Billing, Coding & Reimbursement: 2013 Update

Editor's note: This is a transcript of an AudiologyOnline live expert seminar. Please download supplemental course materials.

Today, we're really going to talk about a 2013 update to billing, coding and reimbursement issues. 

Medicare Fee Schedule

So, first things first, let's talk about the Medicare fees schedule for 2013.  The fiscal cliff negotiations and the resulting legislation yielded some positive outcomes, at least in the short term, for audiologists who provide testing and services to Medicare beneficiaries.  The American Taxpayer Relief Act, also known as the Middle Class Tax Relief Act, passed both U.S. House and Senate on December 31^st, 2012 in the case of the Senate, and January 1^st, 2013 in the House.

The best way I can describe it is they punted on Medicare.  So, the current Medicare physician fee schedule that audiologists are working within in most situations for your locality is extended through December 31, 2013.  So you're really still using the same schedule as 2012, and in some ways even 2011 rates, because they've punted so many times.  The scheduled 26.5 percent cut required by the sustainable growth rate formula has been averted.  As a result, audiology reimbursement through Medicare should stay consistent with the 2012 rates, at least through February of 2013 and I'll talk about that in a moment.

For 2013, the conversion factor is $34.02, give or take a bit.  And you can use that with the relative values if you would want to calculate your own reimbursement to just double check things.  The January 2013 claims will be held.  So, remember, these Medicare contractors had no idea what was going to be happening, so it was going to be very difficult for them to pay the claims until Congress acted.  As a result, the claims through January 15 are going to be held.  So, the claims from January 1 through January 15 will be held and will be paid after the January 15 date.  CMS is extending the 2013 annual participation enrollment period.  Physicians or audiologists have until February 15 to change their Medicare participation status for 2013.  Audiologists can either be enrolled in Medicare as a participating or non-participating provider.  And we do not have the ability to opt out and enter into private agreements with Medicare beneficiaries.

The current Geographic Work Adjustment, that means the additional monies that are afforded or subtracted based upon your geographic location and the cost of doing business in that location, are extended.  They didn't make any adjustments from the 2012 rates.  There is a planned 2 percent sequestration cut, which could in some instances have some impact on reimbursement or coverage through Medicare or Medicaid.  It's been delayed at least through January and February.  Those cuts were mandatory cuts in some cases to grants; in some cases they're administrative.  We really won't know what they're going to be applied to until that date gets closer, but again, it would be a 2 percent cut.  I suspect from what I've read to date that those of you that are working on funding that is coming from grants or research could be affected where others may have no effect at all.  Funding for the Physician Quality Reporting System (PQRS), which we're going to talk about more specifically, has been authorized for another year.

So, in a nutshell, your Medicare reimbursement in most clinical situations is not going to change from the 2012 rates.  In most clinical cases, you're not going to see any reimbursement reductions or cuts in this year.  Those planned 26.5 percent cuts, if no one acts, could still occur for 2014.

Physician Quality Reporting System (PQRS)

The biggest change for audiologists in 2013 is the PQRS.  Let me start with a little background.  In 2006, PQRS was established.  Remember that this was during the Bush administration;  it has nothing to do with Obama Care or the Affordable Care Act.  It was part of a 2006 Tax Relief and Health Care Act.  This Act required the establishment of a physician quality reporting system, with an incentive payment in 2013 and 2014 for eligible professionals who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries.  Centers for Medicare and Medicaid Services (CMS) named this program the Physician Quality Reporting System.  Audiologists have been able to report PQRS since 2010.

PQRS is about care coordination and quality of care.  Care coordination helps ensure that a patient's needs and preferences for care are understood by providers and shared between everyone involved in the patient care continuum: providers, patients, and families, as they move from one healthcare setting to another.  It's especially valuable for audiologists because it facilitates an opportunity for care coordination.  Patient care must be well coordinated to avoid duplication, and communicated to avoid conflicting plans of care.  Given the high-risk nature of transitions in patient care from one provider to the next, PQRS builds upon ongoing efforts among varied health providers and their associations and/or academies to establish principles for effective patient hand-offs across clinicians and providers.

The Audiology Physicians Quality Reporting System is a program, again, designed to improve the quality of care to Medicare beneficiaries.  Audiologists, whether they are participating or non-participating who bill Medicare Part B beneficiaries must participate report on at least one measure in 2013 to avoid deductions in reimbursement in 2015.  If an audiologist doesn't report on at least one eligible measure in 2013, you will see reductions in Medicare reimbursement in 2015 based upon the cases that you did not report.  This program does not apply to Part A claims from hospitals or skilled nursing facilities.  Its focus is outpatient clinical testing.

How PQRS Works

PQRS is very easy once you sit down and think about it.  It's just the circling of another code on a super bill or touching another code in an electronic system.  It's just one more code that you're going to be adding to a claim.  Audiologists can begin any time.  Until December 31, 2014, so really for the next two years, a 0.5% bonus will be given for all Medicare-eligible cases when reporting on 50% of eligible measures.

What Happens in 2015 Matters Now

Beginning January 1, 2015, the voluntary incentive program is slated to end.  So, there'll be no more incentive for participation.  A reimbursement adjustment will be made if eligible professionals such as audiologists don't report on at least one PQRS measure.  The 2015 reduction is based upon reporting in 2013.  The 2016 reduction is based upon reporting in 2014.  The 2015 reduction will be 1.5% reduction in reimbursement of all 2013 eligible claims that weren't reported on.  In 2016, the reduction is 2% of all 2014 eligible claims.

Are there quality measures that audiologists can report on?  There are four, but we're going to stress three of them today, because as a member of the audiology community, we're advising people to not report on the fourth measure.  The fourth measure is a voluntary measure.  While reporting on the fourth measure could keep you from the reduction, you're not incentivized for it.  And so, there are better measures to report on to keep you from the reduction that don't bear the risk.  So, let's talk about the measures that we can report on.

