20Q: Working with Medicare - Reimbursement Rules of Engagement

From the Desk of Gus Mueller

You clinical audiologists have all been there. After a year or so of seeing 8-10 patients/day, there is that day when everything just starts to click. Masking for bone conduction actually makes sense, you could program your favorite hearing aid in your sleep, and you’re pretty darn good at identifying the probable pathology following a complete audiologic work-up. Audiologists doing audiology. Life is good. 

But wait...There is also this thing called getting reimbursed for what you do. Could be you need to understand coverage policies, regulatory influences, how to document your services, and how to appropriately report your work using the CPT and ICD code sets. And of course, an understanding of the Medicare system is all part of this. You ask, aren’t there “other people” to do all that? Maybe yes, maybe no, depending on your work setting. In a sense, however, we all do have “other people,” who might not do the work for us, but certainly can help us get it right. One of them is this month’s guest 20Q author.

Anna Jilla, AuD, PhD, has a unique specialization in payer policy, public health, and health care accessibility barriers, advocating for national and regional payer policy. She has numerous publications on these topics, and works in collaboration with the American Academy of Audiology as the Chair of the Coding and Reimbursement Committee, and the Texas Academy of Audiology as their Vice-President of Professional Issues.

Dr. Jilla is the Jo Mayo Endowed Research Chair and Assistant Professor of Audiology in the Department of Speech and Hearing Sciences at Lamar University in Beaumont, Texas. She is the Director of the Audiology Economics and Rehabilitative Outcomes (AERO) Laboratory, whose mission is to develop high-quality evidence and training opportunities for professionals and students. In recent years she has served on several committees of the American Academy of Audiology, including the Over-the-Counter Hearing Aid Task Force, Systematic Review of Health-Related Quality of Life Benefits of Hearing Aids in Adults, and the Clinical Practice Guideline for the Adult Management of Hearing Loss.

You’ll find Anna’s 20Q extremely informative, and something that you’ll want to keep handy as reimbursement issues appear down the road—particularly in the Medicare arena. And just a guess here...I could be wrong, but I’m thinking that at one time or another you’re going to hear mention of the Medicare Benefit Policy Manual, Chapter 15, Section 80.3!

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: Working with Medicare - Reimbursement Rules of Engagement

Learning Outcomes 

After reading this article, professionals will be able to:

• Identify primary resources and compare coverage policies for audiology services through Traditional Medicare Part B provisions, local coverage determinations, and Medicare Advantage plans.
• Discuss how the classification of audiologists affects the types of services that are considered covered by Traditional Medicare Part B provisions.
• Characterize how medical necessity and physician order requirements for audiology services are defined under the Medicare Benefit Policy Manual for Part B services.

Anna M. Jilla, AuD, PhD

1. Let’s start with the basics. I’m an audiologist. When I practice, my time and expertise have value that is typically represented in some form of payment. But it seems to play out differently in practice. I mean, how do I get paid?

This is a great question! Reimbursement is the result of many factors that often affect successful payments from insurers. We must consider how we bill, how we document, how we report our services using the CPT and ICD code sets, and the coverage policies. Other regulatory influences related to claims filing as well as compliance programs are also part of ensuring we successfully submit claims and receive payment for the audiology services we provide.

2. Coverage, coding, billing, reporting, where can we even start?

Let’s start with coverage. Determining whether items or services are covered or not provides the basis for understanding the rules of engagement under the given insurance plan. If services are non-covered, these may be billed directly to the patient and do not need to be submitted to insurance. The patient is responsible for paying for all non-covered services.  No insurer wants to process claims for services they already said would not be covered.

Unfortunately, many audiologists may not bill for services that do not have established CPT codes. For example, professional work for educational report writing or audiologic counseling activities may go unreported and thus unreimbursed. Clinics are encouraged, however, to determine fees for all professional activities offered within the practice regardless of whether a CPT code exists. With established fees, there is a usual and customary fee that can be billed directly to the patient if the service is not covered through insurance.

3. Coverage seems to be one of the keys to the castle here. But where do you find out whether the services or items are covered?

You’re right, coverage is one of the keys to the castle! While coverage policies may vary from plan to plan and insurer to insurer, audiology providers who are contracted with an insurer have access to the insurer’s fee schedule. The fee schedule outlines how much practitioners will be paid for covered items or services. It might be easiest for us to examine this further through the largest health insurer in the country, Medicare, since they provide the basic framework for all the other insurance companies in the United States. They’ve got this down to a science!

