What Audiologists Need to Know About Medical Necessity and SOAP Reports

Author: Kim Cavitt, Au.D.

Medical necessity is the operative word in today’s managed care environment. Medicare, Medicaid and the vast majority of private insurers in the US state that they only cover items and services that meet their definition of medical necessity. In general, medical necessity means that the item or service provided is required to diagnose, provide treatment options and/or monitor a medical or surgical condition or treatment.

This stipulation of coverage requires all healthcare providers, including audiologists, to provide documentation within the medical record that supports the medical necessity of every item and service provided. Also, it is important to note that several audiologic procedures, such as central auditory function, otoacoustic emissions, and vestibular function testing all require “interpretation and report” as part of the actual procedure.

For example, in Chapter 15, Section 80.3 of the CMS Medicare Benefits Provider Manual, Medicare indicates, “When the medical record is subject to medical review, it is necessary that the record contains sufficient information so that the contractor may determine that the service qualifies for payment. For example, documentation should indicate that the test was ordered, that the reason for the test results in coverage, and that the test was furnished to the patient by a qualified individual” (http://www.cms.gov/manuals/Downloads/bp102c15.pdf). Also, documentation is not just important because it is required; it is important because it demonstrates to both the patient and their ordering or primary care physician a high level of professionalism and patient care. Documentation, in the form of a comprehensive report, can be an effective form of physician marketing.

A comprehensive report or note within the medical record should contain all of the information necessary to document your subjective patient findings, your objective patient findings, and the results of your assessment and a plan of care or treatment. These requirements make up the fundamentals of SOAP (subjective, objective, assessment and plan) documentation. This report should be legible, dated (with the date of service) and should also contain the name and date of birth of the patient as well as the name and title of the audiologist who completed the testing and report.

Subjective findings are those obtained from your case history process. These are the things you cannot observe or measure but that are instead reported by the patient and/or their family. At a minimum, an audiologic case history should address the subjective aspects of the FDA Warning Signs of Ear Disease, such as acute or chronic dizziness or pain or discomfort in the ear (U.S. Food & Drug Administration Rules and Regulations Regarding Hearing Aid Devices: Professional and Patient Labeling and Conditions for Sale, Part IV, Federal Registers, 9286-9296, February 15, 1977). It should also address their oto-neurologic and vestibular history and include questions related to occupational and family history, hearing aid experience, and previous otologic conditions and interventions. An audiologist can also design their case histories to address other medical or surgical conditions, medications, social history, and allergies that can impact the auditory or vestibular systems. The depth and breadth of your case history directly correlates to your ability to document medical necessity and appropriately utilize Evaluation and Management codes.

Objective findings can be obtained from your case history and visual inspection of the patient, including but not limited to otoscopy. These are the things you can personally observe and measure. Minimally, your documentation should address the objective aspects of the FDA Warning Signs of Ear Disease. These include visible congenital or traumatic deformity of the ear, history of active drainage from the ear in the previous 90 days, history of sudden or rapidly progressive hearing loss within the previous 90 days, unilateral hearing loss of sudden or recent onset within the previous 90 days, audiometric air-bone gap equal to or greater than 15 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz, and visible evidence of significant cerumen accumulation or a foreign body in the ear canal. Some additional examples of objective findings are the observation of exotoses, otorrhea, or nystagmus. Your test results are also considered as part of the objective findings. An example of reporting an objective finding could be: “Pure-tone testing was completed bilaterally at octave and interoctave frequencies from 250 through 8000Hz. Results revealed normal hearing sensitivity in the left ear and a mild-to-moderate, sloping hearing loss for the right ear. A significant asymmetry was noted between ears.”

The assessment portion of the report/documentation is where the audiologist ties all of the subjective and objective findings together into a diagnosis or set of possible diagnoses (as allowed by licensure). This is where you describe your overall impressions of the patient’s condition. For example, if a patient reports subjectively unilateral tinnitus and fullness and your objective findings reveal a unilateral hearing loss and abnormal auditory brainstem response results, your assessment might indicate, “Results are consistent with those of a retrocochlear pathology for the right ear”. In this section, it is extremely important to be clear and concise in your reporting and to be consistent with your scope of practice guidelines and limitations.

Next, the plan portion of your report/documentation is the portion where you outline your recommendations and recommended course of treatment. Items should be listed in order of importance and urgency. The section could include statements such as “recommend hearing aid evaluation pending medical clearance” or “recommend a comprehensive tinnitus assessment and tinnitus management program due to the patient’s report of debilitating tinnitus”.

Finally, your summary statement must indicate how things were left with the patient as they departed your office. You should note items such as whether the patient was planning to return to their referring physician, whether they scheduled a hearing aid evaluation for another given date or whether they needed additional testing.

The Academy of Doctors of Audiology (ADA) is providing members with a sample comprehensive adult case history form for reference. This is shown in Figure 1-3 on page 58. This document will help members obtain all of the necessary subjective information needed to appropriately document medical necessity and assist in the creation of a comprehensive assessment and plan of care. Feel free to copy and use this form in your practice.    
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 Board of the Academy of Doctors of Audiology and 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.