benefits under
an insurance policy.
Clinical Improvement Activity: An activity associated with care coordination,
beneficiary engagement, healthcare system efficiency, beneficiary access
and patient safety.
Co-insurance: A provision of an insurance plan by which the beneficiary
shares in the cost of certain covered expenses with the payer on a
percentage basis; cost-sharing.
77
Managed Care Terms
•
•
•
•
Coordination of Benefits: A provision in an insurance plan that,
when a patient has coverage by multiple insurance plans,
benefits paid by all of the plans will never exceed 100% of the
usual and customary fee.
Co-payment: The provision of an insurance plan by which the
beneficiary is required to pay a fixed portion of the cost of their
healthcare expenses.
Contractual Adjustment: The difference between your usual and
customary fee and the amount allowed by the payer; same as
“write-off.”
Credentialing: The process by which managed care organizations
and payers determine that a provider is competent to provide
services to their beneficiaries.
78
Managed Care Terms
•
•
•
•
Customary Charge: The provider’s standard charge for a given
item or service.
Date of Service: The date the service is performed or the item is
dispensed.
Deductible: A stipulated amount which the beneficiary must pay
toward the cost of their healthcare before the benefits and
coverage of the plan go into effect; usually a set dollar amount
that must be satisfied within a given calendar year.
Discount Benefit: This is a benefit that negotiates discounts for
their members for non-covered items or services. There is no
third-party coverage in this instance. This is the same as an
unfunded benefit.
79
Managed Care Terms
• Durable Medical Equipment (DME): Equipment, items,
goods, and supplies ordered by a health care provider for
everyday or extended use; a cochlear implant and hearing
aid are considered to be DME by some payers.
• Electronic Claim: A claim form completed, processed, and
transmitted from one computer to another.
• Electronic Medical Record (EMR): A computerized, digitally
stored and transmitted medical record.
• Eligible Expenses: Same as “allowable” and “negotiated
rate.”
80
Managed Care Terms
•
•
•
•
Explanation of Benefits (EOB): A form included with your
payment/denial from the payer which explains the specifics of
coverage, denial and/or payment for a specific patient for a given
date of service; it also outlines the patient’s financial
responsibilities.
Excluded services: Health care items and services that a health
insurance plan doesn’t pay for or cover; same as “non-covered
service.”
Exclusions: Specific services or conditions which the insurance
policy will not cover or which are covered at a limited rate.
Fee for Service: Refers to reimbursing healthcare providers for
the individual items and services provided.
81
Managed Care Terms
• Fee Schedule: The fixed dollar amount which is billed or
allowed for a specific item or service.
• Funded Benefit: This is a benefit where a third-party payer
is paying in whole or in part of a given item or service.
• Health Maintenance Organization (HMO): A type of health
insurance plan that usually limits coverage to care from
doctors who work for or contract with the HMO; care is
usually coordinated by a PCP.
82
Managed Care Terms
• Incident to: Services defined as are defined as services or
supplies furnished as an integral, although incidental, part
of the physician's personal professional services in the
course of diagnosis or treatment of an injury or illness.
These services are furnished under the supervision of the
attending physician and, as a result, billed under the NPI of
this physician as the rendering provider.
• In-Network (participating): The provider has been
credentialed by a specific payer and has agreed to the
terms of their payer agreement/contract; the provider
must accept the allowable as payment in full.
83
Managed Care Terms
•
•
•
Insured: The individual who represents the family unit in in
relation to the insurance benefits and coverage; usually the
employee who holds the insurance provided by their employer.
Insurer: Payer.
Medicare Access & CHIP Reauthorization Act of 2015 (MACRA):
MACRA makes three important changes to how Medicare pays
those who give care to Medicare beneficiaries. These changes:
•
•
•
•
Create Quality Payment Program (QPP)
End the Sustainable Growth Rate (SGR) formula for determining Medicare reimbursement for
provider services.
Create a new system for rewarding health care providers for giving better, more affordable care
and producing better outcomes and eliminate the incentives for providing more care and
services.
Combine the existing quality reporting programs into one new system.
84
Managed Care Terms
• Medically Reasonable and Necessary: Health care services,
items, or supplies needed to prevent, diagnose, or treat an
illness, injury, condition, disease, or its symptoms and that
meet accepted standards of medicine.
• Member: Same as “beneficiary.”
• Merit-Based Incentive Payment System (MIPS): MIPS is a
new program that combines parts of the Physician Quality
Reporting System (PQRS), the Value Based Modifier (VM)
and the Electronic Health Record incentive program into a
single program in which eligible professionals will be
measured on defined metrics. Audiology is ineligible for
MIPs in 2017.
85
Managed Care Terms
• Negotiated Rate: Same as “allowable” and “eligible
expenses.”
• Network: The facilities, providers, and suppliers a health
insurer or plan has contracted with to provide health care
services and care.
• Non-Covered Service: An item or service that is not a
covered benefit under a specific insurance plan; same as
“excluded services.”
• Order: A request from one healthcare provider to another
healthcare provider requesting that they perform a specific
item or service to a given patient; same as “referral” or
“prior authorization.”
86
Managed Care Terms
• Organization Predetermination: The Medicare Advantage
process of advanced beneficiary notification. This process
varies payer by payer and must occur prior to the provision
of care.
• Out of Pocket Expense: Limitation on the amount a
beneficiary must contribute to their healthcare costs in a
given year; can affect co-insurance.
• Out-of-Network: The provider has not been credentialed by
a specific payer and has not agreed to accept the terms of
the payer agreement/contract; can bill the patient your
usual and customary rate; patient’s coverage and benefits
often reduced.
87
Managed Care Terms
•
•
Patient Centered Medical Home: The patient centered medical
home (PCMH) model facilitates the coordination of care
through a patient’s primary care physician. The PCMH model
integrates mental health and specialty services, and involves a
team-based approach consisting of physicians, nurses and
medical assistants, pharmacists, nutritionists, social workers and
care coordinators. Right now, this model is primarily being
applied to chronic care conditions such as diabetes and cardiac
care.
Patient Responsibility: The amount the patient owes for a given
item or service once the payer has processed the claim.
88
Managed Care Terms
•
•
•
Pay for Performance (P4P): This is a term used to refer to those
payment models aimed at improving the quality, efficiency and
the overall value of health care. In P4P arrangements, providers
are reimbursed based on whether they achieve a predetermined set of quality metrics.
Payable Amount: The amount paid by the payer for a given item
or service; excludes co-insurance, co-payments and deductibles.
Predetermination: The process of obtaining a written estimate
of what a payer will pay for specific items and services before
the item is dispensed or the service is performed; not a
guarantee of payment.
89
Managed Care Terms
• Primary Insurance: The payer who has the primary
responsibility for payment under the coordination of
benefits provisions of the patient’s insurance agreement.
• Prior Authorization: A requirement by the payer that
coverage for a given item or service is dependent on the
item or service being approved by the payer or another
healthcare entity before the item or service is provided to
the beneficiary.
• Provider: The individual who provides items and services to
beneficiaries.
90
Managed Care Terms
• Referral: Same as “order.”
• Secondary Insurance: The payer who has the secondary
responsibility for payment under the coordination of
benefits provisions of the patient’s insurance agreement.
• Submitted Charges: Same as “billed charges.”
• Third-Party Administrator (TPA): A middle-man between
the provider and the payer/employer group who negotiates
discounts, coverage, and benefits for the payer/group and
administers the benefit offerings.
• Unbundling: The process of coding, billing, and requesting
payment for items and services that are typically billed
under a single procedure code.
91
Managed Care Terms
•
•
•
•
Unfunded benefit: The payer has negotiated a discount program
for its members but does not pay any payment towards the
costs of items or services. This is the same as a discount benefit.
Utilization Review: The process of reviewing items and services
provided by a specific provider or facility to determine if the
items and services provided were reasonable and necessary; a
provision included in most third-party contracts.
Verification: The act of predetermining eligibility, coverage, and
benefits for a specific patient for specific items and services.
Write-Offs: The amount that is not paid by the payer but cannot
be billed to the beneficiary; same as “contractual adjustment.”
92
Coverage versus Reimbursement
• Coverage is when a third-party is paying all or part of the
cost of the item or service.
•
Lack of coverage does NOT mean a lack of reimbursement.
• Reimbursement is when you, the provider, receive payment
for the cost of the item or service.
• WE NEED TO CARE MORE ABOUT REIMBURSEMENT AND
LESS ABOUT COVERAGE!
94
Facts
• Other than Medicare, you are a VOLUNTARY participant in
managed care.
•
Participation is a business decision.
• Must be credentialed before you can bill a payer as an innetwork provider.
•
•
Otherwise, you are an out-of-network provider and patient should
pay in-full for any item or service they receive on the date the item
or service is provided.
The patient should be informed of your network status (as it
pertains to their insurance) prior to making an appointment and be
informed of their financial obligations.
95
Medicare Enrollment
• Audiologists CANNOT opt out of Medicare.
• Need enrollment as an individual (855-I) and practice (855B).
• Must have an NPI, license, and address before proceeding
with enrollment.
• Can enroll online through:
https://pecos.cms.hhs.gov/pecos/login.do
•
•
Best way to enroll; avoid paper applications.
Read the tutorials
96
What Is the Medicare Opt Out?
• You enter into private contracts with Medicare
beneficiaries for Medicare covered services.
•
Services will not be covered by Medicare.
• Collect payment from patients.
• You do not file claims to Medicare.
• Opted out for two years
•
https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/OptOutAffidavits.html
• Audiologists cannot opt out!
97
Medicare Enrollment
• Determined on 855-R.
• Options
• Participating:
•
•
•
•
Accept Assignment.
Listed in provider directory.
Rolls-over to secondary.
Medicare pays 5% more.
98
Medicare Enrollment
• Non-Participating:
• Accept assignment on claim by claim basis or
charge patient limiting charge (115% of allowed
amount).
• Patient pays provider on date of service.
• Patient receives 95% of Medicare allowed charge from
Medicare/secondary payer.
• Typically does not roll-over to secondary carrier.
99
Medicare Enrollment
• Free
• Audiologists cannot opt out of Medicare.
• If charge $X to one person, you must charge $X to
all.
100
Medicare Enrollment Options
Par
Non-Par who Non-Par who do
not accept
accepts
assignment
assignment (Limiting Charge)
Billed Amount
$125
$125
$115
Medicare
Allowed
Amount
$100
$95
$95
80% of
Medicare
Allowed
$80
$76
$76
Beneficiary
Co-Insurance
$20
$19
$19
$95
$115 (95 x
1.15 limiting
charge);
patient paid
$20 difference
Total
Payment to
Provider
$100
101
Medicare Revalidation
• This is Medicare’s attempt to update your enrollment.
• ONLY do it online via PECOS at
https://pecos.cms.hhs.gov/pecos/login.do#headingLv1
102
Initial Steps to Contracting: Who?
• Need to do a market analysis.
• What insurers represent the major employers in your area?
• What insurances do your referral sources and local
hospitals accept?
•
Some referral sources cannot, by contract, refer to out of network
providers.
• What insurers offer lucrative hearing aid benefits?
103
Request Information
• Begin the process with a Google search.
•
Most payers have excellent websites that contain useful
information regarding provider enrollment and guidance.
•
•
Take a look at their provider manual or administrative guidance.
You can often begin the application request/enrollment process
directly from the payer website.
•
Provider/healthcare professional section of the website.
104
Payer Reply
• Once your application/enrollment request is completed,
you will receive a reply from the payer. This can include:
•
Rejection:
•
Closed Network.
• They can and do say “no.”
•
Provider Agreement and Payer Fee Schedule.
105
Rejection
• Periodically, attempt to re-enroll if participation with this
payer is lucrative for your business.

Have data to illustrate how many of their members are seeking your
services, how underserved your community is (if a patient has to drive more
than 5 miles to see an in-network provider), or how your practices offers
services or products not provided by other in-network providers (such as
auditory processing, vestibular or tinnitus evaluation or management,
pediatrics or implants).
106
Rejection
• Reach out to the human resources department of the
employer providing these benefits to their employees.