4. Medicare. You mean, The Medicare? I’ll be honest; that’s always been a bit scary to me. Isn’t Medicare among the hardest insurers to deal with?

While I understand Medicare seems big and scary because they are a federally sponsored program, I would argue they are the easiest insurer to work with. The Medicare system’s rules of engagement are clearly outlined and apply (somewhat) more uniformly across beneficiaries within the Medicare system. Everyone who has a Traditional Medicare (Part A and Part B) plan will have the same general terms with nuanced coverage variations occurring across regional jurisdictions in something called Medicare Local Coverage Determination policies.

5. How is Traditional Medicare different from Medicare Advantage?

Traditional Medicare is a publicly sponsored plan for adults ages 65 and older, as well as others with qualifying disabilities. Traditional Medicare beneficiaries receive access to Part A and Part B benefits but may opt to have a supplemental or choice plan for accessing those Part A and B Medicare benefits. Medicare Advantage (or, Part C) plans are optional and can incur an additional cost to the beneficiary for plan premiums. These supplemental or choice plans are subject to a different set of Medicare ‘rules of engagement’ compared to Traditional Part A and B.

There is some oversight from the Centers for Medicare and Medicaid Services (CMS) over plans provided under the Medicare Advantage (Part C) designation. If you’re interested, I’d suggest you take a look at the Medicare Manuals on Medicare Managed Care for review of policies and provisions for these optional plans (CMS, 2023c). Medicare Advantage plans can vary widely in their coverage policies but should, by law, minimally provide benefits equal to those under Traditional Medicare Part A and B provisions. However, Medicare Advantage plans, as I’m sure you’ve heard much about on TV ads, may provide additional benefits such as routine testing, eyeglasses, or hearing aids to their beneficiaries.

Medicare Advantage benefits for other audiology services can vary widely across plans. Indeed, Medicare Advantage or other private coverage options can differ across insurers and even within insurers based on the terms of the plan. Some Medicare Advantage plans even offer different coverage options based on the zip code of the beneficiary. So, when trying to determine coverage for a specific Medicare Advantage or other private plan, you’ll need to find the Evidence of Coverage document for that specific plan. If you’re an enrolled provider for any insurer, you should be able to access an evidence of coverage document for anyone seeking care under that plan through your office. It may take online access to a benefit-checker or a phone call to Provider Relations, but this Evidence of Coverage document will more specifically outline the coverage policies for audiology services and devices under these Medicare Advantage and other private plans. For more on examining coverage policies for Medicare Advantage plans, see Jilla & Cheney (2020).

This is why I always start with explaining Medicare Part B because the policies between public and private plans may differ widely, but the general framework for coverage is similar.

6. Wow. That’s a lot of variability across private and public plans, even down to the zip code! So, what are the audiology ‘rules of engagement’ with Traditional Medicare?

In thinking about the rules of engagement, let’s start with how audiologists are classified within the Medicare system because that classification affects coverage polices.

Audiologists’ participation in and payment under the Medicare system is provided through the “other diagnostic tests” provision of the Social Security Act under 42 U.S.C. 1395x(ll)– Section 1861(s)(2) and further defined under ‘audiology services’ in Section 1861(s)(3) (Social Security Act, 2023). As such, Medicare-covered audiology services provides they are diagnostic in nature—you’ll even see this in the code descriptors for cochlear implant mapping; they’re named ‘diagnostic analysis’ for a reason.

Traditional Medicare specifically notes there is currently no provision to pay audiologists for rehabilitative or therapeutic activities (CMS, 2022). Reclassification of audiologists under the Medicare program requires legislative action to amend the Social Security Act statutes pertaining to audiologists (Miller et al., 2022).

7. We are under the narrow benefit category of “other diagnostic tests,” huh? Yet, audiologists do so much more within our scope beyond that of diagnostic testing. How can this be changed to be in better alignment with the types of services we provide?