Quality Measures that Audiologists Can Report On

These are the measures that audiologists can report on:

• Measure 188, congenital or traumatic deformity of the ear
• Measure 261, referral for otologic evaluation for patients with acute or chronic dizziness
• Measure 130, documentation and verification of current medications in the medical record
• Measure 134, screening for clinical depression and follow-up plan.  Again, I'm advising to avoid reporting on Measure 134 and I will discuss that in more detail shortly.

Eliminations - Do not report on Measure 189 or Measure 190.   Two measures for 2013 were eliminated that were eligible measures prior to this year. Measure 189, active drainage, and Measure 190, sudden and rapidly progressive hearing loss, were permanently retired in 2013.  Those measures will not return, so do not report on these measures as of January 1, 2013.  It will not deny your claim, but it does not apply to reporting on an eligible measure and it does not help in terms of being incentivized.

How do audiologists report on eligible measures?  These measures are reportable via the CMS 1500 claim form or your electronic billing system.  The audiologist would add the Medicare-directed CPT Category II or G-Codes, which are available in the HCPCS system, to the claim to report the measures to CMS.  These codes must be reported on the same claim as the patient diagnosis and diagnostic procedure to which the PQRS code applies.  I'm going to apologize here for not including a HCFA form today.  In an earlier version of this presentation, I had a sample HCFA form to show, and it's so small when you put it in a PowerPoint that it's hard to see.  All the national  audiology professional associations including AAA, ASHA, and ADA, have these forms available through the Audiology Quality Consortium (AQC).  The AQC is comprised of ten stakeholder organizations within audiology, and it has created collaborative guidance materials.  Those materials are available on each organization’s website, and also on the ASHA AQC site.  Go to the ASHA site and type in PQRS, and you will be directed to the materials that were created by all of us through the AQC.  I am a sitting member of this committee and have been involved from the beginning.  In addition, there are sample super bills, sample fee bills, examples, flowcharts, step-by-step guides and just about every material that you could possibly ever want or need in regard to audiology billing, coding and reimbursement.

How Does Participation in PQRS Work?

To participate in PQRS, the audiologist must be a Medicare provider. Unless you're giving your testing away for free to everyone, you must be a Medicare provider if you're an audiologist regardless of your work setting.  Audiologists should not be billing incident to a physician. Audiologists should be billing services that they have provided themselves under their own NPI number, and as a result  they need to be enrolled as a Medicare provider.  This means that in addition to one's own NPI number, the audiologist must have completed the Medicare form 855I for formally registering with Medicare as a provider, and if necessary, the 855R to inform Medicare where regular payment should be directed.  While you can complete these forms on paper, they should be done electronically.  You'll have fewer mistakes, you'll be processed a lot quicker, and it is the preferred method of enrolling or updating Medicare enrollment.  The incentive payment is calculated after the end of the year based upon all qualifying claims submissions throughout the year, and then you'll be afforded a check from the Medicare system.

Why is PQRS Important for Audiology?

PQRS is important for many reasons.  It focuses on audiology's place in the health care arena.  When you are looked at as a provider who is valuable within the health care system, you want to be involved in that process, because the more that you're recognized, the better your status is within the healthcare arena.  It recognizes audiology as providing significant influence on the quality of the hearing health care that we provide.  It offers the 0.5 percent bonus payment in the qualifying submitted procedures at the end of 2013 and 2014.  Accepted measures focus on problems and disorders that go beyond routine issues and focus on those that have significant impact on long-term outcomes and quality of life.  It's also showing that, when referrals are necessary, we refer.

PQRS Reporting Step 1: Review the Measures and Their Codes

Again, these are the measures we talked about before: Measure #188, congenital or traumatic deformity of the ear; Measure #261,  referral for otologic evaluation for patients with acute or chronic dizziness; and Measure #130, documentation and verification of current medications. Avoid reporting on Measure #134, screening for clinical depression.

PQRS Reporting Step 2: Review the Codes for Each Measure

I'm not going to go into this in great detail.  You want to review the codes for each measure.  You don't want to focus on the description.  It is a code combination-driven process.  So, each measures is reportable based upon the CPT and the ICD-9 code that drives a measure being eligible.  You have to have the combination of the two.  With the exception of the current medication and the depression codes, they apply to all diagnoses.  For example, with acute or chronic dizziness and congenital or traumatic deformity of the ear, if you do a hearing test, tympanometry, reflex testing, and have one of these diagnoses that's within the measure, you are eligible to report.  Failure to report is going to mean that you're not meeting the percentage of eligible cases.

So for each measure, the CPT codes indicate the procedure performed on the patient.  This is what, again, drives whether or not you report the measure.  The ICD-9 codes indicate the diagnosis of the patient, and again, represents whether reporting is necessary.  And the G-Codes tell the action that occurred.  So again, don't focus on the description, focus on the codes. 

Codes for referral for congenital or traumatic deformity of the ear.

CPT codes. The CPT codes in the referral for congenital or traumatic deformity of the ear are as follows:

• 92550, tympanometry and acoustic reflex testing performed on the patient on the same date of service
• 92557, comprehensive hearing test
• 92567, tympanometry in isolation
• 92568, acoustic reflex testing in isolation
• 92570, tympanometry, acoustic reflex testing, and acoustic reflex decay performed on the same patient on the same date of service
• 92575, the sensorineural level acuity test
   

If you perform any of those procedures, you may be eligible to report on this patient for this measure regardless of the outcome. 

ICD-9 codes. Next, consider if the patient has one of these resulting diagnosis codes.  This is a very big diagnosis code family, but I'm going to note a few things.  Otitis externa is in this diagnosis code family.  Stenosis of the canal, acoustic trauma of the canal, atresia, a lack of an ear canal or a lack of a pinna, hematoma, and exostosis are diagnoses in this code family.  If you report one of these diagnoses and one of the CPT codes listed above, then you are eligible to report this measure.  And so, failure to report this measure more than 50% of the time means that you would be eligible for the reduction and not eligible for the incentive.

