Question
I work in an ENT practice in North Carolina and I have had some claims rejected by Medicare. For example.... An established patient came in for an annual hearing evaluation and to discuss hearing aid options. She has sensorineural hearing loss and I recommended hearing aids. Our office submits a claim and Medicare denies the claim. In reading the article by Dr Fifer, I was under the impression that ''regardless of the outcome of any visit, Medicare would pay for the audiologist's services'''. The patient has been seen by our physician and has been diagnosed with sensorineural hearing loss and hearing aids were recommended at every visit. She waited initially and returned some time later and wanted to have her hearing re-evaluated and to discuss hearing aid options. Can Medicare deny a claim for those reasons?
Answer
Under the new guidelines that came into play about a year ago, Medicare should reimburse for an audiological evaluation even if the diagnosis is 389.1 (hearing loss; sensorineural). I have heard that not all Medicare regions are abiding by this guideline yet. But, there are two potential caveats to watch out for. The first is medical necessity. If Medicare determines, based on frequency of visit, that the audiological evaluation was not medically necessary, then they reserve the right to deny the claim. Medically necessary can refer to such things as concerns over change in hearing (based on patient report), changes in patient status (i.e. vertigo or tinnitus), or real possibility of progression of hearing loss based on a previous diagnosis. These scenarios in many instances should not apply to the first time a patient is seen if there is concern of hearing loss, but may apply to serial, follow-up evaluations, depending on who is reviewing the claim. However, there should no longer be an automatic rejection of the claim unless the next situation is met which is: cerumen removal.
Medicare has an edit that states cerumen removal and audiological evaluation (i.e., CPT code 92557) cannot be billed on the same date of service. This is one of those issues that makes no sense to the practitioner, but the edit still exists. To the best of my knowledge and with the exception of these two situations, Medicare now should reimburse for audiological evaluations, even with a diagnosis of sensorineural hearing loss.
Robert C. Fifer, Ph.D. is currently the Director of Audiology and Speech-Language Pathology at the Mailman Center for Child Development, Department of Pediatrics, University of Miami School of Medicine. He received his B.S. degree from the University of Nebraska at Omaha in Speech-Language Pathology with a minor in Deaf Education. His M.A. degree is from Central Michigan University in Audiology. And his Ph.D. degree is from Baylor College of Medicine in Bioacoustics (Audiology). Dr. Fifer's clinical and research interests focus on the areas of auditory evoked potentials, central auditory processing, early detection of hearing loss in children, and auditory anatomy and physiology. He is a member of ASHA's Heath Care Economics Committee.