Simply stated, we work hard to get the rules changed, and that’s what we are doing. The Medicare Audiology Access Improvement Act (2023) was introduced on July 19, 2023 as S.2377 and on November 17, 2023 as H.R.6445. These bills propose the following statutory changes: (1) addition of coverage for rehabilitation/treatment services to existing covered diagnostic services, (2) removal of physician’s order requirements for access to audiology services, (3) reclassification of audiologists as ‘practitioners’ within the Medicare system, and (4) addition of audiologists as ‘practitioners’ under Federally Qualified Health Centers and Rural Health Clinics (Medicare Audiology Access Improvement Act, 2023a; 2023b).

‘Practitioner’ status would bring audiology in alignment with other similar nonphysician specialties such as social work and nutrition (Miller et al., 2022). This change in classification could potentially provide beneficiaries access to coverage for certain audiologic evaluation and management activities that are not currently covered under Traditional Medicare. Long story short, this would pull audiologists out of a diagnostic-only category within the Medicare program.

8. Are all our professional organizations in-step with these proposed changes?

Most certainly. This bill is endorsed by the American Academy of Audiology, the American Speech-Language Hearing Association, and the Academy of Doctors of Audiology. Talking to your legislators about this bill can go a long way. I hope all of you reading this will contact or schedule a visit with your respective legislators and indicate your support.

9. That sounds useful, not just for audiologists but also for our patients. So, as the advocacy continues and until the statutes change, where do I find the current Traditional Medicare coverage policies?

Medicare covered audiology services are primarily outlined in Medicare Part B provisions. Part B coverage pertains generally to outpatient services and differs from Medicare Part A, which provides coverage for health services like emergency transport and inpatient hospital stays.

For Medicare policies, your first stop is the Medicare Manuals. These can be found in an online library housed on the CMS website (CMS, 2023c). You’ll find that there are many manuals available, including general rules, claims filing, coverage policies, integrity programs (i.e., avoiding fraud and abuse), and so on. These manuals serve as your unabridged instruction manual for participation in the Medicare program as a provider.

Among the most resourced is the Medicare Benefit Policy Manual, which characterizes coverage and the circumstances of that coverage. Audiology services are discussed in Chapter 15 – Covered Medical and Other Health Services, Section 80.3. Say it with me now, Chapter 15, Section 80.3! You mentioned the Medicare program seeming a bit scary, but this section clearly defines how these services are covered under “other diagnostic tests,” who is considered a qualified audiologist under the program, any requirements for physician orders for testing, and what medically necessary services Medicare will cover—and, under what circumstances. The list of Medicare covered audiology services and their respective CPT codes is found on the CMS website (CMS, 2023h).

This is where the rubber meets the road on audiologists’ classification under the Medicare system. Indeed, Section 1861(s)(3) of the Social Security Act provides audiology coverage under the auspices of “other diagnostic tests” (Social Security Act, 2023). This sets beneficiaries up for narrowly defined benefits for audiology service coverage that are limited to those which are inherently diagnostic (e.g., hearing, tinnitus, vestibular, surgical candidacy for implantable hearing technology, or diagnostic analyses of implantable hearing technologies). These statutes being housed under “other diagnostic tests” thus precludes coverage for hearing aids and other diagnostic assessments for the purposes of obtaining hearing aids through the Traditional Medicare program.

Coming back to covered services, just because a service like tympanometry is on the Medicare covered services list doesn’t mean it’s unconditionally covered. The Medicare program protects its financial investment and assures certain requirements are met prior to debiting the piggy bank to pay claims. In other words, there are guardrails for fraud and abuse to ensure that Medicare is only paying for services that are deemed reasonable and necessary under coverage policies. Two of these conditions for coverage center around (1) the physician order and (2) medical necessity.

10. Can we unpack those last two Medicare coverage considerations a bit? Let’s start with the need for a physician order. I feel like I have heard some things about changes to physician order requirements for audiology services under Medicare. Can you fill me in?

Sure thing! The physician—or other qualified non-physician practitioner—order is basically providing a reason that the testing is needed (e.g., Was there a change in hearing, balance, or tinnitus? Are these medications affecting hearing? Is more information needed after a failed screening?). Again, you can find information on this in Chapter 15, Section 80.3 (Say it again with me now, Chapter 15, Section 80.3!) of the Medicare Benefit Policy Manual, which provides a more comprehensive list of appropriate reasons or indications for ordering audiologic testing (CMS, 2023e).

