Coding and Reimbursement Update for 2017

Author: Kim Cavitt, Au.D.

Physician Quality Reporting System (PQRS) Retirement
PQRS will retire on December 31, 2016. Audiologists will not be eligible for the replacement system, Merit-Based Incentive Payment System (MIPS) until January 1, 2019. As a result, audiologists will have no PQRS reporting responsibilities for 2017. You will not be penalized for failure to report quality measures. We strongly encourage audiologists to continue to voluntarily collect PQRS information from their patients (current medications, tobacco cessation, referral for dizziness, screening of depression with tinnitus patients, and falls risk) as they are valuable patient care and diagnostic tools, they distinguish audiologists from hearing aid dispensers, online retailers, and big box stores, and this type of system, with even greater requirements, with return in two years. Audiologists can voluntarily report via their traditional Medicare claims, via an electronic health record system, or via a registry.

MIPS also has requirements related to clinical improvement activities. Audiologists need to begin exploring things such as electronic health records, expanded hours, telehealth, use of patient satisfaction surveys, sending reports to every ordering/attending physician, participate in humanitarian volunteer work, and group visits for patients with similar conditions. Click here to learn more about this program.
ICD-10 Changes Effective October 1, 2016
  • There are several new codes, but the ones with the biggest impact affect coding for different type of hearing loss in different ears. 
  • Restricted means abnormal.
  • You would need to select two of the above codes to reflect different hearing losses in different ears. The new codes are:
    • 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
    Other new codes to consider are:
    • H93.A1 Pulsatile tinnitus, right ear
    • H93.A2 Pulsatile tinnitus, left ear
    • H93.A3 Pulsatile tinnitus, bilateral
    • H93.A9 Pulsatile tinnitus, unspecified ear
  • The Medicare grace period for using unspecified codes ended on October 1, 2016.  As a result, you need to avoid the use of unspecified codes unless allowed by your Medicare contractor through their local coverage determination. Please consult guidance from private insurers related to whether or not they allow the use of unspecified codes. Sometimes you may need to contact the ordering/referring physician or primary care physician for guidance on specific diagnoses for medical necessity.
  • Avoid the use of a Z code as a primary diagnosis. This can drive a denial.
  • Do not use rule out diagnoses once you know the diagnosis does not exist. (
  • Be aware of local coverage determinations from your Medicare contractors.  These policies determine what diagnoses are required for payment of specific codes.   Here are the current local coverage determinations that apply to audiology and their associated contactors:
    • Vestibular and Auditory Testing
      • Novitas
    • Tympanometry
      • First Coast
    • Vestibular Testing Only
      • First Coast
    • Vestibular Testing
      • Can affect 92557 when completed with vestibular testing
      • Palmetto
How do I code an asymmetric hearing loss?
It is recommended that you just code the loss(es) themselves and do not worry about documenting an asymmetry. For example, a bilateral, asymmetric sensorineural hearing loss is still a coded as a bilateral, sensorineural hearing loss or H90.3.

How do I code a routine hearing test?
There is no CPT or HCPCS code for a “routine” hearing test.   It is recommended that you first explore if the payer recognizes S0618 before you use the code. The best diagnosis code option for routine testing is ICD-10 code Z01.10.  Please remember that it is sometimes the patient’s responsibility to fight for coverage. Audiologists can only code what is reported, what they document, what they measure, and what they see.  Audiologists cannot code for coverage.
CPT and HCPCS Changes for 2017
There are no new CPT or HCPCS codes that impact audiology for 2017.
Common Coding Issues
Otoacoustic Emissions
  • Otoacoustic emissions are not warranted in every test scenario. The rendering provider must be able to document that the otoacoustic emissions are medically necessary for a specific patient.
  • CPT code 92587, distortion product OAEs, limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or TEOAEs, with interpretation and report, is to be utilized when testing TEOAEs and for DPOAES, an identifiable data point at each of the 3-6 frequencies tested. You must perform 3-11 frequencies in both the right and left ears in order to bill this code as well as interpret the results of the test and include a report in the patient’s record. The interpretation cannot be merely a “pass/fail” but, instead, must clearly document the ear and frequency specific test results.
  • CPT code 92588, comprehensive diagnostic evaluation (cochlear mapping, minimum of 12 frequencies), with report, is a much more extensive test that involves at least 12 frequencies in the right ear and 12 in the left and the interpretation of the test and the report in the patient’s record. This test is indicated, but not limited to, baseline and cochlear ototoxicity monitoring, cochlear mapping, to verify cochlear vs. non-cochlear function, and to verify functional hearing loss.
Evaluation of Aural Rehabilitation Status
  • CPT Code 92626: Evaluation of auditory rehabilitation status; first hour
  • CPT Code 92627: Evaluation of auditory rehabilitation status; each additional 15 minutes (list separately in addition to code for primary procedure)
  • For coverage, these codes are used for pre- and post-implantation auditory prosthetic device testing.
  • This is NOT for coverage for the QuickSIN or routine hearing aid testing.
Acoustic Reflexes
  • To appropriately bill for acoustic reflex testing, the audiologist must perform both ipsilateral and contralateral reflexes for at least 2 frequencies in each ear. If you are only performing ipsilateral reflexes, you must append the -52 modifier to indicate reduced services.
  • An ipsilateral acoustic reflex screening at 1000 Hz does not meet the coding criteria for 92568. (CPT manual 2016)
  • Also, as noted with OAEs, acoustic reflex threshold testing is not warranted in every test scenario. The rendering provider must be able to document that the acoustic reflex threshold testing is medically necessary for this specific patient.
Speech in Noise Testing
  • Speech in noise testing could be included in Comprehensive Audiological Evaluation (92557) or as part of Speech Audiometry with Speech Recognition (92556) evaluation. Or, it could be billed as an unlisted otorhinolaryngological procedure code 92700, with documentation & explanation of the procedure.
  • This code should not be filed to Medicare if utilized as a predictor of hearing aid performance in noise .
  • Speech in noise testing should not be billed as a Filtered Speech Test (92571), as this code is one component of a comprehensive central auditory processing evaluation.
  • 92571 became part of a National Correct Coding Initiative (NCCI) edit by the Centers for Medicare and Medicaid Services (CMS) and was bundled with CPT codes 92572 (Staggered Spondaic Word Test) and 92576 (Synthetic Sentence Identification Test) into CPT codes 92620 and 92621- evaluation of central auditory function test, first 60 minutes and each additional 15 minutes, respectively.
For further questions or concerns, please contact Kim Cavitt, Au.D. at    
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 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.