Have data to illustrate how many of their members are seeking your
services, how underserved your community is (if a patient has to drive
more than 5 miles to see an in-network provider), or how your practices
offers services or products not provided by other in-network providers
(such as auditory processing, vestibular or tinnitus evaluation or
management, pediatrics or implants).
107
Rejection
• Have your patients advocate for your inclusion in the
plan.
•
Encourage them to contact customer service or the human
resources department of their employer.
108
Rejection
• Purchase a practice that is in-network with the payer in
question.
109
CAQH
• Credentialing clearinghouse.
• Free.
• http://www.caqh.org/
• To participate:
•
•
Must be a contracted provider with a least one of the CAQH
participating payers.
Must be invited by CAQH once registered.
110
Receive Provider Agreement
•
•
Read the entire agreement and review the fee schedule.
Things to consider:
•
You want these answers IN WRITING ONLY!
•
What products am I participating with: Medicare Advantage? Medicaid? HMOs?
•
•
Does it allow for balance billing or patient upgrades for hearing aids?
•
•
•
•
•
•
•
•
If Medicare Part C, what are the organizational pre-determination requirements?
Is there a required waiver process?
Does it require patients complete notices of non-coverage before non-covered
services are provided?
Can student externs or technicians see members of this plan?
Can hearing aid dispensers see members of this plan?
Can certain services be carved-out of the contract?
What are the termination terms? Renegotiation terms?
For hearing aids, am I required to supply a manufacturer’s invoice?
What are the renewal terms?
•
“Evergreening” of contract.
111
Receive Provider Agreement
•
Things to consider:
•
You want these answers IN WRITING ONLY.
•
•
•
•
•
•
How is medical necessity defined?
What are the requirements for standard processes and procedures for all patients?
What are the means of provider notification of substantive changes to the agreement?
What are the requirements for standard fee schedule/charge master?
What are the timely claims filing requirements?
Are there any other claims filing requirements.
•
•
•
•
•
•
Can I file paper claims?
Are there clinic hour requirements?
What are the medical record retention requirements?
How does it address evaluation and management services provided by audiologists?
Do they require hearing aid patients be referred to a third-party administrator for dispensing?
Does the fee schedule address all of the items and services you provide?
•
•
HCPCS and CPT
How are unlisted codes processed?
112
Fee Schedule
•
What the payer allows, per contract, for each specific item and
service you provide for each specific product you are contracted to
provide.
•
•
•
Never accept less than you can afford.
•
•
Need to know your breakeven plus profit amount per hour to properly analyze
this.
Do the benefits outweigh the costs?
Be careful of:
•
•
•
Inclusive hearing aid coverage benefits.
Large hearing aid discounts (percentages of dollars billed).
“Fitting fee only” or Invoice plus arrangements.
•
•
Requirements to provide the manufacturer invoice.
Sometimes you do not buy the aid in this equation.
Sometimes it is a better business decision to be out-of-network providers
as patients pay you in full on the date of service.
113
Third-Party Administrators
• They exist to:
•
•
•
•
Allow payers a single point of contact and payment for hearing aid
related items and services.
Defined risk for the payer.
Cost containment for the member.
An established standard of care for the member.
Audiologists helped create the need for these programs and help
maintain their existence through their participation.
Considering a TPA
• TPAs (third-party administrators) are becoming more and
more prolific in the audiology space.
• Before you agree to join, please consider the following:
•
•
Is the plan offering a funded or unfunded (discount) benefit?
Is your practice bundle or unbundled?
•
•
•
•
Can you create a competitive product offering?
What is my responsibility in informing the patient of their benefits,
either funded or unfunded?
How many patients do you stand to potentially lose if you do not
enroll in the program?
What products does the plan offer?
•
What if the member wants a product that is not in the program?
Considering a TPA
•
Before you agree to join, please consider the following:
•
•
Can I charge the patient or their healthcare insurer for a hearing test?
What items and services are included in the fitting fee?
•
•
•
•
•
•
If it is not included in the fitting fee, are their limits to what I can charge?
Do I have to notify patients of these costs, in writing, upfront?
Do I receive a greater fitting fee if I am a member of a specific buying
group or membership organization?
How long is the trial period?
What do I receive if the patient returns the aids for credit?
How long do I have to manage the patient for the fitting fee?
•
Are their limits as to what I can charge for service outside of the fitting
fee window?
Before You Initially Sign…
• Make a copy of the entire contract and fee schedule and
SAVE IT.
• Ask questions when you lack answers.
•
Don’t sign until you get your answers!
• Do not be afraid to negotiate.
•
The worse they can do is say “no.”
• What are the pros versus cons of contracting with each
payer?
• If unsure of some of the contract terms, hire an consultant
and/or attorney to review.
117
If You Have Already Signed:
Renegotiation
• It is NOT the payers responsibility to have a copy of your
contract.
•
•
If you cannot locate it, request, in writing, a copy of their current
agreement and review any administrative guidance or provider
manuals on their websites.
Request, in writing, a copy of the current fee schedule.
Renegotiation
• Know what you want and defend why you deserve it.
•
Have a knowledge of your current agreement and your Medicare
fee schedule for your area.
• Follow the guidance in the contract on termination but,
instead of sending a termination letter, send a request for
renegotiation.
• You must also be willing to walk away in negotiation or you
have no power or leverage.
Renegotiation
• Follow the same contract evaluation process you would
follow if you were signing up for the first time.
Non-Participation
•
•
•
•
Again, other than Medicare, you are a voluntary participant in
managed care.
It is an option to not participate in third-party, managed care
plans and be an out of network provider.
In this situation, the patient pays in full on the date of service.
Your office can submit claims to the payer as a courtesy to the
patient.
•
•
The patient is reimbursed, from the payer, their out of network
benefits.
You often see this in mental health, dental and optometry offices.
Two Separate Business Entities
•
•
•
•
This option is often selected when a practice has a large physician
referral base or a large diagnostic practice.
An option that many physician practices choose is to spin their
hearing aid or auditory rehabilitative practice off into a separate
business, with a separate legal structure and separate tax
identification number.
As a result, this second entity would not be encumbered by the
managed care obligations of the original business.
This new, second business could be strategically enrolled in various
managed care enterprises, while avoiding those with poor coverage
and benefits for treatment, including haring aids.
•
•
This is becoming more common in audiology practices as well.
In order to do this, you will need to hire an attorney and an accountant to
evaluate this option for your situation and effectively and legally create this
new business entity.
Billing 101: The Facts
• It is ALL about PROCESS and POLICIES.
• Providers complete the testing, write the report, and fill
out the superbill.
• Data is power!!!
•
Complete a superbill (or OMS encounter) on every patient you see,
even no-charge visits.
• Someone has to collect patient responsibility on the date
of service.
•
Billing costs YOU money!!!
• Office staff takes the superbill information, submits the
claim, and monitors payment.
123
Billing 101: The Facts
• Claims should be posted within two business days.
• Payments should be posted daily.
• No one should be able to write-off sums over $100 other
than the manager or owner.
• Stop seeing patients who owe you money.
124
Billing 101: The Facts
• You must invest in staff training and materials.
•
Office management or billing software.
•
•
Manuals.
•
•
The days of paper claims are almost over!
You will have to make an investment in ICD-10.
Training.
• You must have consistent, no-exceptions financial policies
•
•
STOP GIVING IT AWAY!!
Should be in writing and available.
125
Billing Checks and Balances:
• Owners and managers, regardless of your work setting,
must monitor accounts receivable (especially that outside
of 90 days) and accounts payable.
•
•
Monthly, at a minimum.
Collect patient responsibility on date of service.
126
How You End Up in Insurance Hell
• YOU put yourself there, not the Insurer!
• You do not ask the right questions at scheduling and
intake.
• You sign ANYTHING without reading or negotiating it.
• You do not have a working knowledge of the
agreement YOU agreed to.
• You do not verify an individual patient’s coverage and
benefits EVERY time.
• You insist everyone needs top of the line products.
127
How You End Up in Insurance Hell
• YOU put yourself there, not the Insurer!
• You insist on remaining in a bundled delivery model.
• You do not charge patients privately for non-covered
services and to notify them in writing of their out of
pocket expenses.
• You do not collect patient responsibility (co-pays,
deductibles and co-insurance) at the time of the visit.
128
How Do You Get Out of Insurance Hell
•
•
•
•
•
•
•
Have a strong scheduling and intake process.
Run your practice like your dentist, optometrist, chiropractor, or
podiatrist runs theirs.
All business is not good business.
•
Third-party administrators exist because you sign up.
KNOW your contracts!
Nothing is free!
Collect payment at time of visit.
Fit the patient, with something audiologically appropriate,
within their benefit.
•
http://www.harlmemphis.org
129
Third-Party Coverage
• Know the terms of your third-party contracts and fee
schedules.
• Good reimbursement begins and ends with you.
• Starts from the minute the patient calls.
• Accountability is key.
• Verification is required EVERYTIME!
• Have to ask the right questions.
• Hearing aids.
• BAHA.
• Cochlear implants.
130
Third-Party Coverage
• Third-party coverage of diagnostic and hearing aid services
is the result of an agreement between the PATIENT and the
INSURER.
• Sometimes patients have out of pocket expenses and
financial responsibility for non-covered or denied
coverage for services.
• Sometimes the fight for payment is a fight between the
patient and the payer and NOT you!
131
Insurance Verification
• KNOW YOUR CONTRACTS!!!
• Do as much as possible online.
• Who did you call? At what number? Do
they have a reference number?
132
Insurance Verification
•
•
•
•
•
•
•
•
•
Who did you call? At what number? Do they have a reference number?
Is the benefit or discount only available through a specific third-party
administrator?
Does the patient have a hearing aid benefit? Allowance?
Can the patient have out-of-pocket expense? Can they upgrade?
Is this a funded (the payer is covering all or a portion of the costs of the device) or
unfunded (discount) benefit?
Do they have out-of-network benefits? (You ask this if you are an out-of-network
provider).
What services are covered?
•
Literally, provide the codes 92591, 92593, 92595, V5011, V5020, and V5160.
Are they eligible today?
Know your deductibles!
•
They can sometimes be larger than the cost of the hearing aids.
133
Insurance Verification
• What are the coverage/benefit specifics?
• Does the HL have to be related to accident., illness or
•
injury?
Is this an inclusive benefit?
•
Does the benefit include all services related to the evaluation
and fitting of the device?
• How frequent?
•
X number of months or years
•
A fixed defined dollar amount or an “up to” amount
• Dollars?
• “Up to” generally means your allowable fee for the device itself
134
So I Verified Benefits? Now What?
•
•
•
You must treat managed care patients as you would treat a private pay patient.
The date you bill is the date you fit!
•
Date of service is the day the item is dispensed or the service is provided.
Can the patient upgrade?
•
If no, you must fit within the benefit.
•
•
If yes, you need to offer them a product within their benefit.
•
•
Itemization can help in these situations.
If they choose to “upgrade”, then they need to be notified in writing, prior to fitting, of the
fact that they could have received a product at no-charge (except for co-pays, co-insurance
and deductibles) but, instead, they have opted to upgrade and their financial responsibility is
X.
Is it an “up to” benefit or a fixed dollar amount?
•
“Up to X” does not mean “X”
•
•
Fit a entry level product.
You will need to fit within the benefit.
•
Itemization can help in these situations.
Insurance Verification
•
If the patient does NOT have an inclusive hearing aid
benefit, consider unbundling the charges, even if you remain
bundled to your private pay patients, as it may push about
$200-300 to patient responsibility. You unbundled total needs
to equal your bundled total.
•
•
Restrict the level of product provided.
If a carrier states that they pay a “maximum of x dollars” or
“up to” X dollars but do not specifically define a benefit
amount, assume the $500 rule as, on many occasions, they
will not actually pay the maximum (the maximum would
typically apply to a digital CIC).
•
“Up to X” does not mean you will receive “X”
• It means they cover the allowable rates.
136
Hearing Aid Verification Scenarios:
• Scenario 1: You contact the third-party payer and
complete the insurance verification form in full.
Per the third-party payer, you are allowed to
balance bill the patient for the difference between
the insurance coverage/allowable amount and the
your usual and customary charge.
• This one is easy!
137
Scenario 2: You contact the third-party payer and complete
the insurance verification form in full. Per the third-party
payer, you are not allowed to balance bill the patient for the
difference between the insurance coverage/allowable
amount and your usual and customary charge.
• You must restrict product cost to an aid whose
invoice cost is less than $250-350 per aid
maximum.
• The patient has no out-of-pocket expense in this
scenario (except for unmet co-pays or
deductibles).