To your point, something did recently change. Prior to January 2023, payment for audiology services under the Medicare program always required two things: (1) medical necessity and (2) a physician (or other qualified non-physician practitioner) order. In January of 2023, the Centers for Medicare and Medicaid Services (CMS) implemented policy changes for removing the physician order requirement for certain audiology services (CMS, 2023f; 2023g). Note, however, that even though the physician order may not be required under certain circumstances, demonstration of medical necessity is still required for all covered services.

11. Exactly what audiology services are covered under this limited direct access provision under Traditional Medicare? And are there different circumstances for coverage?

The new policies are clear that a physician order is still required for any acute hearing or vestibular issues. Alternatively, this limited direct access is for non-acute issues within a narrow indication of gradually progressive hearing loss in both ears. In circumstances where non-acute hearing issues (i.e., gradual progression of hearing issues generally in both ears that is unrelated to disequilibrium, hearing aids, or testing for the purpose of prescribing, fitting, or adjusting hearing aids) are suspected, this new policy allows beneficiaries access to a select set of audiologic diagnostic tests without the need for obtaining a physician order prior to testing (CMS, 2023f). Again, the medical necessity requirement remains.

Under the new Medicare limited direct access provisions for audiologists, a limited set of 36 audiology procedures can be provided without a physician order one time per 12-month period under the limited indication of a non-acute hearing issue (i.e., gradual decrease in hearing over time, generally in both ears, not related to disequilibrium or hearing aids). The limited direct-access subset of 36 audiology services covered under Medicare Part B for non-acute hearing issues can be found in a CMS Transmittal (CMS 2023b)

To report services under this new provision, audiologists append the new AB modifier to each service code reported during that episode of care. There are a couple recent publications that provide guidance regarding these changes under the new limited direct access provision (Jilla & Kovar, 2023b; Von Dollen et al., 2023). This is a positive first step in addressing patient barriers for many older adult Medicare beneficiaries seeking audiology services.

12. Agreed. You have been rather vague regarding the medical necessity issue. How does one know whether a service is considered medically necessary?

Great question. We’ve gone down our checklist of whether a specific service is covered, whether a physician order is required, now we must substantiate whether the services are medically necessary. Something that is very clearly stated in the Medicare Benefit Policy Manual—say it with me now, Chapter 15: Section 80.3—is that, and I quote, “Coverage and, therefore, payment for audiological diagnostic tests is determined by the reason the tests were performed, rather than by the diagnosis or the patient’s condition” (CMS 2023e). This means that services are determined to be covered or non-covered based on the reason the tests were performed rather than by the results obtained from diagnostic tests.

There are two big reasons for testing that will cause services to not meet the definition of medical necessity and thus affect the opportunity for reimbursement: (1) routine testing and (2) audiologic testing for the purposes of fitting or adjusting a hearing aid (CMS 2023e). Routine testing pertains to testing when the status is already known or no changes are suspected. This means that if there are no new signs or symptoms, testing would be considered routine and thus non-covered under Part B policies. Audiologic testing for the purpose of fitting or adjusting hearing aids is not currently covered through Medicare Part B provisions, as they fall outside of that ‘other diagnostic tests’ categorization we discussed earlier.

13. How do you substantiate medical necessity in your documentation to support coverage under Traditional Medicare Part B provisions?

A more comprehensive list of reasons that meet Medicare criteria of medical necessity are presented in, you guessed it, Chapter 15, Section 80.3. These include but are not limited to: suspected changes in status related to hearing, tinnitus, or balance; identifying the cause of disorders of hearing, tinnitus, or balance; post-treatment evaluation of the effects of medications, surgeries, etc.; re-evaluation for potential changes among individuals at risk for changes in status (e.g., Meniere’s, cholesteatoma, otosclerosis, acoustic neuroma, ototoxicity, genetic conditions) (CMS 2023e; 2023f).

Documentation in the medical record should clearly support medical necessity noting new signs and symptoms such as changes to hearing, new audiologic or otologic symptoms, reason for serial evaluations (e.g., ototoxicity monitoring, determining effect of surgery or other treatments) (CMS 2023e; 2023f). Keep in mind that routine testing (e.g., annual testing without new signs or symptoms) or testing for the purposes of fitting or adjusting a hearing aid remain non-covered under Medicare Part B policies.

14. I feel that many audiologists simply don’t bill for items when they are not covered. If it’s not covered by insurance, what can we do?