G-codes. These are the actions that would happen if you had a combination.  If you had one of the procedure codes listed for the CPT and one of the diagnosis codes, you need to report one of the following:

• G8556, patient referred to a physician, preferably a physician with training in disorders of the ear, for an otologic evaluation. 
   
• G8557, referral was not performed, and in a nutshell, it wasn't performed because they're already under the care of a physician for this diagnosis.  This could be that they were already or ordered by a physician who's aware of this and who is treating or managing this condition, or it has been a previously diagnosed condition.  That would be a reason why you would report G8557.  Let me give you an example.  If this was referred by a primary care physician who has never noted this and you discover a hematoma, you would want to refer that patient back for the hematoma and document that referral in the PQRS. 
   
• G8558, referral not performed but reason not specified.  That would be something I would avoid.  If a patient needs to be referred, you should refer them if they meet the CPT and diagnosis code combo.  One thing that I really want to stress here, these first two measures that we're going to talk about are two of the eight warning signs of ear disease.  These warning signs are included in many state audiology and/or hearing aid dispensing licensure laws.  Failure to refer could affect your license.  It's not just about PQRS.  So, it's important that when you discover these procedures and have these code combinations that you refer accordingly, because again, this is very common in many, many state licensure laws.
   

Again, avoid the lack of a referral.  If there is ever a case where you do not refer when you have this code combination, make sure the medical record clearly indicates why you did not refer.  Let me give some examples: the patient is in hospice; the patient has many, many underlying healthcare concerns; the patient is leaving the country or they're leaving the state and they have to be referred.  All of this needs to be documented.  Avoid the reporting of G8558 if you do meet the criteria of the code.

Codes for referral of acute or chronic dizziness. This is very important as many people think that if they're not doing vestibular testing than this doesn’t apply to them -  that is not true.  It is important for all audiologists to be, as part of their case history, asking and documenting responses to the eight warning signs of ear disease.  The risk of falls is a big issue in the senior population.  If a patient reports dizziness or unsteadiness and are at risk for falls, they should be referred for that and you should be diagnosing dizziness unspecified. Dizziness unspecified doesn't require you to have done testing.  You're reporting a patient symptom just like you would report tinnitus.  And it's important to refer patients for these conditions, because it can be very problematic for patients who ultimately fall because of lack of treatment or lack of management.

CPT codes. The CPT codes in acute or chronic dizziness include 92540, basic vestibular evaluation.  That means performing positionals, OPKs, oscillating tracking, and gaze on the same patient on the same date of service.  They also include:

• 92541, gaze testing
• 92542, positional testing
• 92543, caloric testing
• 92544, optokinetic testing
• 92545, oscillating tracking
• 92546, rotational chair testing
• 92547, use of vertical electrodes for ENG only except in the state of Florida
• 92548, dynamic posturography 92550, tymps and reflexes
• 92557, comprehensive hearing tests
• 92567, tympanometry 
• 92568, acoustic reflex testing
• 92570, acoustic tympanometry, acoustic reflex threshold and acoustic reflex decay
• 92575, sensorineural level acuity test 
   

ICD-9 codes. If you do any of these procedures and you have a diagnosis of 780.4, which is a very common diagnosis because it illustrates medical necessity and is included in many low coverage determinations or a diagnosis of 386.11 (BPPV, benign paroxysmal positional vertigo), then you are eligible to report on acute or chronic dizziness.

G-codes. For referral for acute or chronic dizziness, the G-codes that you would report in PQRS are:

• G8856, referral to a physician for otologic evaluation
• G8857, the patient isn't eligible because they're already under the care of a physician for acute or chronic dizziness
• G8858, referral to a physician not performed, reason not specified.  Again, you want to avoid G8858.  You want to refer for these conditions, because they are very important.
   

Codes for documentation of current medications.

CPT codes.  The codes included are the vestibular family of codes (92541, 92542, 92543, 92544) including 92547 and 92548.  Note that 92540 is not included.  The code for comprehensive hearing test, 92557; tympanometry in isolation, 92567; acoustic reflex in isolation, 92568; and 92570, acoustic immittance testing, are included. Also included are: 92585, ABR;  92588, comprehensive otacoustic emissions; and 92626, and evaluation of auditory rehabilitate status, first hour. 

ICD-9 codes.  It's important in these procedures to also be documenting current medications, because the medications can impact the outcome of your testing.  Again, it’s clinically important to be documenting these medications, because it has a clinical impact on the procedures we're performing and the recommendations we make.  There's no specified ICD-9 codes in this case, so all are included.  So, we are always eligible to report on this measure when we do a hearing test.  This is an important distinction. 

G-codes.

• G8427. To report this measure means you have a list of current medications, including prescription, over-the-counter, herbals, vitamin and dietary supplements, and that you've documented this in your medical record.  If you work with otolaryngology, it should be in a shared medical record.  Somewhere, this should be documented, and it should be documented on the report that you're sending to the ordering physician.  All of this needs to be documented, all of these medications, plus the drug name; the dosage, how many milligrams is the patient taking; the frequency, how often is the patient taking this drug; and the route, is it oral, is it ingested, is it a suppository, is it intravenous, as in the case of some medications.  You need to know all of these things.  If you don't know every drug they take and all the specifics about those drugs, you cannot report G8427.
   
• G8430 is provider documentation that the patient is not eligible for medication assessment.  A good example is if the patient doesn't take any medications.  I would be on that list.  I don't take anything, ever.  I don't think anything over-the-counter, I don't take any dietary supplements, I don't take anything.  So, I would not be eligible for a medication assessment, because I don't take any medications. 
   