• You must accept the negotiated rate as payment
in full.
138
Scenario 2: Continued
•
•
I strongly encourage you to be honest with the patient about the situation (i.e. “the
negotiated rate is less than my cost for more advanced products”).
The patient then has four options:
•
•
•
•
•
Get a more basic hearing aid paid in full by their third-party payer. This is what most patients
prefer.
Refer the patient to a third-party administrator you are contracted with that IS a contracted
provider for this plan, is allowed to bill the funded portion of their plan, and is also allowed to
balance bill the patient.
Go elsewhere and try to find another provider who will do this for them (in many cases out of
network providers would be allowed to balance bill the patient).
Have the patient sign a completed insurance waiver. In this case, they are waiving their
insurance coverage and you, as the provider, will not be submitting a claim to their carrier.
Please ensure that the patient gets an original copy of their bill or sale and the insurance
waiver in the event they attempt to bill their carrier themselves.
If the patient proceeds with the first bullet, the patient should pay any co-insurance
amounts (based upon usual and customary rates) and deductible amounts (up to the
usual and customary cost of the aids) on the date of the fitting.
139
Scenario 3: You contact the third-party payer and complete the
insurance verification form in full. The carrier states that either
the dispensing fee and/or hearing aid evaluation can be billed as
a separate charge and/or they request that the claim be
submitted unbundled.
• The patient should also pay any co-insurance amounts
(based upon usual and customary rates) and deductible
amounts (up to the usual and customary cost of the
aids) on the date of the fitting.
• You need to unbundle the cost of the hearing aid in this
situation. You can unbundle differently for different
payers, based upon what is allowed in each contract, as
long as the total package always equals the same
amount!
140
Scenario 3: Continued
•
•
•
•
•
•
•
•
•
•
•
Hearing aid (V5…)
Dispensing Fee (V5…, if allowed)
Hearing aid evaluation (92590/1)
Hearing aid check (92592/3)
Electroacoustic analysis of aid (92594/5, if performed)
Fitting and Orientation of aid (V5011)
Conformity Evaluation (V5020, if performed)
Earmold, if applicable (V5264) or dome (V5265)
Earmold Impression, if applicable (V5275)
Batteries (V5266)
Accessories (V5267, if provided)
141
When Dealing with Hearing Aids in a Third-Party World,
Please Consider:
• The insurance verification form and process is completed prior to the
hearing aid evaluation. If possible, the insurance information should be
gathered at the time the hearing aid evaluation is scheduled.
• Please also make sure that the patient pays all outstanding deductibles,
co-pays, and percentages of responsibility on the date of fitting, as well
as any patient responsibility they may have. You want to be in a
position to refund money and not trying to collect outstanding monies
from the patient.
•
•
These are all of the monies you can collect on the date of order or fit if you are an innetwork provider.
Do not discount hearing aids billed to third-party carriers.
•
Have all marketing provide a disclaimer to this effect.
• You must get your cost of goods as low as possible.
•
No manufacturer is irreplaceable.
142
Billing Hearing Aids via Third-Party
Administrators
•
•
They each have their own processes.
The general process is this:
•
•
•
•
•
TPA refers patient to your practice.
Your practice sees the patient and recommends amplification.
You fax, email or submit via their portal the required paperwork to
order and/or acknowledge fitting of the device.
•
The TPA pays for the device and, often, the earmold, if needed.
After the end of the trial period, you are paid a fitting fee.
You manage the patient, at no additional cost to the patient or the
plan, for a fixed time period or number of visits.
The Down Low on Waivers/Patient
Notification
•CANNOT USE IF NOT ALLOWED BY
CONTRACT!!!
• Otherwise, you will be in violation and, if a patient pushes
back, you will have to refund them.
• Do they recognize S1001?
• Patient Notification
• Use to notify and bill patient for non-covered services.
144
The Down Low on Waivers/Patient
Notification
• Upgrade Waiver
• BCBS.
• Must provide an aid (standard) at no-charge to patient .
• Patient can upgrade if they so choose and pay the difference
between the allowable and usual and customary.
145
The Down-Low on Waivers/
Patient Notification
• Insurance Waiver
• Patient waives their insurance benefit.
• They do not bill their insurance and you do not bill
their insurance.
• Rarely happens.
146
CMS 1500 Resources
• http://www.nucc.org
• http://www.practicons.com/2013/another-change-inhealth-care-cms-1500-claim-forms-are-changing/
• http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/clm104c26.pdf
147
CPT Basics
•
•
•
•
•
•
CPT is the acronym for Current Procedural Terminology.
CPT is a listing of codes and their descriptions that outline medical
services and procedures.
CPTs are added, deleted, and modified annually (first Monday in
November) by their creator, the American Medical Association.
As of October 2003, HIPAA requires that all insurance carriers,
including Medicare and Medicaid, use CPT codes.
CPTs are five digit, numeric codes. Most codes that apply to
audiology begin with the numbers 92xxx.
Audiology can be involved in this code creation through ASHA and
AAA.
148
Vestibular Testing: Without Recording
• 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
• Non-covered by Medicare
149
Vestibular Testing: With Recording
•
92540: Basic vestibular evaluation, includes spontaneous nystagmus
test with eccentric gaze fixation nystagmus, with recording, positional
nystagmus test, minimum of 4 positions, with recording, optokinetic
nystagmus test, bidirectional foveal or peripheral stimulation, with
recording, and oscillating tracking test, with recording
•
•
•
•
92541: Spontaneous nystagmus test, including gaze and fixation
nystagmus, with recording
92542: Positional nystagmus test, minimum of 4 positions, with
recording
92544: Optokinetic nystagmus test, bidirectional, foveal or peripheral
stimulation, with recording
92545: Oscillating tracking test, with recording
•
Add the -59 modifier if bill two or three of 92541, 92542, 92543, or 92544 on the
same patient on the same date of service.
150
Vestibular Testing with Recording
• Both replace 92543 in 2016.
•
92543 was eliminated.
• 92537: Caloric vestibular test with recording, bilateral;
bithermal (i.e. one warm and one cool irrigation for each
ear for a total of four irrigations)
•
Add -52 modifier if only perform three irrigations and -22
modifier if perform more than four irrigations
• 92538: Caloric vestibular test with recording, bilateral;
monothermal (i.e. one irrigation in each ear for a total of
two irrigations)
•
Add –52 modifier if only complete one irrigation
Vestibular Testing: With Recording
• 92546: Sinusoidal vertical axis rotational testing
• NOT for vHIT or headshake
• 92547: Use of vertical electrodes (List separately in
addition to code for primary procedure)
• ENG only (except Florida MAC)
• 92548: Computerized dynamic posturography
152
Audiology Codes
•
•
•
•
•
•
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
92557: Comprehensive audiometry threshold evaluation
and speech recognition (92553 and 92556 combined)
•
Add 59 modifier if bill two of 92552, 92553, 92555, or 92556 on the
same patient on the same date of service.
153
•
•
•
•
Immittance Codes
92550: Tympanometry and reflex threshold
measurements
92567: Tympanometry (impedance testing)
92568: Acoustic reflex testing, threshold
92570: Acoustic immittance testing, includes
tympanometry (impedance testing), acoustic reflex
threshold testing, and acoustic reflex decay testing
•
Reflex thresholds should be established both ipsilateral and
contralateral test conditions at at least two to three
frequencies
154
CAPD Codes
• 92620: Evaluation of central auditory function, with report;
initial 60 minutes
• 92621: Evaluation of central auditory function, with report;
each additional 15 minutes
•
Need to have spent 31 minutes or more to bill 92620
155
CAPD Codes
• 92571: Filtered speech test
• NOT for QuickSIN or speech in noise testing
• 92572: Staggered spondaic word test
• 92576: Synthetic sentence identification test
• Code individually only when performed in
isolation.
156
Pediatric Codes
• 92579: Visual reinforcement audiometry (VRA)
•
“Is a test technique that can be performed using either
loudspeakers or earphones, which uses flashing lights, moving
toys, or video to reinforce a head-turn response to sound
stimuli, and it may be used with either tonal or speech stimuli”
•
•
Four frequencies
The procedure is repeated with speech, warble tones, narrow
tone noise, and frequency specific noisemakers
• 92582: Conditioning play audiometry
•
“Is a test technique in which the patient is taught a game that
requires a response to tonal stimuli. A variety of play responses
can be used with CPA, such as dropping a toy in a container or
putting pegs in a board. It is typically done using earphones.”
• 92583: Select picture audiometry
•
These are NOT method codes.
157
Evoked Potential Codes
• 92516: Facial nerve function studies (e.g. ENoG)
•
Can be billed “incident to”
• 92584: Electrocochleography (e.g. ECoG) or for CI 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
158
OAE Codes
•
•
•
92558: Evoked otoacoustic emissions, screening (qualitative
measurement of distortion product or transient evoked
otoacoustic emissions), automated analysis
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: Comprehensive diagnostic evaluation (quantitative
analysis of outer hair cell function by cochlear mapping,
minimum of 12 frequencies), with interpretation and report
159
Hearing Aid Codes
• 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
• 92595: Electroacoustic evaluation for hearing aid;
binaural
160
Cochlear Implant 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; subsequent reprogramming
•
Add 59 modifier if performed on the same day at 92626.
161
Audiology Codes
•
•
•
•
•
•
•
•
92575: Sensorineural acuity level test
•
In some PQRS measures
92596: Ear protector attenuation measurements
92625: Assessment of tinnitus (includes pitch, loudness matching,
and masking)
92626: Evaluation of auditory rehabilitation status; first hour
92627: Evaluation of auditory rehabilitation status; each additional
15 minutes (List separately in addition to code for primary
procedure)
92630: Auditory rehabilitation; prelingual hearing loss
92633: Auditory rehabilitation; postlingual hearing loss
92640: Diagnostic analysis with programming of auditory brainstem
implant, per hour
162
Other Audiology Related Codes
• 69209: Removal of impacted cerumen using
irrigation/lavage, unilateral
• 69210: Removal impacted cerumen, with instrumentation,
unilateral
•
•
Technically, a surgical code
While can be billed with a -50 modifier, it typically only is
reimbursed as one unit
• 95992: Canalith repositioning procedure(s), per day
163
Other Audiology Related Codes
• 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 non-qualified health care professional
• 99368: Medical team conference with interdisciplinary
team of health care professionals, patient and/or family
not present, 30 minutes or more, participation by nonqualified health care professional
164
Other Audiology Related Codes
• 96110: Developmental screening (e.g. developmental
milestone survey, speech and language delay screen),
with scoring and documentation, per standardized
instrument.
165
Use of 92700
•
•
•
•
To classify procedures that do not have CPT codes.
Individually reviewed.
ABN required.
If reporting 92700, submit report with:
•
•
•
•
•
•
•
•
Copy of Patient Report
Description of procedure
Clinical Utility of the Procedure
Time
Skills of Tester
Equipment used
Benefit to patient
Usual and Customary Fee
166
Common Uses of 92700
• VEMPs
• High-frequency audiometry • Sensory organization test
• Audiometric Weber
• Head shake testing
• Eustachian tube function • Speech in noise testing
testing
• Tinnitus management
• ASSR
• Removal of incidental
• Middle/late latency
cerumen
response
• Fistula testing
• Use of goggles
• VHit
• Saccade testing
167
Codes to Use with Caution
• You need to ensure that you have actually performed the
service.
•
•
•
•
•
92504: Binocular microscopy
92560: Bekesy audiometry, screening
92561: Bekesy audiometry, diagnostic
92562: Loudness balance test, alternate binaural and monaural
92564: Short increment sensitivity index
CPT Tips
•
Always have the coding legitimately represent all of the procedures
that were completed on each individual patient on a given date of
service.
•
•
•
•
•
•
Always ensure you actually performed the specific procedure billed.
COVERAGE and PAYMENT does not mean COMPLIANCE.
Make sure you are using the most up to date codes.
Make sure you have a 2016 or newer CPT Manual in your office.
It is legitimate to bill for attempted procedures with the appropriate
documentation.
Use modifiers when needed.
169
Modifiers
• -22: Increased procedural service
•
Some examples to consider are threshold search ABR or
functional hearing assessment (extensions of another
procedure).
• -32: Mandated Service
• -33: Preventative service
•
When billing for follow-up newborn hearing screening only.
170
Modifiers
•
•
•
-50: Bilateral Procedure
-52: Reduced service
•
•
Only tested one ear.
Did not meet all of the components of a code.
-59: Distinct Procedural Service
•
•
Used in situations where you are unbundling parts of a bundled
code.
•
•
92540
92552
Used when performing 92601-92604 and 92626/7 on the same
patient on the same date of service.
171
Modifiers
• -RT: Right ear
• -LT: Left ear
•
Only modifiers that can be used with HCPCS codes.
172
Modifiers
• -GA: Waiver of liability on file
•
Used when an ABN was completed for required reasons, such as
the use of 92700 or the existence of a local coverage
determination.
• -GY: Item or service statutorily excluded or does not meet
the definition of a Medicare benefit.
•
•
You want a Medicare denial.
Used with –GX modifier only.
• -GZ: Item or service expects to be denied as not reasonable
or necessary.
•
Used when an ABN was required but not obtained.
173
Place of Service Codes
• These are two-digit codes placed on claims to indicate
the setting in which a service was provided.
• You change your setting, you change your place of service
code.
• https://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7631.pdf
Place of Service Code Examples
