The Original Unbundled Delivery: Auditory Prosthetic Devices

Author: Kim Cavitt, Au.D.

Cochlear implants, auditory osseointegrated devices, and auditory brainstem devices have, technically, always been unbundled as the devices are purchased by the operating facility or, with an upgraded processor, directly through the manufacturer. Unlike a bundled hearing aid delivery, we, the audiologists, provide the care and service around the device but not the device itself.

So, how do audiologists provide the care and service needed to determine candidacy and provide programming, fitting and orientation, and long-term service, re-programming, troubleshooting, and service AND not lose money doing it? There is a path to fairly monetizing an auditory prosthetic device program, while providing the expertise and care these patients want and need by more accessible means. It just requires some groundwork.

Like all good unbundling projects, it starts with data and knowledge. What is your breakeven plus profit per hour? What is your clinic protocol for candidacy, initial activation, and follow-up? How much time do you spend in these appointments? What codes do you use to represent these visits? You need this data and information to create your pricing structure. Patients, both implanted and prospective, need be informed of this structure and their financial responsibilities within it at scheduling and as part of the candidacy process.

See, much of the auditory prosthetic device activation, delivery, fitting, and management is private pay. CPT codes and coverage exist to cover most, but not all, of the candidacy determination process for auditory prosthetic devices. The CPT codes such as 92538, 92557, 92550, 92584, 92585, 92587/8 are medically necessary and covered services for most payers, including Medicare, for auditory prosthetic device candidacy assessments. The only legitimate use of 92626/7 for third-party coverage is to represent the candidacy assessments (or post-implantation testing such as AZ Bio, MAC, HINT, speech in noise, WIN, etc.) for auditory prosthetic devices performed in the best aided condition. Other services though, such as evaluation and management procedures (99201-99203 and 99211-99213; as allowed by state scope of practice and appropriate use and documentation) and team meetings (99366 and 99368) would typically be the financial responsibility of the patient or their guardian.

Cochlear implants have coverage (via 92601 and 92603) for the costs of initial activation (the programming of the device) but this code does not encompass the time and skill required for orientation (use and care of the coils, cables, processors or batteries) or the often necessary aural rehabilitation or auditory training (92630 or 92633). As there is no code to represent cochlear implant fitting and orientation, 92700 is the most appropriate option. Third-party coverage for 92700 and 92630 or 92633 are extremely limited. As a result, the patient or their guardian is typically responsible for these costs. This holds true as well for the long-term management (follow-up, troubleshooting and service) of a cochlear implant. While third-party payers allow for coverage of re-programming (92602 and 92604), follow-up soundfield testing of 31 minutes or more (92626), neurotelemetry (92584) and eSRT (92568), they do not have a code to represent follow-up care or service. Again, this makes 92700 the most appropriate choice.

Unlike cochlear implants, auditory osseointegrated devices do not have codes to represent the programming, fitting or orientation to the device. Again, as a result, 92700 is the most appropriate code and, as often noted, third-party coverage is rare. In most cases, all of the costs associated with the initial and long-term management (follow-up, initial and re-programming, fitting, orientation, troubleshooting and service) of an osseointegrated device is the financial responsibility of the patient or their guardian.

Patients should be notified of these out of pocket costs at scheduling and, for new potential implantees, during the candidacy process. Patients should complete, prior to services being rendered, all appropriate notices of non-coverage (advanced beneficiary notice for traditional Medicare, organization pre-determination for Medicare Part C/Advantage and notices of non-coverage for Medicaid and private third-party payers). They should also pay the costs of all non-covered services (such as any service that is represented by 92700, aural rehabilitation, evaluation and management codes, team meetings, etc.) at the time of visit.

Some bi-modal patients may have coverage for the hearing aid that aids their non-implanted ear. The costs of the procurement, fitting and care of these devices should follow your typical hearing aid delivery model, insurance process and pricing structure.

All of the device manufacturers offer wonderful provider training and resources and customer support related to insurance as well as the order, repair and shipment of replacement batteries, coils or processors. They also can assist the patient in obtaining desired or needed processor upgrades.

Offering auditory prosthetic device services can be a real differentiator for your practice. It can lead to increased physician and hearing health provider referrals, increased exposure, and increased options and satisfaction for the patients you serve. There is still a significant need for these services in many communities, especially those in more suburban and rural locations that are farther away from many current implant centers. The keys to success are creating a standard pricing and delivery structure, standard appointment types, appropriate notification forms, and materials that allow you and your staff to explain your program to patients and families. Price transparency, setting realistic expectations and the delivery of evidence-based care will help your program grow and thrive.

ADA members may contact me free of charge at Kim.Cavitt@audiologyresources.com with specific reimbursement questions.    
Dr. Kim Cavitt was a clinical audiologist and preceptor at The Ohio State University and Northwestern University for the first ten years of her career. Since 2001, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc. She currently serves on the State of Illinois Speech Pathology and Audiology Licensure Board. She also serves on committees through AAA and ASHA and is an Adjunct Lecturer at Northwestern University.