This is the exact reason I’ve been talking about Chapter 15, Section 80.3 and the importance of referencing the Medicare manuals; we need to know when to bill the insurance for covered services and when it is appropriate to bill the patient if services are non-covered. To make an informed determination on whether a service is covered or not, we must first understand the coverage policies and the circumstances of that coverage.

If we are certain a service will never be covered under Traditional Medicare, then it would be considered patient responsibility. Just because the insurance plan does not cover a service that we are able to provide within our scope of practice does not mean we have to write that off. In fact, we shouldn’t! If insurance isn’t covering the services provided, it becomes the patient’s responsibility. Keep in mind though, it’s important to be forthcoming in that information by notifying our patients of non-coverage prior to those items or services being rendered so that they’re aware of their financial responsibility.

15. One thing that you’ve drilled into my head now is the importance of Chapter 15, Section 80.3 as the primary resource for us as audiologists. So, everything I need to know about Medicare is in that section, right?

Not quite. We also need to review other manuals related to claims filing, appeals, general rules of participation, and compliance programs (CMS 2023d). Just don’t forget that there are other manuals out there to help with the more administrative aspects for providers seeking more information.

When we review the manuals, we have our overarching framework for coverage and reimbursement from the CMS for audiology services (again we chant, Chapter 15, Section 80.3). But when it comes to coverage policies, we have to go a step beyond the Medicare Manuals because there are nuanced differences in coverage policies based on the geographic locality in which the Medicare services were provided.

Remember, Medicare is the largest insurer of Americans. The CMS would be hard-pressed to carry all of this out themselves. Instead, they have delegated and contracted outside entities to manage claims and coordinate benefits across different geographic regions of the country. These are the Medicare Administrative Contractors, or MACs, who serve as the agents of the CMS and liaise between the CMS, providers, and beneficiaries.

16. Who are these Medicare Administrative Contractors? Does everyone have one, and how do I find mine?

MACs are private contractors that process Medicare claims as well as provide support to enrolled providers and beneficiaries within a given regional jurisdiction (CMS, 2023d). It is the job of the MAC to get into the specifics, and this is where we find even more specific coverage policies for Medicare Part B. The beloved Chapter 15, Section 80.3 provides us with the general coverage policies. Our MACs give us the more specific guidance by outlining the codes, frequency limitations, and other requirements that support coverage and reimbursement for audiology services provided by audiologists to Part B beneficiaries within that jurisdiction.

Everyone who is enrolled to provide Part B services to Medicare beneficiaries has a MAC. For example, at Vanderbilt University in Tennessee, the MAC would be JJ Palmetto, but would be JF Noridian if an audiologist were seeing patients in Bismarck, North Dakota. You can find your MAC on the CMS website (2023a). Be sure to note the extra letters in the MAC’s name. Some contractors coordinate benefits across multiple jurisdictions. For example, Palmetto coordinates benefits for two jurisdictions, JJ Palmetto and JM Palmetto.

17. I start with Chapter 15, Section 80.3. Then, I need to go to my MAC for more information? What is the function of the MACs and how does this relate to coverage policies?

MACs will provide Local Coverage Determination policies which more specifically outline other coverage criteria, frequency limitations to testing, as well as coding guidance to substantiate reimbursement and coverage under the policy. Local Coverage Determination Articles will outline the specific ICD or diagnosis codes that support coverage of certain CPT procedure codes. I always like to think about CPTs being what you did, and ICDs supporting why you did it as your substantiation for the reason for the testing. This is why reviewing your Local Coverage Determination is important. This will help determine if your ‘why’ (i.e., ICD codes) adequately supports ‘what you did’ (i.e., CPT codes) to be considered medically necessary.

Local Coverage Determination policies and articles are found on the CMS Coverage Database at: https://www.cms.gov/medicare-coverage-database/. These will provide the region-specific guidance needed for filing claims with your MAC. Resources noted as ‘LCD policies’ are generally overarching guidance for that MAC’s jurisdiction, while resources categorized as ‘articles’ will typically provide the specifics on CPT and ICD codes. When researching your MAC’s coverage policies under your Local Coverage Determination, be sure to review both ‘LCD policies’ and ‘articles’ as they may provide different information. Audiologists are strongly encouraged to utilize their MAC’s website to obtain other additional information on coverage policies, claims filing, and appeals specific to the jurisdiction in which they are providing services to Medicare beneficiaries. For more information on National and Local Coverage Determinations as they apply to audiology services, check out the article that I recently published in Audiology Today with Carrie Kovar (2023a).