•
•
•
•
•
•
•
•
•
•
•
11: Office
12: Home
13: Assisted Living Facility
14: Group Home
15: Mobile Unit
21: Inpatient Hospital*
22: Outpatient Hospital*
31: Skilled Nursing Facility*
32: Nursing Facility
34: Hospice*
62: Comprehensive Outpatient Rehabilitation Facility**
•
•
•
* The facility must submit the claim. Your practice will need a contract with the facility to provide care.
** Audiologic testing is non-covered by Medicare.
https://www.cms.gov/Medicare/Coding/place-of-service-codes/Place_of_Service_Code_Set.html
176
Home Visits
• You have to reflect the place of service as HOME (12).
• If you provide diagnostic services in the home, certain,
specific criteria must be met for Medicare COVERAGE.
• The patient needs to be homebound.
• https://www.medicare.gov/Pubs/pdf/10969.pdf
• https://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/bp102c07.pdf
Skilled Nursing or Hospice
• Medicare Part B coverage is dependent on the status of the
patient, on the specific date of service, within the Medicare
system.
•
You also have to be careful if they are living in these facilities and
are seen in your office.
• If they are covered within the Part A time frame, the facility
must bill and receive payment from Medicare and the
audiologist will receive payment from the facility.
•
You will need a contract with the facility that outlines the
responsible party.
Skilled Nursing or Hospice
•
•
https://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNProducts/Downloads/SNFSpellIllnesschrt.pdf
https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/SNFPPS/ConsolidatedBilling.html
Hospital OPPS Billing
•
•
•
•
•
“Bundling” is the name of the game.
This is how many hospital outpatient claims are paid, but
does not effect how they are billed.
http://www.audiology.org/practice_management/reimburse
ment/2017-hospital-outpatient-prospective-paymentsystem-opps-final
http://www.asha.org/Practice/reimbursement/medicare/fees
chedule/
http://www.asha.org/uploadedFiles/Audiology-SLPHOPPS.pdf
•
•
•
•
Certain services are not reimbursed separately if provided on the
same date of service as other services.
You are reimbursed a “package” price for a given date of service.
The reimbursement can often be higher.
This is also a system that is sometimes mandated by a payer.
Evaluation and Management Code Basics
• These are the codes physicians and non-physician
practitioners (such as nurse practitioners and physician
assistants) utilize to bill for office visits.
• Per the CPT manual, these codes can be used by
“qualified health professionals who are authorized
to perform such services within the scope of their
practice.”
•
So, can an audiologist in your state “evaluate” and
”manage”? Only your state licensure board can
determine that.
181
Evaluation and Management Code Basics
• Common codes to be considered by audiologists are 9920199203 (new patient) and 99211-99213 (established patient).
•
Avoid 99204-99205 and 99214-99215 as inappropriate for
audiologists as this level of code requires a high risk of morbidity
and mortality (which otologic issues do not contain).
182
Evaluation and Management Codes:
New Patient
• 99201
•
Requires these key components: a problem focused history,
examination (screenings) and straightforward medical decision
making. Usually, the presenting problem(s) are self limited or
minor.
• 99202
•
Requires these key components: an expanded problem focused
history, examination (screenings) and straightforward medical
decision making. Usually, the presenting problem(s) are of low to
moderate severity.
183
Evaluation and Management Codes:
New Patient
• 99203
•
A detailed history, examination (screening) and medical decision
making of low complexity. Usually, the presenting problem(s) are
of moderate severity.
184
Evaluation and Management Codes:
Established Patient
• 99211
•
May not require the presence of a physician or other qualified
health care professional. Usually, the presenting problem(s) are
minimal.
• 99212
•
Requires a problem focused history, examination (screenings) and
straightforward medical decision making. Usually, the presenting
problem(s) are self limited or minor.
185
Evaluation and Management Codes:
Established Patient
• 99213
•
An expanded problem focused history, examination (screenings)
and medical decision making of low complexity. Usually, the
presenting problem(s) are of low to moderate severity.
186
The Do’s of E/M
• Confirm that your state licensure laws allow for
evaluation and management services.
• Is it in your state defined scope of practice?
• Consult your payer contracts and fee schedules to
determine if they allow for the use of E/M codes by
audiologists.
• If they do not AND it is allowed by state licensure, can the patient
be held financially responsible for the costs?
•
They do not have to allow their use by audiologists.
187
The Do’s of E/M
•
•
•
If you bill one payer for E/M codes, you must bill all payers and patients
(including patients when non-covered, such as Medicare).
• Can have it solely apply to specific test scenarios only as long as it
applied to every patient.
•
•
•
•
Auditory prosthetic device candidacy
Vestibular assessment
Tinnitus evaluation
CAPD evaluation
You must meet the documentation requirements of E/M codes or you
shouldn’t use them.
Read the E/M section of your CPT Manual at:
https://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/Downloads/eval-mgmt-serv-guideICN006764.pdf before proceeding.
188
The Don’ts of E/M
• Do not utilize these codes for hearing aid visits.
•
These are only for use in diagnostic test situations.
• Do not accept payment from traditional Medicare
for these codes.
• Use these codes with caution if you work in an ENT
or hospital setting.
• Risks can be great if billing two E/M codes from the same facility
for the same patient on the same date of service.
189
Evaluation and Management Codes
• New patient versus established patient:
• They are established if they have seen you or
another audiologist in your practice within the last
three years.
• Outpatient versus inpatient.
• Examination: Typically paid separately, except
for the screenings.
• As a result, ignore the time designates on the code
and focus on the complexity of the visit.
190
Evaluation and Management Codes
• Type of history: problem focused, expanded problem
focused, detailed, comprehensive.
• Chief complaint
• History of present illness (brief or extended)
• Review of systems (none, problem pertinent,
extended, complete)
• Past, family, and/or social history (none, pertinent,
complete)
191
Evaluation and Management Codes
• Problem focused:
•
•
Chief complaint
Brief history of present illness or problem
• Expanded problem focused:
•
•
•
Chief complaint
Brief history of present illness or problem
Problem pertinent system review
192
Evaluation and Management Codes
• Detailed:
•
•
•
•
Chief complaint
Extended history of present illness or problem
Problem pertinent system review expanded to include a
limited number of additional, appropriate systems
Problem pertinent past, family, and/or social history
• Comprehensive:
•
•
•
•
Chief complaint
Extended history of present illness or problem
Review of all 14 body systems
Complete past, family, and/or social history
193
Evaluation and Management Codes
• Medical decision making: Straightforward, low
complexity, moderate complexity, high complexity.
• Number of diagnoses or management options:
minimal, limited, multiple, extensive.
• Amount and complexity of data to be reviewed:
none, minimal, limited, moderate, extensive.
• Risks of significant complications, morbidity, or
mortality: minimal, low, moderate, high.
194
Utilizing E and M Codes
• For evidence based evaluation and management beyond
audiometric assessment.
• Consider applying them uniformly, but only to specific
clinical situations such as:
•
•
•
•
Vestibular assessment
Auditory prosthetic device candidacy assessment
Central auditory processing assessment
Tinnitus assessment
195
Pediatric Testing
• Can bill for testing that is attempted if documentation of:
•
•
•
•
What happened?
Why you were unable to complete the testing?
Did you spend at least half of the typical test time attempting the
procedure?
Documentation is key!
196
Examples of Pediatric Test Situations:
Child Less Than Two Years
• VRA (92579) in soundfield or headphones, includes tones
and/or speech
• Tympanometry and reflexes (92550)
• OAEs (92587)
• ABR (92585)
197
Examples of Pediatric Test Situations:
Child Two to Five Years
• Conditioning play audiometry (92582)
• Select picture audiometry (92583)
• Tympanometry and reflexes (92550)
• OAEs (92587)
198
CAPD
• Very hard to do, if participating with third-party payers.
• CAPD evaluation (92620/1).
• First 31-60 minutes, please report writing
• Treatment
• 92633 versus 92700
• Team meeting with patient (99366) and team meeting
without patient (99368).
• Evaluation and management codes?
199
Vestibular Assessment
• Basic vestibular evaluation (92540):
•
•
Gaze (92541).
Positionals, minimum of four positions (92542).
•
•
•
Hallpike testing is a position.
Optokinetic (92544).
Oscillating tracking (92545).
• Caloric testing (92537)
• Evaluation and Management codes?
200
Vestibular Assessment
• Positional testing, without recording (92532)
•
Could be used for Hallpike in isolation.
•
Must have a rotational chair.
•
For ENG only (except in Florida).
•
Need a platform.
•
Ends up being private pay in most cases.
• Rotational testing (92546)
• Use of vertical electrodes (92547)
• Dynamic posturography (92548)
• Saccades, VEMPs, SOT, and/or use of goggles (92700)
201
Auditory Osseointegrated Device
•
•
•
•
•
•
Need pre-determination in writing, if not clearly listed as a benefit on
the patient’s contract.
Never call a BAHA a BAHA
•
Call it an “auditory prosthetic device”.
Candidacy testing, if completed (92626).
Evaluation and Management codes?
Fitting (L9900).
•
Patient pays this amount on the date of the device fitting.
Troubleshooting/service (L9900).
•
Suggest patient be billed and pay privately.
202
CI Candidacy
• Audiogram (92557)
• Tymps and reflexes (92550)
• ABR (92585)
• OAEs (92587 or 92588)
• Caloric testing, per irrigation (Calorics x 2)
• Evaluation of A/R status (92626/7)
• Team meeting with patient (99366) versus team
meeting without patient (99368)
• Evaluation and Management codes?
203
CI Surgery
• NRT (92584)
204
CI Initial Tune-up
• Programming (92601 if less than 7 years or 92603 if 7 years
or older)
•
Could bill as two line items, with RT/LT modifiers or add -50
modifier for bilateral implants
• Testing (92626)
•
Add -59 modifier
• NRT (92584)
205
CI: Everything Else
• Re-programming (92602 or 92604)
• NRT (92584)
• Testing (92626)
• Must spend at least 31 minutes.
• Troubleshooting/service (L9900)
• Suggest patient be billed and pay privately.
• Recommend you send patients to manufacturer for
supplies.
•
•
More time to bill and collect than you actually receive.
L codes exist.
206
Cerumen Removal
•
Impacted (69209 or 69210):
•
•
Use 69209 if you used lavage or irrigation or use 69210 for use of any other form of
instrumentation.
Can bill Medicare patients privately.
•
•
•
•
Voluntary ABN.
Consult your contract for guidance with other payers.
50 modifier for binaural, although they may only pay for one ear.
Non-impacted (92700):
•
•
•
Inclusive to audiogram if performed on same date of service for Medicare.
Can bill Medicare patients privately if done on a separate date of service.
Consult your contract for guidance with other payers.
•
Voluntary ABN.
207
Tinnitus Management
•
•
•
•
What does your typical patient look like in terms of test battery, case history, and
counseling???
•
•
•
•
92625
Evaluation and Management?
This will help you determine the codes you use and the prices you set.
Will need to screen for depression, as allowed by state licensure, for PQRS.
Very hard to do, if participating with third-party payers.
Medicare does not cover tinnitus maskers.
•
•
•
Medicare patients are financially responsible for costs.
Consult payer guidance for private insurers.
V5299.
Tinnitus rehabilitation (92700 versus 92633).
•
•
Consult payer guidance for private insurers.
Medicare patients are financially responsible for costs.
208
Aural Rehabilitation
• 92630 or 92633
•
•
Medicare beneficiaries are financially responsible for the costs.
Consult payer guidance for private insurers.
209
VA, Workers Compensation and
Medicaid Coding
• These entities follow their own, defined coding conventions
• Following the coding recommendations and requirements
outlined by these specific payers
210
ICD-10-CM
•
•
•
ICD-10-CM is an acronym for the International Classification of
Diseases, 10th Revision.
ICD-10s are a listing of codes designed to classify diagnoses and
symptoms.
Created by the World Health Organization and Centers for
Disease Control.
•
These codes typically consist of up to seven characters.
•
Changed on October 1 of each year.
•
Went into effect October 1, 2015.
211
Fundamentals of ICD10
•
Code what the patient, their family and/or their physician report in your
case history.
•
•
•
•
•
Case histories need to focus on the whole patient, not just the
auditory system
Code co-morbidities that support medical necessity.
•
i.e. cancer, vascular disorders, autoimmune diseases, diabetes, MS
Code what you, the audiologist, measure.
•
i.e. hearing loss
Code what you, the audiologist, personally visualize.
•
i.e. exotoses, cauliflower ear
Do not code merely for coverage.
•
This could be VERY important with the repeal of ACA.
Importance of Documentation
• Documentation of comprehensive case history, test
results, and plan of care is key to successful ICD 10 coding,
especially if working with certified coder at your facility
and they are coding for you
Meaning of “Unrestricted”and
“Restricted” in ICD 10
• Unrestricted means “normal” in ICD 10
• Restricted means “abnormal” in ICD 10
What the Numbers Mean
• A “3” as the last number means bilateral.
• A “2” as the last number means left ear.
• A “1” as the last number means right ear.
Local Coverage Determinations
• A Local Coverage Determination (LCD) is
a decision by a Medicare Administrative
Contractor (MAC) whether to cover a
particular service on a MAC-wide, basis.
Local Coverage Determinations
•
•
•
•
•
•
Vestibular and Auditory Testing
•
Novitas
Evoked Potentials
•
Novitas
Intraoperative Monitoring
•
•
•
Novitas
First Coast
Wisconsin Physician Services
Tympanometry
•
First Coast
Vestibular Testing Only
•
First Coast
Vestibular Testing
•
•
•
Also affects 92557
Palmetto
Noridian
ICD-10 Examples
• H93.293 Abnormal auditory perception, bilateral
• H93.292 Abnormal auditory perception, left ear