• G8248. What may happen, and it is okay in this case, is that current medications not are not documented, reason not specified, because you haven't gotten all the specifics.  My hope is that we could get all the specifics, but I'm realistic that sometimes the patient can't provide you with all the specifics.  This is becoming less and less common.  You're going to find (and what I would recommend asking your patients about) that many of your patients carry a list of their medications with them.  Ask about it and make a copy of the list for those who have it, and then you have it documented.  It can be that simple.  But in your report to the ordering physician, which you should be doing for Medicare beneficiaries, you really want to outline these medications, because you don't know if that ordering physician knows about all these medications.  They may not.  That’s why this is important, and that's why this is valuable to patient care.
   

Codes for screening of clinical depression. Regarding the screening of clinical depression, it is not recommended for audiologists to report on this measure but I will review the codes quickly for your information.  Here are the CPT codes: 82557, 92567, 92568, 82625, 92626.  None are specified.  You can report either that you saw a positive screen (G8431) or a  negative screen (G8510), and you have a follow-up plan documented.  Or, you can report G8433 indicating that you've screened, and that you've not documented a screening because the patient wasn't eligible or appropriate ( such as they were cognitively impaired, or they were very, very ill).  Or, you can report G8432, indicating no documentation of clinical depression screening using an age-appropriate tool (which means you haven't done it).  The worst option here is reporting G8511, indicating that you've screened but you didn't document a follow-up plan of care.  As you look at these, you're going to see a lot of pitfalls.  And this is why the audiology community is advising against audiologists doing this.

The rationale for not reporting these measures, first and foremost, is with regard to your state licensure scope of practice – is it within your scope to provide a clinical depression screening?  That is why we're very hesitant to have audiologists do it.  In many state licensure laws, that is not mentioned.  It would be outside our scope.  I'm on the audiology licensure board in the state of Illinois.  It was a question that we posed to the board attorney, and the board attorney is saying it is not listed  in our scope of practice in IL to perform a clinical depression screening.  Were you educationally trained to perform this screening?  And the answer was no.  That's the second issue.  Have we as audiologists been appropriately trained to perform this screening and to develop a follow-up plan of care, which is part of this measure?  Again, the answer is typically no. 

So, this is why we are telling people to really avoid this measure unless you have determined that it is within your scope of practice and you've been appropriately trained and you are confident in the plan of care you're putting forth, because the ramifications of failure could be great, for example, if that patient commits suicide.  So again, you really want to be very, very careful.  From a patient care continuum, if you suspect that your patient is clinically depressed, the better route may be to refer the patient to a health care provider who is appropriately trained to screen them for depression and manage them and create a follow-up plan of care.

PQRS Reporting Step 3

PQRS reporting step 3 is fill out the HCFA 1500 claim form.  You're going to see sample claim at the CMS website, and at your professional associations’ websites.

The ICD-9 codes are placed in box 21 of the HCFA 1500, the CPT codes are in 24D, and the G-codes are placed in box 24D following the CPT code.  They are not placed in the modifier box.  They are in the CPT HCPCS box 24D beneath the CPT code that they apply to.

PQRS Step 4

Ensure you're meeting the CMS minimum reporting requirements.  CMS require that PQRS participants report on at least 50% of eligible patients to be eligible for the 0.5% incentives in 2013 and 2014.  Therefore, an audiologist would need to report on 50% of the patients they see that fit into any of the available measures.  CMS requires that PQRS participants report on at least one measure in 2013 and 2014 to not be penalized in 2015 and 2016.  Therefore, you need to report on at least 50% of the eligible patients you see that fit into one measure to not be penalized.  Reporting on current medications will keep you away from the penalty.

PQRS Examples

The first example is Patient A, who is a 70-year-old male.  He reports hearing loss and tinnitus.  You did not document current medications and you did not screen for depression, and you report perform 92557.  You diagnose 389.18, bilateral sensorineural hearing loss, and 388.30, subjective tinnitus.  You could report in this case a Measure 130, the documentation of current medications, and you could document G8428 that you didn't document current medications.  I would do my best faith effort of documenting them, with the hope that I could report that I did document them.  But if I did not have drug name, frequency, route and dosage, but I still got some information, still document what you have and put that on the report, but you cannot report that you have everything if you don't.  So, you would instead report that you did not document current medications fully.

The next example is Patient B, a 70-year-old female.  She reports hearing loss and dizziness.  You did not document current medications and you did not screen for depression.  You perform 92557.  You didn't do balance testing.  This is what the patient came in to you for, which is very common.  You diagnose 389.18, bilateral sensorineural hearing loss, and 780.4, dizziness.  You refer the patient for otologic evaluation due to the dizziness.  Again, you could report Measure 261 using G8556 because you did refer the patient, and you could report Measure 130, G8428, that you didn't document the current medications.

And in the last example, Patient C is a 70-year-old male.  He reports hearing loss.  Otoscopy revealed prominent exotoses in both ear canals.  You did not document all of your components of your current medications, and you do not screen for depression.  You perform 92557.  You diagnose, again, bilateral sensorineural hearing loss and exotoses of the ear canal.  You could report Measure 188.  Again, you're using G8556 because you referred the patient to an otolaryngologist for the exotoses before proceeding with amplification.  I'm going to tell you I've had exotoses removed for my patients when they were large and numerous, because the hearing aid fitting was going to be extraordinarily difficult if they weren’t removed. So, it's important to refer for these exotoses if they've never been documented or the patient has never been under the care of their physician.  And again, use Measure 130 because you did not document current medications, although I hope that we can document current medications.

For more information, you can consult the CMS website, https://www.cms.gov.  And also, you can consult the websites of these Audiology Quality Consortium member organizations, ADA, AAA, and ASHA, and the links to their PQRS sections are in the handout that accompanies this course.

New HCPCS Codes for 2013

Before we get into new codes for 2013, let’s talk about some basics for 2013.  It will be important for each practice to obtain a 2013 HCPCS Coding Manual.  Unless you're performing intraoperative monitoring, there were no significant CPT changes for 2013.  So, if you have a 2012 CPT manual, you're fine unless you're doing intraoperative monitoring.  ICD-9 has not changed because we're waiting for ICD-10.  So, if you have a 2009 or newer ICD-9 book, you're fine.  Regarding HCPCS codes book, you're going to need a 2013 version.  These are available through many online vendors.  I always get mine through the American Medical Association because I like how they're written.  The cost is between $75.00 to $100.00 each.