As a side note, try to stay connected with your MAC. If you’re a Medicare provider, subscribe to email updates and transmittals through your MAC. You’ll find that audiology coverage policies are reviewed regularly and provide audiologists with opportunities to improve health policies through each MAC by engaging during public comment periods. And, don’t forget, the MAC is your friend. They want to help you understand the policies such that you can be reimbursed for your services to Medicare’s beneficiaries. The MAC is your knowledge base. Benefit from their expertise and ask them your questions because they have the answers!

18. Manuals, Medical Necessity, and my new MAC “friends.” Oh my! There’s a lot to consider here. Is there anything else that clinicians should be aware of when providing services under the Medicare Program?

There are plenty of other aspects related to audiologists who are enrolled providers and who are providing services through the Medicare program. There is additional guidance on how to file claims and how to handle appeals. But perhaps one of the more important sidecars in this discussion is the National Correct Coding Initiative, or NCCI. This NCCI program is exclusive to Medicare, although many insurers may adopt similar policies. The NCCI program exists to promote correct coding. Incorrect coding can be costly to the Medicare and subsequently the federal budgets for this publicly-funded health program.

Policies such as those under the NCCI seek to reduce unnecessary spending that occurs due to inaccurate reporting of services performed, unbundling of codes where a comprehensive procedure code is available, correct reporting of quantity- or time-based codes, and so on. The NCCI considers the codes available for reporting, Medicare coverage policies, standards of clinical practice, and current coding practices. In action, the NCCI works as a kind of automated prepayment system that flags certain combinations of procedures that would not be considered reasonable and customary to bill in that way.

There is guidance released quarterly through Medicare’s NCCI and these are the NCCI Edits. These edits typically come in one of three categories: (1) procedure-to-procedure, (2) medically unlikely edits, and (3) add-on code edits. Under the Medicare program, nearly all NCCI edits for audiologists fall under the procedure-to-procedure edits category. These procedure-to-procedure edits pertain to certain combinations of CPT codes when reported together on the same date of service. Therefore, not all audiology codes have an NCCI edit attached to them.

One example of an audiology NCCI procedure-to-procedure edit would be billing each of the component codes separately (e.g., pure-tone air and bone, speech recognition threshold, and word recognition testing) instead of a bundled code for comprehensive audiometry evaluation, which encompasses those component codes in the CPT manual definition. Another example would be an unlikely double-reporting of services by billing for both the lesser and more extensive procedures (e.g., reporting both the limited and comprehensive otoacoustic emissions codes), where the work of the lesser procedure is already encompassed in the work of the more extensive procedure.

A full list of NCCI edits for audiology services through the Medicare program is available at: https://www.audiology.org/national-correct-coding-initiative-cci-edits-for-audiology-procedures/. A primer on the subject has also been provided for audiologists (Jilla, 2022). As a reminder, NCCI edits only apply to codes reported for reimbursement under the Medicare program. However, private insurers may have similar policies under a different program name.

19. As you said, private insurers will function differently. So, what about the rest of the world of insurers? How do we find out their ‘rules of engagement?’

The rest of the world of insurers will have the same basic policy framework as Medicare: coverage (which may include pre- or prior authorization) and medical necessity. Physician order or referral requirements may also vary across plans.

Private insurers will have coverage policies outlined in their Evidence of Coverage document specific to that plan. Any potential requirements to obtain a physician order or referral prior to accessing audiology services as well as the specific circumstances under which those services would be considered medically necessary for coverage are outlined in that Evidence of Coverage document. Additional information may also be found in your contractual provider agreement with the insurer (e.g., fee/reimbursement schedules, claims filing requirements).

This Evidence of Coverage is your go-to resource when determining whether services or items will be covered under a given private plan. And keep in mind that one plan from one carrier is not generalizable to all other plans offered through that insurer. So, the XYZ Insurance plan for the Auto Workers Union may be different from a plan offered from XYZ Insurance through the HealthCare Marketplace, which may be different from an employer-sponsored plan who contracts XYZ insurance to coordinate those health benefits for their entire group of employees. Moral of the story here is that we need to reference plan-specific information and avoid assumptions that all plans from one carrier will be the same in their coverage policies. As always, contracted or in-network providers may contact Provider Relations to address any coverage- or billing-related questions.

