2015 Coding and Reimbursement Updates

Author: Kim Cavitt, Au.D.

PQRS
The Academy of Doctors of Audiology, the American Academy of Audiology (AAA) and the American Speech-Language-Hearing Association (ASHA) have created a 2015 PQRS Step by Step Guide available at www.audiologyquality.org. The 2015 rules are essentially the same as the 2014 rules.

Audiologists have three measures they may report in 2015:
  • Measure #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
  • Measure #130: Documentation of Current Medications in the Medical Record
  • Measure #134: Screening for Clinical Depression and Follow-Up Plan
The details of 2015 PQRS implementation for audiology have been finalized. To avoid the 2.0% Medicare penalty in 2017, audiologists must report the following in 2015:
  • Report on Measure #261 (Dizziness) on at least 50% of each provider’s Medicare claims which contain the diagnosis codes of 780.4 (Dizziness) or 386.11 (BPPV).
  • Report on Measure #130 (Documentation of current medications) on at least 50% of each provider’s Medicare claims where they bill for a hearing test, caloric testing, tympanometry, auditory brainstem response testing, comprehensive otoacoustic emissions, and/or cochlear implant/auditory osseointegrated device candidacy testing.
  • Reporting that you DID NOT do something (G8858, G8428, G8432, or G8511) is JUST LIKE you did not report at all!
You MUST report a POSITIVE ACTION (referral, documentation, or screening) for the reporting to count and to assist in avoiding the penalty!

Measure #134 is an optional measure; as a result, you will not be penalized for failure to report on this measure in 2015. It should be noted though that, when appropriately reporting Measure #134, your incentive payment could be increased (if no other measure is reported on this claim) due to the addition of another measure.
  • We advise that each provider report on Measure $134 (Screening for clinical depression with follow-up plan) on every Medicare claim where you bill for a hearing test, tympanometry, tinnitus assessment and/or cochlear implant/auditory osseointegrated device candidacy testing AND when:
    • Allowed by their state licensure law (when deemed within the scope of practice of an audiologist within your state; determined through written contact with their state licensing board)
    • The provider is appropriately trained and competent to screen with a standardized tool AND create a patient plan of care
    • A follow-up plan of care is created, implemented and documented in the medical record
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.

The following providers may order audiologic and vestibular testing as long as they are acting within their state defined scope of practice:
  • Doctor of Medicine (MD)
  • Doctor of Osteopathy (DO)
  • Dentist (DDS)
  • Podiatrist (DPM)
  • Optometrist (OD)
  • Chiropractor (limited; please review the guidance - click here)
  • Clinical Nurse Midwives
  • Clinical Nurse Specialists
  • Clinical Psychologists
  • Clinical Social Workers
  • Interns, Residents and Fellows
  • Nurse Practitioners
  • Physician Assistants
You can learn more and find a list of Medicare enrolled ordering providers - click here.
CPT Assistant and Pediatric Testing
In August, 2014, a CPT Assistant article was released that defined most of the audiology code set. CPT Assistant is the official source, from the American Medical Association (who owns CPT codes and their use) of code usage, regardless of payer. CPT Assistant indicated:
  • Visual Reinforcement Audiometry (92579)
    • “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”
  • Conditioned Play Audiometry (92582)
    • “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.”
-59 Modifier
In Audiology, the -59 modifier is used in situations where you are providing aspects of a bundled code, such as 92557 or 92540. Many of you may have seen mention of the new modifiers that could replace the -59 modifier. These new X- modifiers are not appropriate for audiologic services. We recommend you continue to use the -59 modifier in the situations mentioned above.

Medicare Advantage
Advanced Beneficiary Notices are not applicable for Medicare Advantage members. They are only valid for use with traditional Medicare patients. You need to consult each Medicare Advantage program for their guidance on pre-service organization determination process (the Advanced Beneficiary Notice of Medicare Advantage).

You may need to complete a pre-service organization determination from the payer prior to perform the service or dispensing the item.    
Kim Cavitt, Au.D. 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 as President of the Academy of Doctors of Audiology and 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.