As we all know, the mere existence of a code does not guarantee coverage.  It will be important for audiologists to review their current third-party contracts and contact the third-party payers and determine how these codes will be processed and potentially covered by each individual payer.  Audiologists may need to renegotiate their contracts to account for these codes and their accompanying reimbursement and coverage.  They may be included in your contract.  Many contracts will say that they cover any current CPT or HCPCS codes, and it may be – and if it's not listed in your fees schedule, they cover it at a discount.  It is important to read your contracts.  Everyone needs to have a working knowledge of their contracts. 

You will also need to work with your state audiology associations to create a coordinated approach to Medicaid and potentially many larger payers in your state or community.  Please make sure that organizations are careful about recommending pricing as this type of action can be construed as a violation of antitrust laws.  Pricing and coverage specifics should be determined and negotiated by each independent audiologist based upon their breakeven plus profit needs and costs of goods.  Your state associations would be negotiating to get the codes covered.  The pricing is something that you're going to negotiate in your individual contract.

FM/DM Systems

There is now a new family of HCPCS codes that can be used to bill for FM/DM (DM stands for  digital modulation if you didn't know) assistive listening devices and systems as well as many of their individual components.  So, let's go through the family, which are all in the V-code family of the HCPCS where hearing aids are. 

• V5281, assistive listening device, personal fm/dm system, monaural (one receiver, transmitter and microphone), any type.  This code is appropriate when fitting an entire monaural system regardless of the type of receiver or transmitter used.  This does not include the boot or audio adapter as it's coded separately. 
   
• V5282, assistive listening device, personal fm/dm system, binaural (two receivers, transmitter, microphone), any type.  This code is appropriate when fitting an entire binaural system regardless of the type of receiver or transmitter used.  This does not include the boots, again, as they're coded separately.
   
• V5283, assistive listening device, fm/dm, neck loop induction receiver.  This code is appropriate when dispensing a neck loop receiver in isolation (a replacement, an additional or extra receiver, etc.) that is coupled with a t-coil of a hearing aid.  Again, this is when you're buying them in isolation, not as a whole system but in isolation. 
   
• V5284, assistive listening device, personal fm/dm, ear-level receiver.  This code is appropriate when dispensing an ear-level receiver in isolation, again, a replacement or additional ear-level receiver.  This code is for an ear-level device for those with normal hearing, and the code is per receiver.
   
• V5285, assistive listening device, personal fm/dm, direct audio input receiver.  This code is appropriate when dispensing a direct audio input receiver, again, a replacement or an extra, in isolation. This does not include the boot as the boot is sold separately.  
   
• V5286. This code will be more commonly used: assistive listening device, personal, Bluetooth fm/dm receiver.  This code is appropriate when dispensing a streamer in isolation.  Again, in isolation means it is not part of a receiver/microphone system; rather, it is in isolation, such as a replacement or an extra. 
   
• V5287 is assistive listening device, personal fm/dm receiver, not otherwise specified.  This is for any existing or yet to be released receiver that is not represented by another code above.
   
• V5288, assistive listening device, personal fm/dm transmitter assistive listening device.  Again, that's when you're dispensing any type of transmitter in isolation, replacement or additional. 
   
• V5289, assistive listening device, personal fm/dm adapter/boot coupling device for receiver, any type.  This code is appropriate for the audio boot dispensed in any situation.  The code is per boot.  An initial binaural FM fitting would constitute two boots. 
   
• V5290, assistive listening device, transmitter microphone, any type.  This code is appropriate when dispensing any type of microphone transmitter in isolation. 
   
• V5267, hearing aid or assistive listening device, supply or accessory not otherwise specified.  This code is used to represent any hearing aid fm/dm or fm/dm accessory or supply that's not otherwise listed or capture by another new or existing code.
   

Intraoperative Monitoring Codes

Now, let’s look at the new intraoperative monitoring codes. 

92594. This code is for continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes.  In audiology, it would be common to add it to the ABR code 92585 to show that we're monitoring the auditory nerve.  You might add it onto a different code if you were monitoring a different nerve. 

95941.  This code is for continuous intraoperative monitoring from outside the operating room (remote or nearby) or for monitoring more than one case while in the operating room, per hour.  Again, I would stress that you need to look into your licensure laws within your states.  Medicare doesn't allow audiologists to monitor outside the operating room. Before you start utilizing these codes, you need to educate yourselves on their applicability.  If you do intraoperative monitoring, I strongly suggest you get a new CPT manual and a book called CPT Changes 2013.  They're available from the American Medical Association, and they will go in detail about the appropriate utilization of these codes based upon your provider type and your clinical situation.

99360.  This is a code for standby services requiring prolonged attendance, each 30 minutes.  I'm going to tell you that, in my opinion, this is potentially only applicable for those audiologists that are waiting in the OR, scrubbed and waiting, to do NRT testing of a cochlear implant.  It's really the waiting game.  It's not necessarily appropriate for intraoperative monitoring, because you're typically monitoring front to back.  But NRT is something that you would be standing by right before they're ready to close.  And again, before you would ever utilize this code, I strongly advise you to buy a 2013 CPT manual and CPT Changes to review the specifics of the use of this code for your provider type and situation. 

95907 – 95913.  These are new codes for nerve conduction studies, for those audiologists who do those procedures.  They are selected by the number of nerves you're monitoring and the studies you're performing.  Again, please educate yourselves before proceeding by referring to the new CPT manual and CPT Changes.