• H93.291 Abnormal auditory perception, right ear
• H93.3X3 Acoustic nerve disorder, bilateral
• H93.3X2 Acoustic nerve disorder, left ear
• H93.3X1 Acoustic nerve disorder, right ear
• H61.303 Acquired stenosis of external ear canal, bilateral
• H61.302 Acquired stenosis of external ear canal, left ear
• H61.301 Acquired stenosis of external ear canal, right ear
218
ICD-10 Examples
• Z45.320 Adjustment and management of implanted bone
conduction device
• Z45.321 Adjustment and management of cochlear implant
• H93.213 Auditory recruitment, bilateral
• H93.212 Auditory recruitment, left ear
• H93.211 Auditory recruitment, right ear
• Q16.1 Aural atresia
• G51.0 Bell's Palsy
219
ICD-10 Examples
• D33.3 Benign neoplasm of cranial nerves
• H81.13 Benign paroxysmal vertigo, bilateral
• H81.12 Benign paroxysmal vertigo, left ear
• H81.11 Benign paroxysmal vertigo, right ear
• M95.12 Cauliflower ear, left ear
• M95.11 Cauliflower ear, right ear
• H93.25 Central auditory processing disorder
220
ICD-10 Examples
• H90.0 Conductive hearing loss, bilateral
• H90.12 Conductive hearing loss, left ear, unrestricted
hearing in right ear
• H90.11 Conductive hearing loss, right ear, unrestricted
hearing in the left ear
• H90.A11: Conductive hearing loss, unilateral, right ear,
with restricted hearing loss on the contralateral side
• H90.A12: Conductive hearing loss, unilateral, left ear,
with restricted hearing loss on the contralateral side
221
ICD-10 Examples
• R62.0 Delayed milestone in childhood
• F81.89 Developmental disorder of scholastic skills,
•
•
•
•
other
H93.223 Diplacusis, bilateral
H93.222 Diplacusis, left ear
H93.221 Diplacusis, right ear
R42 Dizziness
•
This is a symptom, not a diagnosis.
• Z51.11 Encounter for antineoplastic chemotherapy
222
ICD-10 Examples
• H69.81 Eustachian tube disorders, other
specified, right ear
• H69.82 Eustachian tube disorders, other
specified, left ear
• H69.83 Eustachian tube disorders, other
specified, bilateral
• H61.813 Exostosis, bilateral
• H61.812 Exostosis, left ear
• H61.811 Exostosis, right ear
223
ICD-10 Examples
• Z82.2 Family history of hearing loss
• Z46.1 Fitting and adjustment of hearing aid
• T16.2XXA Foreign body in left ear, initial encounter
• T16.2XXD Foreign body in left ear, subsequent encounter
• T16.1XXA Foreign body in right ear, initial encounter
• T16.1XXD Foreign body in right ear, subsequent encounter
224
ICD-10 Examples
• Z01.12 Hearing conservation and treatment
• Z01.110 Hearing examination following failed hearing
screening
• Z01.10 Hearing/vestibular examination without abnormal
findings
• H61.123 Hematoma of pinna, bilateral
• H61.122 Hematoma of pinna, left ear
• H61.121 Hematoma of pinna, right ear
• Z91.81 History of falling
225
ICD-10 Examples
• H93.233 Hyperacusis, bilateral
• H93.232 Hyperacusis, left ear
• H93.231 Hyperacusis, right ear
• H61.23 Impacted cerumen, bilateral
• H61.22 Impacted cerumen, left ear
• H61.21 Impacted cerumen, right ear
226
ICD-10 Examples
• F70 Intellectual disabilities, mild
• F71 Intellectual disabilities, moderate
• F72 Intellectual disabilities, severe
• F73 Intellectual disabilities, profound
• F78 Intellectual disabilities, other
• F79 Intellectual disabilities, unspecified
227
ICD-10 Examples
• H83.13 Labyrinthine fistula, bilateral
• H83.12 Labyrinthine fistula, left ear
• H83.11 Labyrinthine fistula, right ear
• Z79.2 Long term (current) use of antibiotics
• Z79.82 Long-term use of aspirin
• Z76.5 Malingering
• H81.03 Meniere's disease, bilateral
• H81.02 Meniere's disease, left ear
• H81.01 Meniere's disease, right ear
228
ICD-10 Examples
•
•
•
•
•
•
•
•
•
H90.6 Mixed hearing loss, bilateral
H90.72 Mixed hearing loss, left ear, unrestricted hearing in right ear
H90.71 Mixed hearing loss, right ear, unrestricted hearing in left ear
H90.A31: Mixed conductive and sensorineural hearing loss,
unilateral, right ear, with restricted hearing loss on the contralateral
side
H90.A32: Mixed conductive and sensorineural hearing loss,
unilateral, left ear, with restricted hearing loss on the contralateral
side
Z96.22 Myringotomy tube(s) status
H83.3X3 Noise effects on inner ear, bilateral
H83.3X2 Noise effects on inner ear, left ear
H83.3X1 Noise effects on inner ear, right ear
229
ICD-10 Examples
• H55.00 Nystagmus
• Z0.58 Observation and evaluation of newborn for other
specified suspected condition ruled out
• H92.03 Otalgia, bilateral
• H92.02 Otalgia, left ear
• H92.01 Otalgia, right ear
•
Can represent pressure and fullness as well.
• H92.13 Otorrhea, bilateral
• H92.12 Otorrhea, left ear
• H92.11 Otorrhea, right ear
230
ICD-10 Examples
• H91.03 Ototoxic hearing loss, bilateral**
• H91.02 Ototoxic hearing loss, left ear**
• H91.01 Ototoxic hearing loss, right ear**
• ** Code poisoning or adverse effect
• T36.5X5A Poisoning, adverse effect, aminoglycosides, initial
encounter
• T36.5X5S Poisoning, adverse effect, aminoglycosides, long
term follow-up
• T36.5X5D Poisoning, adverse effect, aminoglycosides,
subsequent encounter
231
ICD-10 Examples
• T37.2X5A Poisoning, adverse effect, antimalarials, initial
encounter
• T37.2X5S Poisoning, adverse effect, antimalarials, long
term follow-up
• T37.2X5D Poisoning, adverse effect, antimalarials,
subsequent encounter
• T45.1X5A Poisoning, adverse effect, antineoplastic, initial
encounter
• T45.1X5S Poisoning, adverse effect, antineoplastic, long
term follow-up
• T45.1X5D Poisoning, adverse effect, antineoplastic,
subsequent encounter
232
ICD-10 Examples
• T39.015A Poisoning, adverse effect, aspirin, initial
encounter
• T39.015S Poisoning, adverse effect, aspirin, long term
follow-up
• T39.015D Poisoning, adverse effect, aspirin, subsequent
encounter
• T50.1X5A Poisoning, adverse effect, loop diuretic, initial
encounter
• T50.1X5S Poisoning, adverse effect, loop diuretic, long
term follow-up
• T50.1X5D Poisoning, adverse effect, loop diuretic,
subsequent encounter
233
ICD-10 Examples
•
•
•
•
•
•
T36.3X5A Poisoning, adverse effect, macolides, initial encounter
T36.3X5S Poisoning, adverse effect, macolides, long term followup
T36.3X5D Poisoning, adverse effect, macolides, subsequent
encounter
T46.7X5A Poisoning, adverse effect, vasodilators, initial encounter
T46.7X5S Poisoning, adverse effect, vasodilators, long term
follow-up
T46.7X5D Poisoning, adverse effect, vasodilators, subsequent
encounter
234
ICD-10 Examples
•
•
•
•
•
•
•
•
•
•
H93.A1 Pulsatile tinnitus, right ear
H93.A2 Pulsatile tinnitus, left ear
H93.A3 Pulsatile tinnitus, bilateral
H93.A9 Pulsatile tinnitus, unspecified ear
Z97.4 Presence of external hearing aid
H90.3 Sensorineural hearing loss, bilateral
H90.42 Sensorineural hearing loss, left ear, unrestricted hearing in right ear
H90.41 Sensorineural hearing loss, right ear, unrestricted hearing in left ear
H90.A21: Sensorineural hearing loss, unilateral, right ear, with restricted hearing
loss on the contralateral side
H90.A22: Sensorineural hearing loss, unilateral, left ear, with restricted hearing
loss on the contralateral side
235
ICD-10 Examples
• I69.998 Sequealae following unspecified cardiovascular
disease, other
• F80.4 Speech and language delay due to hearing loss
• F80.1 Speech-language disorder, expressive
• F80.2 Speech-language disorder, expressive/receptive
• F80.89 Speech-language developmental disorder, other
• F80.0 Speech-language disorder, phonological
236
ICD-10 Examples
• H91.23 Sudden idiopathic hearing loss, bilateral
• H91.22 Sudden idiopathic hearing loss, left ear
• H91.21 Sudden idiopathic hearing loss, right ear
• H93.243 Threshold shift, temporary, bilateral
• H93.242 Threshold shift, temporary, left ear
• H93.241 Threshold shift, temporary, right ear
• H93.13 Tinnitus, bilateral
• H93.12 Tinnitus, left ear
• H93.11 Tinnitus, right ear
237
ICD-10 Examples
•
•
•
•
•
•
H93.013 Transient ischemic deafness, bilateral
H93.012 Transient ischemic deafness, left ear
H93.011 Transient ischemic deafness, right ear
H82.3 Vertiginous disorder of vestibular function, bilateral*
H82.2 Vertiginous disorder of vestibular function, left ear*
H82.1 Vertiginous disorder of vestibular function, right ear*
•
•
•
•
*Code first underlying disease
H81.313 Vertigo, aural, bilateral
H81.312 Vertigo, aural, left ear
H81.311 Vertigo, aural, right ear
238
ICD-10 Examples
• H81.43 Vertigo, central, bilateral
• H81.42 Vertigo, central, left ear
• H81.41 Vertigo, central, right ear
• H81.393 Vertigo, peripheral, other, bilateral
• H81.392 Vertigo, peripheral, other, left ear
• H81.391 Vertigo, peripheral, other, right ear
• H81.8X3 Vestibular function disorder, other, bilateral
• H81.8X2 Vestibular function disorder, other, left ear
• H81.8X1 Vestibular function disorder, other, right ear
239
Different Hearing Losses in Different
Ears
•
•
•
•
•
•
H90.A11: Conductive hearing loss, unilateral, right ear, with restricted hearing loss on the
contralateral side
H90.A12: Conductive hearing loss, unilateral, left ear, with restricted hearing loss on the
contralateral side
H90.A21: Sensorineural hearing loss, unilateral, right ear, with restricted hearing loss on the
contralateral side
H90.A22: Sensorineural hearing loss, unilateral, left ear, with restricted hearing loss on the
contralateral side
H90.A31: Mixed conductive and sensorineural hearing loss, unilateral, right ear, with
restricted hearing loss on the contralateral side
H90.A32: Mixed conductive and sensorineural hearing loss, unilateral, left ear, with restricted
hearing loss on the contralateral side
•
You would need to select two of the above codes to reflect different hearing losses in different ears.
240
Toxicity from Viagra
• H91.02 Ototoxic hearing loss, left ear
• T46.7X5A Poisoning, adverse effect, vasodilators,
initial encounter
•
First date you diagnose an ototoxic loss.
241
“Routine” Hearing Test
• There is no CPT or HCPCS code for a “routine” hearing test.
• The best option is ICD 10 code Z0.110.
• Sometimes, again, it is the patient’s responsibility to fight
for coverage.
Normal Hearing with No Other
Symptoms or Co-Morbidities
• Z01.10 Hearing/vestibular examination without
abnormal findings
• Or
• H93.2 - - Abnormal auditory perception
•
If they report communication difficulties.
243
Normal Vestibular
• Z91.81 History of Falling
or
• R42 Dizziness
or
• H81.93 Vestibular function disorder, unspecified, bilateral
or
Comorbidities that drove medical necessity.
Newborn Hearing Screening Follow-up
• Code pre and post natal conditions or symptoms.
• Code any co-morbidities.
• Code anything you see or measure.
• If they previously failed a hearing screening, code
Z01.110.
• Add the -33 modifier to all of the procedures.
• Consider Z0.58 (Observation and evaluation of newborn
for other specified suspected condition ruled out).
ICD 10 Tips
•
We code what we learn and find, not for coverage.
•
•
Do not use rule out diagnoses once you know they do not exist.
•
•
•
Can link diagnosis to procedure (diagnosis pointer; 24e).
Field can accommodate up to four pointers.
Use the most specific code possible whenever possible.
•
•
http://www.cgsmedicare.com/partb/pubs/news/2013/0113/cope21072.html
Can code up to 12 diagnoses per claim.
•
•
You could be giving someone a pre-existing condition.
Can be denied over lack of specificity.
We have NO IDEA the impact of use of a Z code on reimbursement as
this varies payer to payer.
•
•
As a result, use other codes whenever possible.
Avoid these codes being a primary or only diagnosis.
246
ICD 10 Resources
•
•
Online Look-up (free options):
•
•
•
www.icd10data.com
https://www.aapc.com/icd-10/codes/
https://www.cms.gov/medicare-coveragedatabase/staticpages/icd-10-code-lookup.aspx
Manuals/Software
•
•
•
https://commerce.amaassn.org/store/catalog/subCategoryDetail.jsp?category_id=cat1150
010&navAction=push
https://www.optumcoding.com/Category/100091/100276/
https://www.aapc.com/medical-coding-books/icd-10-books.aspx
HCPCS Basics
•
•
•
•
•
•
HCPCS is the acronym for Healthcare Common Procedure
Coding System.
HCPCS is a listing of codes and their descriptions that outline
items and supplies and the services that surround them.
HCPCS are added, deleted, and modified annually by the Centers
for Medicare and Medicaid Services (CMS).
As of October 2003, HIPAA requires that all insurance carriers,
including Medicare and Medicaid, use HCPCS.
HCPCS are a letter followed by four numbers. Most codes that
apply to audiology begin with the letters L (cochlear implants or
BAHA) or V (hearing aids).
Anyone can submit an application for HCPCS codes but need
some form of vendor support as you need their data.
•
It is now about products only.
248
HCPCS “L” Codes
 L9900: Orthotic/prosthetic supply, accessory and/or service
component of another HCPCS L code (can be used for an
abutment revision)
 I do not think audiology practices should be in the
auditory prosthetic device replacement part business
(due to DME requirements).
 Patients should work directly with device manufacturers.
249
HCPCS “S” Codes
•
Need to determine how each private payer recognizes and
reimburses this code before you use any of the codes.
•
•
Not appropriate for Medicare or Medicaid.
Sometimes these codes may be used to represent a service for
productivity and not billing.
• S1001: Deluxe item, patient notified
•
It is listed in addition to the code for the basic item.
•
May help with upgrades.
• S0618: Audiometry for hearing aid evaluation to determine
level and degree of hearing loss
•
Some payers may consider this the code to be used for a routine
hearing test.
250
HCPCS “S” Codes
• S5165: Home modifications, per visit
•
Home falls hazard assessment and modification.
• S9445: Patient education, not otherwise classified, nonphysician provider, individual, per session
• S9446: Patient education, not otherwise classified, nonphysician provider, group, per session
• S9476: Vestibular rehabilitation program, non-physician
provider, per diem
251
HCPCS “S” Codes
• S9981: Medical records copying fee, administrative
• S9982: Medical records copying fee, per page
•
State medical records policies dictate what can be charged.
• S9999: Sales tax
252
HCPCS Codes
•
•
•
•
•
V5008: Hearing screening
•
Same as 92551.
V5010: Assessment for hearing aid
•
Same as 92590/1.
V5011: Fitting/orientation/checking of hearing aid
•
“Checking” aspect same as 92592/3.
V5014: Repair/modification of hearing aid
•
•
•
•
Repairs
Reprograming
Recase
Replate
V5020: Conformity evaluation
•
Verification.
253
HCPCS Codes
• V5050: Hearing aid, monaural, in the ear
• V5060: Hearing aid, monaural, behind the ear
• V5130: Binaural, in the ear
• V5140: Binaural, behind the ear
•
These are without technology.
254
HCPCS Codes
• V5170: Hearing aid, CROS, in the ear
• V5180: Hearing aid, CROS, behind the ear

