Recent Coding, Billing and Reimbursement Questions from Members Addressed

Recent Coding, Billing and Reimbursement Questions from Members Addressed

ADA has received numerous member inquiries related to the following topics. We wanted to take this opportunity to provide guidance and insight and address member questions and concerns.

Billing Services of Technicians to Health Plans, Including Medicare and Medicaid

Medicare is very clear that 1) technicians/audiology assistants can only provide technical services (performing the procedure but not interpreting and reporting the procedure) when the procedure has a TC/PC split, 2) technicians/audiology assistants must be trained, and, most importantly, 3) can only provide covered services under the direct supervision of a physician (not an audiologist). This is clearly documented in chapter 15, section 80.3 (D) and 80.3.1 of the Medicare Benefit Policy Manual. Many state Medicaid programs and commercial insurers follow these same requirements.

So, it is important that providers confirm the scope of practice requirements of audiology assistants and technicians in their state and the supervision and billing limitations of each payer before utilizing technicians and audiology assistants in their practice for managed care covered services. Lack of mention in licensure does not mean it is allowed; instead you could be supporting unlicensed practice of audiology or medicine. It is important to get clarification from your state on the ability to utilize audiology assistants and technicians when not specifically addressed in licensure.

It is also important to know that, when you bill the services of an audiology assistant or technician to an insurer or third-party under the NPI of an audiologist and it is not explicitly allowed, you could be supporting the unlawful practice of audiology or hearing aid dispensing without a license and/or filing a false claim. Please consult all payers before allowing audiology assistants or technicians to provide covered services to their beneficiaries and determine, with each payer, how these services are to be billed.

Billing for Binocular Microscopy

As its name indicates, Binocular Microscopy (CPT Code 92504), requires use of a binocular microscope to visualize the ear canal and tympanic membrane.

In the October 2011; Volume 21: Issue 10 of CPT Assistant, which documents appropriate code use across all health plans, the following was provided:

Question: Please provide an example of when it is appropriate to report code 92504.

Answer: An example for reporting code 92504, Binocular microscopy (separate diagnostic procedure), is when a patient presents with ear fullness and decreased hearing. Routine otoscopy suggests an abnormality of the tympanic membrane. To further evaluate this finding, binocular microscopy is performed.

Binocular microscopy may be medically reasonable and necessary when 1) you have a binocular microscope (an otoscope or video otoscope is insufficient to meet the code description), 2) you were unable to visualize clinically significant portions of the ear canal or tympanic membrane with an otoscope and 3) your documentation supports the medical necessity of the procedure for the specific patient.

Use of this code implies binaural. As a result, a 50 (bilateral procedure) modifier would be inappropriate. If only one ear is viewed, the 52 (reduced services) modifier must be added.

Evaluation and Management Code Use in Audiology

There are clinical situations where the consistent use of evaluation and management codes (CPT 99-) are warranted and recommended BUT, before these codes are used in your practice, there are several considerations each provider must be aware of:

  1. Per the American Medical Association, who owns the CPT code set, evaluation and management codes are accessible to “physician and qualified healthcare professional”. Per the AMA, a physician or other qualified healthcare professional” is an individual who is qualified by education, training, licensure/regulation (when applicable), and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service”.
  2. It important, as a result, that “evaluation and management” is within the scope of practice of audiology in your state. This documentation will be useful in situations where the health plan assigns financial responsibility of the service to the provider and you need to be able to override that decision, in appeal to charge a patient privately.
  3. These codes should be applied to diagnostic test visits only; their descriptions and requirements are incompatible with hearing aid visits (and there are better codes for that situation anyway).
  4. These codes and their usage should be consistently applied to all patients in the same clinical situation, regardless of payer. In most situations, the patient will be responsible for the costs as many payers do not cover evaluation and management services provided by an audiologist, even if it is clearly in scope in their state.
  5. The provider must meet the requirements of the specific code, especially documentation requirements.
  6. Code selection is NOT merely based upon time; it is also based upon new or existing patient, level of case history, type and amount of data reviewed, the complexity of the case and the risks of morbidity and mortality.
  7. Your providers must be trained on the appropriate use, documentation and billing of these codes.

There is a history of audiologists being audited for use of this code set and being unsuccessful in appealing the payer decision. This is why it is important to educate yourself on the appropriate use of these codes before utilizing them in your practice.

Electronic Hearing Protection

In general, health plans do not cover items or services for recreational, occupational, or educational uses. They cover items and services that are medically reasonable and necessary to manage or treat an illness, disorder, or condition.

These considerations are important when considering the billing of electronic hearing protection to a health plan:

  1. Health care plans, as a general rule of thumb, do not cover hearing aids in the absence of a documented peripheral hearing loss.
  2. Health plans generally do not cover hearing aids for ear protection or for the treatment of tinnitus, balance, or auditory processing in the absence of at least a documented mild hearing loss (26dB).
  3. Some health plans, including UHC, Tricare, Aetna, and many BCBS Association plans, have medical policies that indicate requirements for minimum hearing loss, medical necessity, recommendations/clearance, and, importantly, documentation. We encourage you to locate and review these policies yourselves if you participate with or bill health plans for hearing aids.
  4. If the patient has a hearing loss (greater than 26dB or as specifically allowed by payer medical policy or benefit) and the devices are being prescribed as a treatment for that hearing loss, I recommend billing these aids to a health plan using the code V5298 (hearing aid not otherwise classified). For binaural devices, you will add the 50 (bilateral) modifier.
  5. If the patient does not have a hearing loss or if the devices are being recommend solely as a means of hearing protection, the devices should be billed as V5274 (assistive listening device not otherwise classified). ■

Academy of Doctors of Audiology members (individual and practice) have access to ADA resources for support on compliance, coding, billing, reimbursement, and insurance questions. This is a value-added benefit of ADA membership. Please contact Kim Cavitt at This email address is being protected from spambots. You need JavaScript enabled to view it. for any questions, guidance or support.