Officer of Inspector General – Work Plan

This is something I wanted to make sure that I talked about.  The Work Plan is the compliance and enforcement projects and priorities for the coming year.  So, the 2013 work plan could have an impact on audiology in what they opt to audit or what they opt to explore.  The following are the important things that I want audiologists to be aware of. 

“Incident to" Billing

If you're an audiologist working for a otolaryngologist and you are still billing the procedures you are providing under the NPI of the physician, I strongly advise you to stop, because this is, again, a priority in the work plan, that they are going to now begin to audit.  From the 2010 update revisions and reissuance of audiology policies, they now have the data to begin auditing the "incident to".  It’s in their crosshairs.  It's very important that you start moving away from that.

 Inappropriate Payments for Evaluation and Management Codes 

If you are an audiologist and Medicare by accident has ever paid you for an evaluation and management code because you did not add a -GY modifier, you need to return those payments.  They are going to be auditing the inappropriate payment of evaluation and management codes to those that it is not a covered procedure. 

Inappropriate Payments from the use of the -GA, -GZ, -GY, and -GX Modifiers

If you were paid and specifically you used the -GZ, -GY, or -GX modifiers and your claim was paid, I strongly encourage you to return those payments, because they are going to find those payments and ask you to return them.  At that time it is probably going to be too late to collect any payment from the patient.  It’s very important that if you received payment for something that wasn't medically necessary or was statutorily excluded by accident, therefore, if Medicare pays you for something you never expected to be paid for, you need to return the money.  And if you haven't, you need to do so, because they will be auditing that.

Noncompliance with Assignment Rules and Excessive Billing to Medicare Beneficiaries

What we mean by that is and where we could get caught, is that if you are billing a Medicare beneficiary for hearing testing and you are not enrolled as a Medicare provider but you're still billing Medicare beneficiaries for hearing testing, you need to be very careful.  One patient just needs to turn that in for reimbursement, and that could trigger an audit on your practice.  Again, you don't want to excessively bill patients for things that Medicare covers.  That again is something within the work plan.

Local Coverage Determinations

I also want to discuss local coverage determinations.  This is where the Medicare area contractors who pay Medicare claims specifically dictate the coverage terms for audiology or vestibular procedures.  Local coverage determinations exist for Palmetto, which is predominant in the Southeast and California, and Novitas, which has areas all over the country.  They have local coverage determinations for both audiology and vestibular services.  That means that if you perform a vestibular procedure, you must have a particular diagnosis.  If you don't have a particular diagnosis, that claim is unpaid and you cannot bill the patient unless you had an ABN signed prior.  First Coast, which is Florida, has a local coverage determination governing vestibular.  CGS and Novitas also have local coverage determinations revolving around cerumen removal. 

You're going to see your national associations talking more about ABNs with cerumen removal in the coming months.  When your national audiology associations send you information via email, please read those blasts.  That's how we inform you of information that could help protect you from these types of situations.

Evaluation and Management Codes

I also want to bring up Evaluation of Management codes.  Several payers are now disallowing claims payment for Evaluation and Management codes provided and billed by audiologists.  Examples in some localities are Aetna, Cigna, and Blue Cross Blue Shield.  One thing that I will tell you, is that this is not something that we in audiology community can fight as a coverage because audiologists are not in the description of the code.  There would be really nothing we can fight because we were not included in the code description.

Questions

That covers the material I have prepared, but I know there are always a lot of questions on these topics, so please send in your questions now.

What if the patient doesn't fit any of the ICD-9 codes listed?

 If the patient doesn't fit the ICD-9 code listed, then you, when it comes to PQRS, are not required to report that measure.  If that ICD-9 code was not listed, you're not required to report that measure.  But documentation of current medications doesn't have an ICD-9 code kicker.  So, as a result, you can always report on that anytime you perform vestibular testing,  a hearing test or tympanometry. 

But in the other two cases, and if you don't have one of those ICD-9 codes, my first question is if they're reporting dizziness, why are you not diagnosing the ICD-9 code?  Why are you not putting that diagnosis on your claim?  But again, if you don't have that diagnosis, then you do not need to report that measure. Dr. Deb Abel has commented that I did not have a typo in Measure 130.  Interestingly, the comprehensive vestibular evaluation is not a procedure in the documentation of current medications.

If the Part B patient is in a nursing home, do – would you have to report the PQRS G-code?

I don't like the term "nursing home," and let me tell you why.  If they are in a Part B skilled nursing facility, you would not report.  It depends on their classification.  What I would tell you is, it is better to err on reporting than to err on not reporting.  The whole classification of nursing home is the issue here; people use the term "nursing home" when they're really in a different type of facility, and I don't want to inappropriately answer that question.  If they are in a Part B facility that is not a hospital or skilled nursing facility, you actually would report.  But I can't just guarantee that when you talk about “nursing home” that they're not actually in a skilled nursing facility.

I noticed regarding ICD-9 code 780.4, some will only accept a five-digit code.  How do you handle this? 

They will accept this four-digit code, because it doesn't have a fifth digit.  They require the fifth digit when a fifth digit is possible.  The dizziness code doesn't have a fifth digit.

On reporting referring, what if the referral is coming from neurology?

If they are already under the care of a physician for that condition, you would use the indicator that they're already under the care.  Let me give an example.  If the patient was referred by neurology and they had an exostosis, I would still refer them to otolaryngology, because the neurologist can't manage the exostosis.  But if they're referred by neurology for dizziness, they're already under a care of a physician who manages that type of condition, and I would feel comfortable reporting that they're already under the patient's care.

Are 99201 and 99212 considered Evaluation and Management codes?

Yes.  They are considered Evaluation and Management codes.  So, again, when it comes to Evaluation and Management codes, it's really important that you make sure that first it's in your scope of practice of your state's form of Evaluation and Management.  Second, that you've educated yourself on Evaluation and Management coding and that you are meeting the criteria of the code, which can be extensive.  Audiologists should never ever be billing a code above a 99203 or a 99213, because we don't meet the risk of morbidity and mortality. Third, when it comes to private insurances, make sure that your private insurance allows the use of Evaluation and Management codes by audiology.  Also make sure that your contract with that private insurer allows you to bill them for something and not bill that same thing to other people.  If not, then you've got to privately bill those Evaluation and Management codes to patients.  You really need to do your homework before doing Evaluation and Management coding.

