Medicare Facts

Author: Kim Cavitt, Au.D.

ADA recently introduced weekly e-Member Alerts, featuring fast-facts about Medicare regulations as they relate to audiology services. We have received significant requests to reprint this material, and have chosen to highlight some of the most-requested information here.

MEDICARE FACTOID:
Audiologists CANNOT opt out of Medicare. In other words, audiologists cannot charge a Medicare beneficiary privately (or enter into a private contract) to provide an item or service that COULD have been covered if the beneficiary would have secured a physician order and if the item or service were medical necessity.

BACKGROUND
MEDICARE FACTOID:
Medicare should NOT reimburse Audiologists for providing Evaluation and Management services. This service is statutorily excluded from coverage if provided by an audiologist.

BACKGROUND
  • Medicare does NOT cover Evaluation and Management services (99201-99215) provided by audiologists.
  • If you are inadvertently receiving payment for these services from a Medicare Area Contractor, please refund these payments immediately. They have been paid to you in error.
  • Audiologists may utilize and bill for Evaluation and Management services (99201-99215) if the following criteria are met:
    • You determine that your state defined scope of practice allows for audiologists to “evaluate and manage”.
    • You bill these codes consistently across all patients when providing the same level of care, regardless of their age or payer.
    • You educate yourselves on these codes and their appropriate use.  This includes the level of case history and medical decision-making you are providing.  To learn more, click here and in the Evaluation and Management section of your CPT Manual.
      • These codes are NOT to be used for hearing aid related visits. Hearing aid visits should be billed using 92590-92595 and/or V5008-V5299.
    • You meet the documentation requirements of Evaluation and Management services.  To learn more, click here.
    • When billing Medicare, you add the –GY (item or service statutorily excluded or does not meet the definition of a Medicare benefit) modifier to the Evaluation and Management code.  This modifier will produce a Medicare denial.  Without the modifier, you could be submitting a False Claim. The patient can be financially responsible for these charges.  Click here to learn more about the GY modifier.
    • When billing Medicaid or private insurers, please consult each individual provider contract/agreement and/or payer guidance for specific guidance on the use of Evaluation and Management codes for each payer. 
MEDICARE FACTOID
Medicare NEVER pays for anything related to the purchase, fitting or adjustment of a hearing aid.

BACKGROUND
  • Per Section 100 of Chapter 16 of the Medicare Benefit Policy Manual, “hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids are excluded from coverage”.
    • This regulation includes the coverage of pure-tone, air conduction testing (92552), Pure-tone air and bone conduction testing (92553), comprehensive hearing testing (92557), evaluation of aural rehabilitation status (92626) and Quick-SIN (92700)
  • Medicare ONLY COVERS audiologic testing that is physician ordered and medically necessary to diagnose, treat or monitor a medical or surgical condition.
  • Hearing testing for the purpose of prescribing, fitting or changing hearing aids is the financial responsibility of the Medicare beneficiary.    
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.