V5210: Hearing aid, BICROS, in the ear
•
Receiver and transmitter
• V5220: Hearing aid, BICROS, behind the ear
•
Transmitter and hearing aid/receiver
255
HCPCS Codes
• V5254: Hearing aid, digital, monaural, CIC
• V5255: Hearing aid, digital, monaural, ITC
• V5256: Hearing aid, digital, monaural, ITE
• V5257: Hearing aid, digital, monaural, BTE
256
HCPCS Codes
• V5258: Hearing aid, digital, binaural, CIC
• V5259: Hearing aid, digital, binaural, ITC
• V5260: Hearing aid, digital, binaural, ITE
• V5261: Hearing aid, digital, binaural, BTE
257
HCPCS Codes
• V5200: Dispensing fee, CROS
• V5240: Dispensing fee, BICROS
• V5090: Dispensing fee, unspecified hearing aid
• V5110: Dispensing fee, bilateral
• V5160: Dispensing fee, binaural
• V5241: Dispensing fee, monaural hearing aid, any type
•
What encompasses the ordering, programming, and fitting that is
not represented by another code.
258
HCPCS Codes
•
•
•
•
•
•
•
V5268: Assistive listening device, telephone amplifier, any type
V5269: Assistive listening device, alerting, any type
V5270: Assistive listening device, television amplifier, any type
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
259
HCPCS Codes
• V5281: Assistive listening device, personal FM/DM system,
monaural (1 receiver, transmitter, microphone), any type
• V5282: Assistive listening device, personal FM/DM system,
binaural (2 receivers, transmitter, microphone), any type
• V5283: Assistive listening device, personal FM/DM neck,
loop induction receiver
• V5284: Assistive listening device, personal FM/DM ear level
receiver
260
HCPCS Codes
• V5285: Assistive listening device, personal FM/DM, direct
audio input receiver
• V5286: Assistive listening device, personal Bluetooth
FM/DM receiver (streamer)
• V5287: Assistive listening device, personal FM/DM receiver,
not otherwise specified
• V5288: Assistive listening device, personal FM/DM
transmitter assistive listening device
261
HCPCS Codes
• V5289: Assistive listening device,
personal FM/DM adaptor/boot coupling
device for receiver, any type
• V5290: Assistive listening device,
transmitter microphone, any type
262
HCPCS Codes
• V5264: Ear mold/insert/not disposable, any
type
• V5265: Ear mold/insert/disposable, any
type
• V5275: Ear impression, each
263
HCPCS Codes
• V5267: Hearing aid or assistive listening
device/supplies/accessories, not otherwise specified
• V5266: Battery for use in hearing device
• V5298: Hearing aid, not otherwise classified
• V5299: Hearing service, miscellaneous
264
V5299 Examples
• Extended warranty
• Loss and damage deductible
• Tinnitus device
• Earmold service
• Service plan
• PSAP
• Noise ear plug/filter
265
HCPCS Tips
•
Medicaid and the VA see HCPCS code use differently.
•
Follow their specific requirements.
•
•
Available on their websites.
No code for tinnitus devices or maskers.
•
Use V5299.
266
HCPCS Tips
• There are some “duplicates” across CPT and HCPCS
codes.
• V5010 vs. 92590/1
• V5014 vs. 92592/3 and 92594/5
•
Use the code covered in your insurance contract, which has the highest
reimbursement in your fee schedule, or which is required by the insurance
benefit.
• Remember, there is one code for each type of aid
(digital BTE, monaural) and it does not take into
account level of technology.
267
CMS Audiology Policies
• Update to Audiology Policies:
•
•
Effective October, 2008.
http://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads//R84BP.pdf
• Revisions and Re-Issuance of Audiology Policies:
•
•
Effective September, 2010.
http://www.cms.gov/Outreach-and-Education/MedicareLearning-NetworkMLN/MLNMattersArticles/downloads//MM6447.pdf
268
CMS Audiology Policies
•
Addresses:
•
“Incident to” billing.
• Not allowed except for cerumen removal, canalith repositioning,
ENoG and tympanometry.
•
Required physician orders.
• No order…no coverage.
•
Treatment Services
• Medicare never covers treatment provided and billed by an
audiologist.
•
Computerized audiometry.
• Not covered.
•
Role of technicians and their supervision requirements.
• Require training and 100% direct supervision of the treating
physician.
• Audiologists cannot supervise technicians and bill the services
they provide under the NPI of an audiologist.
269
CMS Audiology Policies
•
Addresses:
•
Role of students, including but not limited to, the final year
extern and their supervision requirements.
• Students require 100% personal supervision for Medicare
coverage.
•
Medical necessity.
• No medical necessity…no coverage.
•
Billing of technical and professional components.
• Audiologists should bill the global fee for the services they
provide.
•
Documentation.
• An audiogram in and of itself does not constitute sufficient
documentation if audited.
•
92700
• You use this code to bill for procedures and services that have no
CPT code.
•
“Opt Out” (audiologist cannot opt out of Medicare).
270
Documentation and Medicare
•
“Documentation for Orders (Reasons for Tests):
•
•
The reason for the test should be documented either on the order, on
the audiological evaluation report, or in the patient’s medical record.
(See subsection C of this section concerning reasons for tests.)
Documenting skilled services. When the medical record is
subject to medical review, it is necessary that the record
contains sufficient information so that the contractor may
determine that the service qualifies for payment. For example,
documentation should indicate that the test was ordered, that
the reason for the test results in coverage, and that the test was
furnished to the patient by a qualified individual.
•
Records that support the appropriate provision of an audiological
diagnostic test shall be made available to the contractor on request”.
271
Medicare and Medical Necessity
•
“Under any Medicare payment system, payment for
audiological diagnostic tests is not allowed by virtue of their
exclusion from coverage in section 1862(a)(7) of the Social
Security Act 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.”
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMsItems/CMS012673.html (Chapter 15, section 80.3)
272
Medical Necessity
•
“Examples of appropriate reasons for ordering audiological diagnostic tests
that could be covered 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;
Re-evaluation to follow-up changes in hearing, tinnitus, or balance that
may be caused by established diagnoses that place the patient at
probable risk for a change in status including, but not limited to:
otosclerosis, atelectatic tympanic membrane, tympanosclerosis,
cholesteatoma, resolving middle ear infection, Meniere's disease, sudden
idiopathic sensorineural hearing loss, autoimmune inner ear disease,
acoustic neuroma, demyelinating diseases, ototoxicity secondary to
medications, or genetic vascular and viral conditions;
Failure of a screening test (although a screening test is non-covered);
Diagnostic analysis of cochlear or brainstem implant and programming;
and
Audiology diagnostic tests before and periodically after implantation of
auditory prosthetic devices.”
273
Physician Order Requirements
•
•
•
•
•
•
•
Needed for each incident of care.
Needs to be in place before testing is performed.
Does not guarantee medical necessity.
Should state “audiologic and/or vestibular evaluation.”
•
Should avoid the term “hearing aid.”
For audiologists, tests do not need to be individually listed.
Delivery methods:
•
•
•
•
Submitted via EMR.
Hand delivered, faxed, or mailed.
E-mailed.
Telephone.
•
Avoid this option.
https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/InternetOnly-Manuals-IOMs-Items/CMS012673.html (Chapter 15, section 80.6)
274
Advanced Beneficiary Notices
• ABN
• http://www.cms.gov/Medicare/Medicare-GeneralInformation/BNI/ABN.html
• Applicable to traditional Medicare only.
• Has required and voluntary (notice of non-coverage) uses.
• Must be completed prior to rendering care.
• Mandatory claims submission.
•
If they select Option 1.
275
Advanced Beneficiary Notice (ABN)
• Required ABN
• Use of 92700 or L9900
• Local Coverage Determination in place in
your locality
•
For traditional Medicare ONLY.
• GA Modifier required.
• Waiver of liability on file.
276
ABN
• Voluntary ABN
• When item is statutorily excluded from
coverage or does not meet the definition
of a Medicare benefit.
• Serves as a Notice of Non-Coverage for
when an item or service is never covered.
• GX Modifier required.
• Can use with a GY modifier.
277
Voluntary ABN Uses
•
•
•
•
•
•
•
•
•
•
Routine or annual audiologic testing where medical necessity was not met.
Hearing aids or testing for the sole purpose of obtaining a hearing aid.
Treatment services such as cerumen removal, canalith repositioning, tinnitus
management, and aural rehabilitation.
Tinnitus maskers and devices.
Evaluation and Management codes.
Audiologic and/or vestibular testing where a physician order was not obtained
prior to testing.
Audiologic evaluations that were the result of solicitation (e.g. reminder cards,
marketing events).
Audiologic and/or vestibular testing that was completed by a student in the
absence of 100% personal supervision by an audiologist or physician.
Audiologic testing that requires the skills of an audiologist or physician but was
completed by a technician.
Screenings.
278
Medicare Advantage
• Advanced Beneficiary Notices are not applicable.
•
•
May need pre-service organization determination from the payer
prior to perform the service or dispensing the item.
You need to consult each payer for their guidance on pre-service
organization determination process.
•
•
•
•
•
92700
L9900
V5298
V5299
Some require this process for all non-covered services as well.
Who Can Order Testing?
• As allowed by their state licensure.
•
•
•
•
•
•
•
•
•
•
•
Certified Nurse-Midwives
Clinical Nurse Specialists
Clinical Psychologists
Clinical Social Workers
Interns, Residents and Fellows
Nurse Practitioners
Physician Assistants
Doctors of Medicine or Osteopathy
Doctors of Dental Medicine or Surgery
Doctors of Podiatric Medicine
Doctors of Optometry
•
http://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html
280
Ordering Physicians
• Medicare requires a physician order for coverage of
audiologic and vestibular services.
• The ordering physician MUST be enrolled in Medicare as
either a participating, non-participating or opt out
provider.
• You need to ensure this prior to submitting the claim or
your claim will be denied.
•
•
If the claim is denied, the patient cannot be financially responsible
for the costs.
https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/MedicareProviderSupEnroll/MedicareOrderingandRe
ferring.html
Medicare Advantage (Part C)
• Most (except HMOs) do not require a physician order.
•
•
Need to consult each plan to determine requirements.
Many Medicare Advantage plans are reimbursing audiology and
vestibular services consistently with Local Coverage
Determinations where they exist.
Medicare Data on YOU
• Google yourself and many of you will find that your
Medicare claims data is available online to consumers
•
•
https://www.cms.gov/research-statistics-data-andsystems/statistics-trends-and-reports/medicare-providercharge-data/physician-and-other-supplier.html
http://graphics.wsj.com/medicare-billing/
Physician Compare
• Allows patients to find, choose, and compare physicians
and other health care providers who are enrolled in
Medicare.
•
A provision of the Affordable Care Act.
• Audiologists are currently listed.
•
Your PQRS participation will be noted as well.
• http://www.medicare.gov/physiciancompare/search.html
284
Medicaid
•
Varies greatly state by state.
•
•
•
•
•
•
Know the guidelines and follow them!
Medical necessity always applies here.
Managed Medicaid can differ greatly from state Medicaid programs.
Ask yourself: Why are you participating????
Medicaid is generally NOT a revenue generating business unless doing
volume!
•
•
Managed programs may be GREATLY affected by repeals in ACA so make sure
to check eligibility at every visit.
You would need volume to make money.
Know how to handle non-covered services and do not provide them for
free!
•
There may be notification requirements prior to providing care.
285
Audiology Physicians Quality Reporting
System (PQRS)
• PQRS was retired on December 31, 2016.
• Your practice can still be penalized in both 2017 and 2018
for failure to appropriately report in 2015 and 2016.
•
The penalty is 2%.
• The replacement program, the Merit-Based Incentive
Payment System (MIPS) went into effect on January 1,
2017.
• Audiologists are ineligible for the MIPS program in 2017.
•
As a result, we have no required reporting responsibilities in
2017.
Audiology Physicians Quality Reporting
System (PQRS)
• The audiology community is strongly encouraging folks
to keep doing the actions, although not necessarily
reporting on claims because the data will not be
maintained or reported by CMS, because:
•
•
•
It differentiates us in the marketplace,
It is evidence based care, and
This system and these measures will return and be required
again, with even greater consequences.
Merit Based Incentive Payment
System (MIPS)
• The Merit-based Incentive Payment System (MIPS)
consolidates three existing quality reporting programs:
the Physician Quality Reporting System (PQRS), the
Value-based Payment Modifier (VBPM), and meaningful
use (MU). The system also adds a new performance
category, called improvement activities (IA).
•
https://qpp.cms.gov/
Merit Based Incentive Payment
System (MIPS) and Audiology
Merit Based Incentive Payment
System (MIPS): What We Do Know
•
•
•
•
PQRS like measure reporting will be back.
There will be clinical improvement reporting requirements.
Registry reporting only?
•
•
Likely…
ASHA is developing an audiology registry as we speak.
•
•
Slated for September 2018.
Details are yet to be released.
Electronic medical record requirements?
•
Maybe….we need to start to prepare for this.
Clinical Improvement Activities
• Expanding practice access
• Population management
• Care coordination
• Beneficiary engagement
• Patient safety and practice assessment
• Achieving health equity
• Integrating behavioral and mental health
• Emergency Response and Preparedness
Clinical Improvement Activity
Examples
•
•
•
•
•
•
•
•
•
•
•
•
•
Expanded hours
Telehealth
Patient satisfaction surveys
Data registry participation
Reports to physicians
Timely communication to physicians
Electronic health records
Peer led support groups
Enhanced websites
Falls risk screening and assessment
Humanitarian work
Depression screening
Tobacco screening
Facts About Documentation
• Think beyond the ear…
• If it is not documented, it did not happen.
• An audiogram in and of itself does not constitute
sufficient documentation, specifically as it relates to
medical necessity.
•
•
Does the testing result in payment?
Was the testing ordered?
• Needs to be complete and legible.
• It needs to be dated.
• Must document name and professional identity.
•
https://www.cms.gov/Outreach-and-Education/MedicareLearning-Network-
294
Case History
• This is the first step to strong documentation of patient
history and medical necessity.
• Components
•
History of chief complaint(s)
•
•
•
•
Right ear, left ear, or binaural.
Acute, chronic, progressive, fluctuating, or sudden.
Detailed description of chief complaint(s).
Congenital versus acquired.
295
Case History
• Components
•
Family history:
•
•
•
Health status or cause of death of parents, siblings, and children.
Specific disease history of parents, siblings, and children.
Hereditary medical conditions.
296
Case History
• Components
•
Past history:
•
•
•
•
Prior major diseases, illnesses, injuries, or accidents.
Surgical history.
Current medications or treatments.
Allergies (specifically latex).
297
Case History
• Components
•
Social history:
•
•
•
•
Marital status, including domestic partners.
Employment history.