What if patient has Medicare but pays privately as they don't have any medical condition and they're coming in for hearing aids?

Okay.  So, Medicare pays for hearing testing that was ordered by a physician and is medically necessary to diagnose, treat, monitor or manage a medical or surgical condition.  If both of those two things are not met, the patient is responsible.  If Medicare is not paying or processing the claim, but you need it for a denial, you need to add that -GY modifier to show that the item or service is statutorily excluded or doesn't meet the definition of medical necessity.

You are not going to be penalized for reporting.  It’s not going to deny your claim.  I think that this is important for people to know.  Audiologists are best served when they're creatures of habit.  So, what that means is, if you have a Medicare patient than you have a super bill (or you have uploaded into your electronic system if you're doing electronic health records) that indicates what your procedures are and what codes are options.  If you are seeing someone that's a Medicare beneficiary and you have the code combinations or you're documenting current medications, it is good patient care to perform this, to make these referrals, to document these medications, to put this in your report.  This is a good time to stress it is extraordinarily important that audiologists realize that an audiogram itself is not documentation. 

You really need to document, and this is very clearly defined in the Medicare – chapter 15, section 80.3 of the Medicare Provider Manual.  And if you want to read it for yourself, simply  type "Medicare Provider Manual chapter 15" into any search engine, and then go to section 80.3.  It states that the medical record needs to indicate what procedures you performed, why they were performed, and what the outcome was, and all this needs to be documented in the record.  Unless you're doing that on an audiogram form, you are not documenting this.  If you're billing it out under your NPI and you have a shared patient record, I would be cautious of trusting the ordering physician to have documented all these issues.  You need to do it - it's good patient care. 

So, to go back to your original question,  it's good to have processes in place for the procedures you conduct and how you report them whenever you see a Medicare beneficiary, regardless if Medicare is denying that claim or not, because they're passing it on, rolling it over to the secondary.  It's better to over-report than it is to under-report.  So, I would suggest you get a process in place because you don't necessarily know always that it's a medical necessity until the patient's there.  Just get a process in place, and when it's a Medicare patient, they meet this criteria, you circle this code, and it goes down on the claim.  That's the process that I would put in place.

What CPT code do you use for ECAP (NRT or NRI) with a cochlear implant patient?

Please contact me separately with regards to that question.  It's a little bit more complicated, and something that I've actually been working on with some of the national cochlear implant manufacturers. You can also contact your cochlear implant manufacturer about what code they would recommend.

What is the status of getting paid for VEMPs?

Okay, let's take this as a twofold approach.  Number one, let's talk about it from Medicare, and then let's talk about it from a private insurance standpoint.  For Medicare, it doesn't have a code, and it would be difficult to apply for a code when it's not FDA-approved.  I mean, that's a question in the application.  So, if you want to bill for VEMPs, the first question that always has to be met is, no matter who the payer is, is it medically necessary for this patient in order to diagnose and treat the medical or surgical condition, or to monitor a medical or surgical condition?  The routine application of procedures is not paid for by any insurer.  So, just doing VEMPs on everybody or just doing tymps on everybody, is not covered.  You need to make sure that you've documented medical necessity.

 When we're talking about VEMPs, you would've documented medical necessity and you would've created a report.  You would use the code to bill to a payer 92700 which is an unlisted otorhinololaryngological procedure, because it is a vestibular potential.  The ABR code is not appropriate, because the American Medical Association owns the CPT codes.  And they can determine when things are gray and how you code certain things.  Payers follow this guidance, because again, they own the codes and what they mean.  CPT Assistant has been very clear, and they have actually published this in 2011, that VEMPs should be billed with 92700.  This is how VEMPs should be billed.

So, when you're billing VEMPs to a payer, you would bill VEMPs with the unlisted code.  You would send a copy of the patient's report that outlines medical necessity, why it was important, what you found.  And then anytime I've ever billed 92700, I have had a sheet that outlined the procedure, what it is, what it means, what it's assessing, its clinical utility, the special equipment used, any special education of the tester, the time it took.  And so, because these claims have to come with documentation because they're unlisted, I would send a copy of the super bill with 92700, VEMP - that's what you would circle when it got to my billing office.  My billing office would've sent that with a copy of the report.  My billing office would then take that report, pull out of their file 92700 VEMP that they have by their desk, attach that to the front of the report and send that with the claim.

In general, 92700 is reimbursed about 30 percent of the time, because it's independently reviewed.  When it comes to private payers, private payers can make their own rules.  So, let me give an example.  A private payer at any point in time can say, "I'm not going to pay for hearing tests," or, "I'm not going to pay for X," or, "I'm not going to pay for Y."  They have the right to do that.  As long as they are meeting their legal obligations to the member or that member's employer group or whomever they've contracted with, they can at any time deny coverage for anything.  You're seeing this happen in some places with OAEs, and also with tympanometry.  VEMPs is also falling into that category. 

Aetna, for example, has a national coverage guidance document that they deem VEMPs experimental.  It is not uncommon for a payer to not pay for a procedure that's not FDA-approved.  So, that was a very long story, but I wanted to give you the status and information regarding billing and payment for VEMPs.  The biggest hurdle is the fact that it doesn't have a code, but applying for a code would be very difficult.

Can you explain billable time units and how they're calculated?  How do these apply to audiology?

No, I cannot.  They can be different things in different facilities, and they can be calculated differently based upon the facility.  Billable time units are not a Medicare issue.  Medicare uses terms such as relative value units, and that's calculated based upon how complicated a procedure is and how time-consuming it is.  Billable time units are a hospital or a facility-driven system, and every facility can have them mean something else and can apply them differently. I’m sorry I don't really have a clear-cut answer.