20. This all seems like a lot of trouble. Why is all this even important?

I think this is why the whole thing continues to seem a bit scary. When we don’t do things correctly, there is the opportunity for fraud and abuse. So, we first must understand the rules in order to best follow them. Then, as we work within the constraints of coverage policies, we can maximize reimbursement potential to boost financial solvency of clinics which rely on successful payment of claims. If we can do it right the first time, this not only helps our practices, but also helps the patients we serve by maximizing access to their benefits from those insurance companies. It’s my hope that our discussion will arm audiologists with the information they need to better address coding and billing questions in their practice.

References

Centers for Medicare and Medicaid Services. (2022, November 14). Audiology Services. https://www.cms.gov/medicare/payment/fee-schedules/physician/audiology-services

Centers for Medicare and Medicaid Services. (2023a, March 28). A/B MAC Jurisdiction Map. https://www.cms.gov/files/document/ab-jurisdiction-map03282023pdf.pdf

Centers for Medicare and Medicaid Services. (2023b, June 15). CMS Manual System: Pub 100-20 One-Time Notification, Transmittal 12091. https://www.cms.gov/files/document/r12091otn.pdf#page=12

Centers for Medicare and Medicaid Services. (2023c, September 6). Internet-Only Manuals (IOMs). https://www.cms.gov/medicare/regulations-guidance/manuals/internet-only-manuals-ioms

Centers for Medicare and Medicaid Services. (2023d, September 6). What’s a MAC?. https://www.cms.gov/medicare/coding-billing/medicare-administrative-contractors-macs/whats-mac#A/BMACs

Centers for Medicare and Medicaid Services. (2023e, October 12). Medicare Benefit Policy Manual: Chapter 15: Covered Medical and Other Health Services. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

Centers for Medicare and Medicaid Services. (2023f, October 27). Allowing Audiologists to Provide Certain Diagnostic Tests Without a Physician Order. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/provider-partnership-email-archive/2023-07-13-mlnc#_Toc140123839

Centers for Medicare and Medicaid Services. (2023g, November 17). Medicare Physician Fee Schedule Final Rule Summary: CY 2023. https://www.cms.gov/files/document/mm12982-medicare-physician-fee-schedule-final-rule-summary-cy-2023.pdf

Centers for Medicare and Medicaid Services. (2023h, November 22). Audiology Code List effective 01/01/2024. https://www.cms.gov/files/zip/audiology-code-list-updated-7522.zip

Jilla, A. M. (2022). Medicare National Correct-Coding Initiative: A Tutorial. Audiology Today, 34(2), 71-77.

Jilla, A.M., & Cheyney, M. (2020). Deciphering Medicare Advantage Hearing Benefits. Audiology Today, 32(6): 52-57.

Jilla, A.M., & Kovar, C. (2023a). Medicare National and Local Coverage Determinations: A Tutorial for Audiologists. Audiology Today, 35(2): 68-72.

Jilla, A.M. & Kovar, C. (2023b). Updates on Medicare Limited Direct Access and Use of the AB Modifier on Audiologists’ Claims. Audiology Today, 35(6): 56-59.

Medicare Audiology Access Improvement Act of 2023, H.R.6445, 188th Cong. (2023a). https://www.congress.gov/bill/118th-congress/house-bill/6445/text

Medicare Audiology Access Improvement Act of 2023, S.2377, 118th Cong. (2023b). https://www.congress.gov/bill/118th-congress/senate-bill/2377/text

Miller, E.L., Jilla, A.M., & Arnold, M.L. (2022). Defining Audiology through Occupational and Health Policy Action. Seminars in Hearing, 43(1):3-12. https://doi.org/10.1055/s-0042-1743123

United States Social Security Administration. (2023, November 17). Social Security Act, Pub. L. No. 118-122, Codified as Amended at Title XVIII of 42 U.S.C. 1395x(ll). Section 1861. Amendments as enacted. Retrieved from https://www.govinfo.gov/content/pkg/COMPS-8768/pdf/COMPS-8768.pdf

Von Dollen, S., Jilla, A.M., & Kovar, C. (2023). Medicare Physician Fee Schedule Changes for 2023. Audiology Today, 35(1): 54-58.