Recreational history.
History of drug, alcohol, and tobacco use.
298
Case History
•
Components
•
Review of systems:
•
Constitutional symptoms.
•
•
•
•
•
•
•
•
•
•
Weight loss, fever, chills,
fatigue
•
•
•
•
•
Neurological.
Psychiatric.
Endocrine.
Hematologic/lymphatic.
Allergic/immunologic.
Non-specific
Eyes.
Ears, nose, mouth, and throat.
Cardiovascular.
Respiratory.
Gastrointestinal.
Genitourinary (urinary/genital).
Musculoskeletal.
Integumentary (skin and
breast).
299
Results
• Need to outline results and explain why you did what you
did.
•
•
•
•
•
Otoscopic inspection.
Comprehensive hearing test (air, bone, speech and discrimination).
Immittance testing.
OAEs.
Other tests.
300
Recommendations
• Make sure to take into account test results and case history
findings.
•
Don’t forget:
•
•
•
Medication management.
Tinnitus.
Amplification.
• Maybe not just hearing aids.
•
•
•
•
Assistive devices.
Aural rehabilitation.
Ear protection.
Referral information.
301
SOAP Notes
• S= Subjective
• O=Objective
• A=Assessment
• P=Plan
• All documentation should contain these
components.
• These components can be flipped to focus on
assessment and plan at the outset.
• Useful link: http:// www.physiciansoapnotes.com/
302
Notes versus Report
• Documentation, in the medical record, is what is needed to
document patients’ history, results, plan of care and
medical necessity.
• A report to the ordering and/or attending physician can
replace the notes (in the medical record you would indicate
to see reported dated X) IF the report is comprehensive.
Example
Dan Brown was seen at the Northwestern University
Hearing Clinic on May 21, 2014 for a comprehensive
audiologic evaluation. His primary care physician, Ed
Jones, MD, ordered the testing.
304
Example
Mr. Brown reported hearing loss in his left ear, dizziness that
is accompanied by nausea, and tinnitus in his left ear. The
patient does not report any ear deformities, ear drainage, ear
pain, sudden or rapidly progressive hearing loss or foreign
bodies in the ear. The patient does report a history of cardiac
issues, high blood pressure, smoking and occupational noise
exposure. Currently, Mr. Brown is taking Lasix, Lipitor and
aspirin daily.
305
Example
Otoscopic inspection revealed evidence of non-occluding
cerumen in both ears. This cerumen was removed, using a
headlight and curette, prior to testing. Following cerumen
removal, otoscopy was unremarkable.
306
Example
A comprehensive hearing test was completed to determine
the patient’s hearing sensitivity and speech recognition
abilities. Pure-tone audiometry revealed a mild-tomoderate, sensorineural hearing loss in the right ear and a
mild-to-severe, sensorineural hearing loss in the left ear.
Speech reception thresholds were in good agreement with
the pure-tone findings. Speech recognition scores were
excellent for the right ear and fair for the left ear at
elevated presentation levels. Significant asymmetries were
noted between ears throughout the testing, with the left
ear being significantly poorer.
307
Example
Immittance testing, which accesses the integrity and
function of the outer and middles ear systems, revealed
normal, Type A tympanograms bilaterally. Acoustic reflex
thresholds were established due to the asymmetries
between ears and to assist in the differential diagnosis.
Acoustic reflex thresholds were within normal limits for the
right ear but were elevated or absent for the left ear.
308
Example
Mr. Brown’s test results revealed a binaural
sensorineural hearing loss, with the left ear being
significantly poorer. The tests results are consistent
with possible retrocochlear pathology in the left
ear.
309
Example
• Recommendations:
•
•
•
•
•
Comprehensive otologic evaluation with Michael Shinner, MD. I
have already contacted Dr. Shinner’s office and I have scheduled
Mr. Brown to see him on May 24.
Hearing aid evaluation and selection once the cause of the
patient’s hearing loss has been determined, a medical plan of care
has been developed and implemented and the patient has been
medically cleared for amplification.
Consistent use of ear protection in noisy settings. I have provided
Mr. Brown with a set of disposable earplugs and have instructed
him on their use and purchase.
I have cautioned Mr. Brown about the risks of driving or operating
heavy machinery while experiencing dizziness.
Gave Mr. Brown literature regarding smoking cessation.
310
The Importance of Data
• The purpose of coding is not just reimbursement; it is data
collection.
•
Every patient needs to generate an encounter.
• You need to collect, via your OMS or EMR.
311
Data You Need (at a minimum)
• Number of patients
seen
• Number of no charge
visits
• Dollars billed
• Number of hearing aid
repairs
• Dollars collected
• In-house
• Number of hearing aid
evaluations completed
• Manufacturer
• Number of aids fit
312
Pricing Strategies
•Most pricing strategies I see in this
industry are based on NOTHING.
•You CANNOT be afraid to charge for
your time and services.
313
Pricing Strategies
• All prices should reflect:
• An understanding of your personal breakeven analysis.
• An understanding of your third-party payer fee schedules.
• An understanding of the prevailing rates in the area.
314
Breakeven Analysis
• Breakeven analysis is what does your practice needs to bring
in, per hour, per full-time equivalent provider to cover your
expenses (salary, overhead, calibration, fixed costs, benefits,
annual fees, etc.).
•
•
•
Hearing aid procurement costs are not here as they are variable.
http://www.audiology.org/sites/default/files/20141001_AAA_Guide2Itemi
zingUrProfeServices.pdf
You want to add a “profit” amount to this.
• This is the minimum you can charge.
• You base your fees for items and services where no fee
schedule exists.
• Based upon the time required to complete the procedure.
316
Breakeven Analysis and QuickBooks
• Print a Quickbooks Expense Report for a 12 month period
of time.
• Take a Black Sharpie and mark through any line item that
accounts for goods that are sold (i.e. hearing aids,
earmolds, ALDs).
• Add up the remaining expenses (including salaries) from
the Report.
• These are your expenses for the year.
317
Breakeven Analysis and QuickBooks
• Divide this amount by 12.
•
This is the amount you need to breakeven per month.
• Divide this amount by the number of full-time equivalent,
revenue generating providers.
• Divide this amount by the number of available hours your
providers are available to see patients in an average month.
•
No one should see patients 40 hours a week.
318
Third-Party Fee Schedules
• Be aware of the third-party fee schedule amounts.
• You do not want to charge less than you could have
collected.
• Must have a standard fee schedule for all patients .
• If you charge one, you must charge all.
319
Prevailing Rates
• Least important aspect, as you must charge what you
need to cover your overhead and you do not want to
charge less than you could have collected.
• Just because your competitors are idiots does not
mean you have to be one too!
320
Pricing Diagnostic/Treatment Services
• Compare break-even rate plus profit to that of your
highest third-party payer for each code.
• Consider how much time you schedule each
procedure for.
• NEVER charge what you expect to receive unless
instructed to do so by the payer!!
321
Pricing Hearing Aid Services
• What is your breakeven plus profit amount?
• How much time do you schedule for each hearing
aid procedure?
• What is the prevailing third-party reimbursement
rate?
322
What is Bundling?
Billing all items and services
associated with the evaluation,
fitting, and management of a
hearing aid, as well as its related
goods, under one code on the date
of fitting.
324
Why do the Majority of Practices
Bundle Their Hearing Aid Pricing?
Honestly, because that is how
hearing aid pricing has always
been; long before audiologists
began dispensing hearing aids in
1978
Why Bundle???
Despite changes in medical and retail
sales, the influx of audiologists into
the delivery paradigm, and changes in
technology, hearing aids are delivered
in essentially the same manner as they
were 50 years ago
Do You Buy
“Commodities” the
Same Way Today as
You Did in 1970?
The Answer….
Has to be “No” for Most of
Us…but we are forcing our
patients into the same delivery
and pricing model we have
always had.
What is this Bundled Pricing
Strategy Actually Based On?
•Typically, nothing tangible.
•Rather it is typically a
rudimentary calculation of
invoice times X
330
Why we Need to Move Past 1970: The
New Norm and Why We Need to
Re-Evaluate our Pricing Models
•
•
The “status quo” may no longer suffice.
We have to differentiate ourselves and our services from
these disruptive forces that now exist in the marketplace.
•
•
•
•
How do we price the product and value the service?
How do we provide care and services not offered or available
through these disruptive entities?
How do we embrace these patients who have procured their
devices by “disruptive” means?
• Do we turn them away?
• Do we engage the “price shoppers”?
How do we expand our focus from just selling a “widget” or a
“commodity”?
331
Your “Real” Competition
• Your Manufacturers You Work With:
• Sonova (Phonak), William Demant, (Oticon),
Widex, Starkey, Great Nordic (GN Resound)
and Sivantos all own clinics, buying groups,
and managed care enterprises (EPIC, AHAA,
HearUSA, American Hearing Benefits,
Audigy, and Hearing Planet).
• Their goal is to control the delivery streams of
amplification.
333
Your “Real” Competition
• Your Third-Party Payers (which you
voluntarily participate with):
• HiHealth Innovations
• Medicaid.
334
Your “Real” Competition
• Retail/Franchise
•
Hearing aid dispensers
• Medical Community:
•
•
•
Otolaryngologists.
Internists.
Optometrists.
335
Your “Real” Competition
• Third-Party Administrators:
•
•
•
•
•
•
•
•
HearPO/Amplifon Hearing.
EPIC.
TruHearing.
HearUSA.
AudioNet
Arizona Hearing Network.
Hearing Care Solutions.
American Hearing Benefits.
•
•
Some offer funded benefits.
Many have some degree of manufacturer ownership and
involvement.
336
Your “Real” Competition
• Discount Programs
•
•
•
•
•
Hearing Planet
Hear.com
Ally
Nations Hearing
Many third–party administrators offer discount plans as well.
•
Technically, every consumer in the US has access to a discount
plan.
Your “Real” Competition
• Big Box Retailers:
•
•
•
•
Walmart/Sam’s Club.
CostCo
Walgreen’s
CVS
338
Your “Real” Competition
• The Government:
• Expansions of VA and Medicaid Benefits and
Coverage.
•
Many of these patients would have privately paid for hearing
aids 10 years ago.
339
Your “Real” Competition
• Applications
•
•
Available on mobile phones.
No FDA regulations.
•
•
•
•
•
•
•
•
EarMachine: http://www.earmachine.com/
EarSpy: http://www.earspyapp.com/
Enhanced Ears: http://www.bxtel.com/enhanced.html
Hearing Aid Pro
HearingOS: http://www.hearingos.com/
Jacoti: https://www.jacoti.com/
Petralex: http://petralex.pro/
Super Hearing Aid
Your “Real” Competition
•
Personal Sound Amplification Products Currently Available Over the Counter:
•
•
•
•
•
•
•
•
•
Able Planet: http://ableplanet.factoryoutletstore.com/cat/52440/Personal-SoundAmplifiers.html
Bean:
http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidanc
edocuments/ucm373747.pdf
Eargo: http://eargo.com/
Otofonix: https://otofonix.com/?gclid=Cj0KEQiApqTCBRC977Hi9Ov8pkBEiQA5B_ipV4Fde6K-q55QQCygObj2rAtrNVLoB1_hyIpOcyFsIaAmzH8P8HAQ
Phantom: https://phantomhearing.com/
PocketTalker: https://www.williamssound.com/pocketalker
Sound World Solutions: http://www.soundworldsolutions.com/store/personal-soundamplifiers-psa/cs50
Thousands of options available through traditional and online retailers.
Personal Sound Amplification Products Currently Available from a Provider:
•
•
Amp:
http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidanc
edocuments/ucm373747.pdf
Plaid: http://www.plaidhearing.com/provider-info.html
Your “Real” Competition
•
Hearing Aids Currently Available Over the Counter:
•
•
•
•
•
•
•
•
•
Audicus: https://www.audicus.com/why-audicus/
Embrace: https://www.embracehearing.com/
HiHealth Innovations: https://www.hihealthinnovations.com/
IHear: http://ihearmedical.com/ihear-hd/
Listen Clear: https://www.listenclear.com/
MD Hearing: https://www.mdhearingaid.com/
Sound World Solutions:
http://www.soundworldsolutions.com/store/hearing-aids/companion
Hearing Help Express: https://www.hearinghelpexpress.com/default.aspx
Advanced Affordable Hearing: http://advancedhearing.com/quality-lowpriced-hearing-aids
•
•
Mail Order Entities
EBay
How Will You Differentiate Yourself
in the Marketplace and
Compete????
• Products:
• Expand the “products” we offer to our patients.
• Maybe it is time to kick it old-school and have a less
product based practice and a more service based
practice.
• THIS is what differentiates us from our
competitors and the “disruptions.”
• Expertise and Services:
• Raise the level and standard of care.
343
How Will You Differentiate Yourself
in the Marketplace and
Compete????
• Promotion:
•
Marketing strategies will need to change.
• Pricing:
•
Unbundling/Itemization.
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Products:
• Assistive Listening Devices
• FM/DM Systems
• Accessories
• Tinnitus Maskers
•
Affects 20% of patients.
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Expertise and Services
• Patient education and training programs
for non-traditional purchases.
• Aural rehabilitation.
• Tinnitus evaluation and management.
• Vestibular rehabilitation.
• Auditory processing screening, evaluation,
and treatment of adults and children.
• Primarily cash services.
• All can influence patient performance and
satisfaction with amplification.
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Promotion
• Do we continue to market “price” when consumers
•
•
•
can obtain amplification for sometime a fraction of
the “price” we are touting?
Do we market a “commodity’ when that
“commodity” can purchased less expensively
elsewhere?
Do the strategies of old (direct mail, newspaper,
yellow pages) hold up in a digital, social media
driven marketplace?
Does your marketing tell consumers anything about
what makes your practice different?
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Pricing
• Bundling
•
•
You “bundle” all of your hearing aid product and service costs, as
well as our professional fees, under one, singular price (and
code).
You do not charge separately for the hearing aid
evaluation/consultation and, as a result, receive no payment if a
patient does not proceed with amplification.
Why Keep Bundling???
•Pros:
•Easy.
•What everyone else does.
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Why Keep Bundling???
•Cons:
• Price often based on nothing tangible.
• Not how insurance typically pays for items and services.
• No patient choice.
• Prices are not transparent.
• Increases patient costs for many.
• Does not reflect your professional time.
• May be collecting less than you need to receive to cover the
“average” patient.
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Bundled Package Includes:
•
•
•
•
•
•
•
•
Hearing aid evaluation
Earmold impression, if
required
Electroacoustic evaluation, if
done
Hearing aid itself
Fitting and orientation
Dispensing fee
Verification, if performed
Dome or custom earmold, if
required
•
•
•
•
•
•
Batteries
Accessories, if provided
Manufacturer warranty
Loss and damage coverage
Counseling and/or aural
rehabilitation
One year to lifetime of followup hearing aid office visits,
checks, in-house repairs, and
cleanings
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What is Unbundling?
•Charging separately for each item or
service as it occurs.
•Breaking the “bundled” cost into
each individual piece or aspect of
service .
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Why Unbundle?
Pros:


Collecting the amount you need to cover your costs and make
a profit (price based on something tangible).



Price better reflects actual financial needs.
Potential for increased revenues long-term and improved cash
flow.
Allows for increased reimbursement with most managed care
situations.

Makes you price competitive.

What consumers have been requesting for a decade.
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Why Unbundle?
Pros:


Allows for patient choice on how their hearing aids are
delivered.

Forces a higher standard of care.

Allows for some potential marketing advantages.

Allows for pricing for online or e-bay purchases.

They pay everything but the cost of the hearing aid itself.

You care less about where the aid comes from.
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Why Not?
Cons:






Does not work as well with managed care plans where you
have to take a large, provider discount.
May have to rebundle hearing aids for certain managed care
situations.
Will need to change office policies and procedures.
Have to collect money from patient and be comfortable with
that.
Will need to change marketing program.
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Hardest Parts of Taking the Leap to
Itemization
•
Analyzing financial needs.
•
•
•
•
- What are the risks versus the rewards?
Overcoming fear of change.
Valuing yourselves, your skills, and your time.
Overcoming fear of the unknown.
-
The “unknown” should be reduced if you have a strong knowledge
of your financial needs.
Hardest Parts of Unbundling
•
Charging for testing and hearing aid evaluations in a
world of “free”.
•
•
- Is it really “free” and what are they really getting?
Practicing a “doctor” mentality and “prescribing”
solutions rather than “selling” a product.
Hardest Parts of Unbundling
•
Letting patients make decisions.
•
•
A letting them live with the consequences of those decisions.
Raising the bar on the standard of care you provide.
-
Patients are not willing to pay for the privilege of you selling
them something.
Unbundled Pricing Model:
HAE/Communication Needs Assessment
On the date of the hearing aid evaluation, you
bill the hearing aid evaluation (92590/1 or
V5010; whichever pays more for your average
third-party hearing aid contract) to the thirdparty payer or patient, even if they do not
proceed with amplification.



Most third-party payers who cover hearing aids cover
hearing aid evaluations.
You would also bill for the earmold impression, each
(V5275), if a custom earmold is warranted.
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Unbundled Pricing Model:
Hearing Aid Fitting

On the date of fit, you would bill the following codes to the patient or the
third-party payer:

V52--: The code for the hearing aid itself

V5---: Dispensing fee

92594/5:Electroacoustic analysis (if performed) with date service is performed

V5011: Fitting and orientation

V5020: Conformity evaluation (if you perform real-ear and/or functional gain testing)

V5264: Earmold (custom) or V5265 Dome (disposable earmold), each

V5266: Batteries (per battery)

V5267: Accessories

92592/3: Follow-up visits within the Evaluation and Adjustment (global) period
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Unbundled Hearing Aid Evaluation
and Adjustment Period
• Bill 92592/3 or V5011 on the date of each follow-up visit (if
billing third party payer).
• If private pay patient, you may opt to bill these visits on the
date of the fitting.
•
Could “bundle” these visits into the fitting visit.
•
Charge a “global” fee for this period.
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Unbundling: End of Evaluation and
Adjustment Period
On this date, the patient has four choices:


Exchange the hearing aid.

Return the hearing aid for credit.

Keep the hearing aid and “pay as you go” for service.

Keep the hearing aid and purchase a service package.
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Unbundling: Exchange
• What was the reason for the exchange?
• Can charge a patient a second fitting fee.
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Unbundling: Return for Credit
As allowed by State law, you would refund the patient only
the cost of the hearing aid itself (you would retain all other
monies as the services were provided).

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Unbundling: Pay As You Go
Have a fee established for every item or service and charge
a patient or their third-party payer (if their benefits have
not been exhausted) every time the item is provided or the
service is performed.

Fees based upon breakeven analysis and/or cost of goods.

Nothing is free or no-charge.

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Unbundling: Service Package
This is the service you are currently providing at no-charge
once the aids are fit and accepted.

Think of it as the difference between your current bundled
fees and the unbundled package cost.

A patient pays you a fixed rate per aid or per fitting (based
upon the breakeven analysis) for managing their hearing
aids and services for a given period of time.

Base this on the data of your “average” patient.

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Unbundling: Service Package
• Could have a fixed number of visits, accessories (hard to
track and maintain) or services OR unlimited number of
visits, with defined amounts of accessories or services
(built upon the average number of visits you provide per
ear per aid fit now in your bundled model).
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Disclaimer
Prices listed are for illustrative purposes only and should
not be construed as a recommendation of any given price.
Price must be established individually by each clinic.

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Example of Bundled Price
V5261 (Hearing aid, digital, behind-the-ear, binaural):
$5100

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Example of Unbundled Price
V5261: The code for the hearing aid itself


92633: Aural Rehabilitation, post lingual

$2400 (single unit two aids)

V5160: Dispensing fee, binaural

V5266: Batteries (per battery)


$200 (represents one hour)

92595:Electroacoustic analysis, binaural

$1.50 x 8
V5264: Earmold (custom)


$100 (30 minutes)
$33 (10 minutes)

$40 x 2
V5011: Fitting and orientation


$200 (one hour)
V5020: Conformity evaluation


$66 (20 minutes)
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Example of Unbundled Price
•
•
•
Assume example of $200 per hour fee
(breakeven plus profit)
Hearing aid evaluation of $200 and $33 x 2
earmold impression paid on the date of that
service
$100 for each 30 minute hearing aid checks can
be billed on the date of service (if insurance
case) or at fitting (for private pay patient)
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Unbundled Package
• $266 paid on date of hearing aid evaluation
• $3091 paid on date of fitting
• $200 total paid for two, 30 minute follow-up visits within
evaluation and adjustment period
Collected $3557 by date of acceptance
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Unbundled Pricing Model Example: After
the Fitting
Pay as You Go:


They can purchase a service plan at any point

$100 for every 30 minute visit (hearing aid follow-up)

$50 for every 15 minute visit (earmold service, hearing aid check,
drop off repair)

Does not matter if one or two aids; it is all about the time scheduled
(as you cannot see anyone else).
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Unbundled Pricing Model Example: After
the Fitting
One Year Basic Service Plan (based upon an average of five
follow-up visits, one in-house repair, and one manufacturer
repair per patient fit): $700



Based upon data from your average patient in a bundled model
Includes unlimited follow-up visits, in-house repairs, manufacturer
repairs, loss and damage fittings, and earmold service visits over 12
calendar months
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Unbundled Pricing Model Example: After
the Fitting
Three-year Premier Service Plan (based upon an average
of 15 follow-up visits, three in-house repair, three
manufacturer repairs, 220 batteries, and one Dry and Store
per patient fit and ): $2540



Based upon data from your average patient in a bundled model
Includes unlimited follow-up visits, in-house repairs, manufacturer
repairs, loss and damage fittings, 220 batteries, loaner aids, Dry and
Store, earmold impressions and earmold service visits over 36
calendar months
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Price Comparison:
Bundled versus Unbundled (Private Pay)
Bundled = $5100

Unbundled


Pay as You Go = $3557

With One Service Package (monaural or binaural) = $4257

With Three Year Premier Service Package (monaural or binaural)
= $6097
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Want to Dispense an Better Aid than a
Online HA Retailer at a Better Cost?
• Patient pays $1620 ($810 each) at an online, health
insurance backed retailer for a hearing aid with no tax,
no service, no evaluation, no verification, 30 batteries,
package of wax guards, no extra domes or earmolds, no
follow-up, no loss and damage coverage, and no
manufacturer warranty for repairs due to moisture or
wax (one year otherwise).
• Unbundled: $1757 total - $957 in professional fees plus
two hearing aids with a single-unit price of $400 each,
with no tax, no service, evaluation, verification, two
follow-up appointments, aural rehabilitation, custom
earmolds, a three-year manufacturer warranty for any
repair issue, loss and damage, and 8 batteries
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Want to Compete with an Online PSAP or
Hearing Aid?
• Patient pays $605 at an online retailer for two devices
with $56 in tax (if that is required in your state), no
service, no evaluation, no verification, no batteries, no
follow-up, no loss and damage coverage, and no
manufacturer warranty for repairs due to moisture or
wax (one year otherwise).
• Unbundled: $1083 total - $478 in professional fees with a
single-unit price of $349 each, with no tax, no service,
evaluation, fitting, verification, and 8 batteries or $749
to purchase over the counter with evaluation and no
services.
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How Unbundling Can Help with An
Insurance Case (Non-inclusive Coverage)
• Bundled: You bill an insurance carrier for $4000 for binaural,
digital, behind the ear hearing aids using V5261. Insurance
pays $1800 ($900 each). The patient cannot be balance
billed. You have manage that aid for the same number of
years as you would a private pay patient.
• Unbundled: $2175 total –You bill an insurance carrier in an
unbundled manner and receive $1800 for the hearing aids,
$50 for the HAE, $40 for the EMI, $80 for the HAF, $80 for the
dispensing fee, $25 for the EAA, $60 for the REM, $40 for the
EM. This patient can pay as they go for service or purchase a
service plan, just like their private pay counterparts.
Patient Buys Their Aids Elsewhere...
• WHO CARES?!!
• They are still NOW your patient.
• Can charge them:
• $450 for electroacoustic analysis, fitting, programming,
verification, and one follow-up appointment (no follow-up, no
batteries, no accessories).
• Sell them a service package.
• Allow them to pay as they go for service.
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Integrating Itemization
• It would begin with all new Communication Needs
Assessments/Hearing Aid Evaluation and Selections.
•
Everyone who previously purchased within the bundled model
would still be covered within the bundled model.
• It would also affect:
•
•
Anyone who purchased their devices elsewhere.
Anyone who’s hearing aids are out of your bundled pricing
package or warranty.
Integrating Itemization
•
•
•
•
You would explain that this program gives them, the
purchaser, control over how their aids are delivered.
You would explain that there is a fee for the Communication
Needs Assessment but that they will receive a copy of their
evaluation and plan of care (like an optometrist does).
You would explain that, if they choose to get a device from
you, the fess will be itemized and separated from the cost of
the product itself and that, as a result, they will pay less up
front.
You would explain that is is their choice to pay as they go for
service or purchase a bundled, comprehensive service plan.
Integrating Itemization
• You will explain that there are different costs for different
services, depending on how much time each service
requires.
• If there is a need for repair, they will pay the invoice cost
of the repair plus shipping as well as a fee for any service
provided by your office.
• If there is a need for an earmold, they will pay for the
earmold impression as well as the cost of the earmolds.
• For accessories, they will pay invoice plus a markup for
stocking/ordering the items and profit. They may also
pay a fee if you must fit or explain the use of the
accessory.
Integrating Itemization
• All the while, you can educate them with materials from
HLAA and the NASEM on the role and goals of
unbundling and itemization.
• Some may offer them the ability to purchase certain
items themselves or from Big Box retailers, rather than
stocking them in their office or having the patient pay
more for the same item from them.
•
Audiology becomes more evaluative and rehabilitative.
• Some may want to stock many different types of
products in their offices, including PSAPs, OTCs,
Hearables, and ALDs.
Integrating Itemization
• Audiologists will need:
•
•
•
•
•
Well defined informational websites.
Well defined, itemized state required bills of sale.
Informational office pieces and forms that explain and list your
pricing and process.
Social media driven marketing campaign.
Physician referral program that outlines the differences of your
approach to patient outcomes.
Forms Discussed in Boot Camp
• Many of the forms discussed in the Boot Camp can be
purchased through the Academy of Doctors of Audiology
and their Practice Resource Catalog at
http://www.audiologist.org/resources/audiologists/practice
-resource-catalog.
• Forms may also be available to members through AAA and
ASHA or through your state audiology association.
Questions:
• Kim Cavitt, AuD
• [email protected]
• (773) 960-6625 (phone)
• I answer questions at no charge for Boot Camp attendees
ONLY until September 1, 2017.
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