What is the status of reimbursement for cerumen removal?

You're going to get me on my soapbox now.  I'm going to tell you the term reimbursement is completely misused.  Reimbursement is that you are receiving money from someone for something you provided.  Reimbursement does not mean insurance reimbursement or third-party reimbursement.  Reimbursement means you received payment.  Right now, we can get reimbursed for cerumen removal.  Sometimes that reimbursement is from a third-party payer.  A vast majority of the time it's from the patient.  We have to be better in audiology of charging patients for our services.  Everybody else in health care does.  We need to stop depending and relying on payment from a third-party and focus more on payment from the patient.

Reimbursement for cerumen removal from Medicare may be what you are asking. We are classified in the Medicare system as a diagnostic-only profession.  As a result, we are not reimbursed for any treatment services we provide.  That would include, for example, vestibular rehab,  cerumen removal, aural rehab, and cochlear implant rehab, to name a few.  In other words, any semblance of treatment.  We would need literally an act of Congress to change that. 

Medicare is not reimbursing us, audiologists, for cerumen removal.  That being said, impacted cerumen can be reimbursed privately by the patient if performed on the same day as a hearing test.  Incidental cerumen that is not impacted, that is not blocking clinically significant portions of the canal, is inclusive to a hearing test when it comes to Medicare patients.  If it's impacted and it's been documented as such, you can charge the patient privately for removal of impacted cerumen if the removal was done on the same day as a hearing test or if no hearing tests were done.  Removal of incidental cerumen when a hearing test or no other testing was done on that day can also be privately billed to the patient.

Private insurances may or may not reimburse for cerumen removal. I'm back on my soapbox about having a working knowledge of your contracts.  And if your contract with a private insurer doesn't address cerumen removal or it doesn't address CPT, HCPCS codes that are not on a list or that are outside your scope or whatever, you need to pose that question in writing to your insurer and find out how they want to manage it.  Many private insurers pay for removal of cerumen.  But we need to be very cautious that the code 69210 is for removal of impacted cerumen.  It is not for removal of incidental cerumen.  And if you're removing incidental cerumen, you would use the code 92700.  I hope I addressed that question.

Who can perform CPT code 92558, the OAE screening code?  Can it be support personnel?  Okay, let me first say Medicare doesn't reimburse for 92558.  So, that's a moot point in the Medicare system.  It's a non-covered code.  Let's talk about Medicaid.  You would need to consult your Medicaid provider, your Medicaid system, and find out what their rules are of who can provide this procedure.  It may be support personnel, but typically there must be documented training.  I can't address that question in a general term, because it depends on the Medicaid system.  When it comes to private insurers, you would need, again, to consult your contract to determine how it addresses the non-credentialed provider.  And that's something that, again, you would need to pose that question to your provider when we're specifically talking about 92558.

What is the difference between 92587 and the new screening code?

Well, I would say these codes aren't new.  They went into effect January 1 of 2012.  There are two big differences.  One, was it an automated interpretation?  So, if the interpretation was an automated pass/fail where you weren't looking at specific frequencies, it's a screening.  If you assess 3 to 11 frequencies (the code specifies 3 to 6) but don't do 12, you can't use the comprehensive code.  I like to say if you assess 3 to 11 distinct frequencies per ear, and you interpreted the results yourself as the audiologist, you would choose 92587.  If the equipment interpreted the testing for you, then you'd use 92558.

Is balanced billing under Medicare prohibited under federal statute?

I don't know what you mean by that.  You cannot bill a Medicare beneficiary if you are a nonparticipating provider.  You can't bill a Medicare beneficiary more than the limiting charge if you're a participating provider.  And these are for covered services.  We're talking about covered services under Medicare.   Balanced billing would mean can the patient be charged the difference between your usual and customary and the allowable?  The answer is no.  When you're Medicare-participating, you agree to take the Medicare allowable as payment in full.  When you're Medicare non-participating, you agree to not charge more than the limiting charge.  So, balance billing for diagnostic procedures under Medicare?  No.

Now, when it comes to non-covered procedures, statutorily excluded procedures, such as hearing aids, routine annual hearing tests, hearing tests that aren't medically necessary, hearing tests that weren't ordered, then you can bill the patient your usual and customary rate.  But for those that you're billing to Medicare, Medicare payment is payment in full, either Medicare payment or the limiting charge.

Can audiologists perform services on Medicare patients without a physician referral if the patient agrees to pay for the service out of pocket?

Yes.  And the ABN would be voluntary in that case, because we are statutorily excluded from receiving payment for Medicare services that were not ordered by a physician.  That's what direct access is about.  The sole purpose of direct access is the elimination of the physician order, which also requires an act of Congress, by the way.  So, without a physician order, the testing is statutorily excluded.  When it's statutorily excluded, you can have the patient pay up to your usual and customary charge.  I always tell people the safest rule of thumb is to have a standard fee schedule, and charge the patient somewhere between your usual and customary fee and the Medicare allowable.

Where can we get a sample ABN form?

Well, you can get a sample ABN form from any of the national audiology associations of which you are a member.  You can also go Google CMS and go to Center for Medicare/Medicaid Services.  The bar on the far left is Medicare, click on that. Medicare is a fantastic website, and  you will see something called Beneficiary Notice Initiatives, and that is the section on the ABN. Also, the goal is that the national associations will be putting out some ABN guidance soon. We've been trying to work on together to really guide people on the appropriate use and management of the ABN form.

So, please, things that I cannot stress enough.  Read your journals and trade publications.  When there are super important changes to billing, coding and reimbursement in regard to audiologists, we write articles to keep you updated.  Dr. Abel, the brilliant woman she is, writes great articles for AAA as does Lisa Satterfield from ASHA.  I always write on behelf of ADA.  And when anything important comes out, we blast our members, so we make it easy to stay informed.

Thank you for your time and attention today.