Interview with Steven White Ph.D. Director of Health Care Economics and Advocacy ASHA
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Topic: Medicare, CPT Codes, Billing, Reimbursement, Cochlear Implants and More
Beck: Good morning Steve. Thanks for meeting with me today.
White: Hi Doug. Thanks for having me.
Beck: Steve, I think many of the folks reading this interview will be familiar with your name from various coding, CPT and billing issues. However, before we get to those same issues, would you please tell me about your professional education and your early career positions?
White: Sure Doug. I earned my bachelor's degree in 1966 and my master's in 1969 in Speech Pathology and Audiology from Ithaca College.After that, I worked three years at the Upstate Medical Center in Syracuse. I earned my Ph.D. in audiology in 1974 at Wayne State University. Following my doctoral studies, I taught and did clinical work at Michigan State University for 7 years. I was the clinical coordinator for audiology and an assistant professor from 1974 until 1981. From there I went to ASHA as the director of the Reimbursement Policy Division, and have been here ever since.
Beck: Oh my...24 years with the same employer! I guess you're starting to learn your way around the building?
White: Yes, but the learning never stops!
Beck: Steve, tell me, what does your office do on a day-to-day basis regarding
health care economics and advocacy?
White: Well, that's a great question. We work on everything to do with third party reimbursement, private health plans, HMO, PPO, Fee-For-Service, whatever! If a member needs information on these programs, we handle it. We've also assembled handbooks, pamphlets and guidelines to help our members obtain reimbursement for their services.
Beck: I thought the pamphlets were available to ASHA members and non-members, too?
White: Yes. They're available via the ASHA website and I think they're very practical. For example, we have one handbook called "Getting Your Services Covered" and another titled "Health Plan Coding and Claims Guide" and "Negotiating Health Care Contracts and Calculating Fees." I also recommend "Appealing Health Plan Denials." We also have a few free publications available on the ASHA web site, and in particular, I recommend the Medicare physician fee schedule (www.asha.org/NR/rdonlyres/7304CDC4-FA4E-4AEB-8AA4-1010DAFE83AD/0/2005MFS_Aud.pdf)- that's very useful, too. So, as you can see, there are quite a few, and, except for the fee schedule, they're all listed under PUBLICATIONS and SALES on the ASHA website.
Beck: Another major publication for you is the recently released "Medicare Handbook for Audiologists."
White: Yes, you're right. That one is really important. It's specific to audiology, and covers everything related to billing, coding and reimbursement related to Medicare issues, rules and regulations. Additionally, Medicare is administered by many different local and regional offices across the USA, and sometimes what is true at one Medicare office is not true elsewhere. So it's important to make sure the audiologist is knowledgeable about the local rules and regulations, as well as the national standards. It also addresses skilled nursing facilities and Medicare Parts A and B too.
Beck: And for those not familiar with Parts A and B, can you please give us a quick tutorial?
White: Sure. Once you're eligible for Medicare and Social Security, which has generally occurred at age 65, you are automatically eligible for Medicare Part A of Medicare. Then, you can elect to enroll in Part B, and almost everyone does. There is a monthly premium for Part B, and you do have to pay 20 percent of the approved fees. Part A primarily covers hospital stays and related expenses and Part B is looked on as covering physicians' office fees and physicians' surgical expenses. So everyone is automatically enrolled in Part A, and again, you might think of Part B, essentially as "outpatient" services. Private practice audiologists have their Medicare diagnostic services covered under Part B.
Beck: I know I've heard of Part C, but I have no idea what that is?
White: Part C, better known as Medicare Advantage, was created in 1997 and is the latest iteration of Medicare managed care. It is provided through such entities as HMOs and PPOs. Congress and the administration believe that managed care will save money so they are providing financial incentives to managed care organizations to become Medicare providers..
Beck: And lastly, what is Part D?
White: Part D is the new term used to describe the prescription drug benefit. The "D" stands for drugs, and these benefits are not covered under Parts A or B or C.
Beck: For professionals not familiar with Medicare protocols, I'd like to cover a few basic issues. First, patients are not supposed to "self refer." In other words, even though some audiology services have CPT codes and are billable to Medicare, simply having Medicare is not enough...the patient is only allowed to use their Medicare benefits if their physician has referred them...is that correct?
White: Yes, you're correct. Medicare beneficiaries need to have a referral from a physician before seeing an audiologist. The patient is supposed to contact their physician first, and after the patient has been referred by their physician because of a diagnostic or treatment question, the patient can be seen by the audiologist and Medicare can be billed. But, it must be documented in the physician's chart and in the audiology office chart. In other words, it must be documented at the source, and at the audiologist's office, too. Then, the patient can be seen and Medicare can be billed for audiology services.
Beck: And so the goal of Medicare is not to provide hearing tests or audiometric evaluations for their members - right?
White: Exactly. We audiologists may not like the way that Medicare has designed this part of its program but Medicare's goal is for the audiologist to support the physician in their diagnosis and treatment plan, not to provide audiometric evaluations for each Medicare beneficiary. Medicare basically does not want to pay for evaluations if the reason for the testing is to determine the need for a hearing aid or is a "routine test.". Medicare reimbursement is only available to help diagnose the patient, if the physician believes there is a medical issue to be considered.
Beck: But in reality, it often seems like Medicare presumes we know the answer before we ask the question. In other words, if the patient's chief complaint is bilateral hearing loss, and indeed, it is determined to be presbycusis and the only viable option is hearing aid amplification -- Medicare says they don't want to pay for that test, but how can we know the test result if we haven't yet performed the test?
White: Yes, well that's the problem in a nutshell! The Medicare system was never intended to provide hearing tests for patients who have presbycusis. However, if the physician believes the hearing loss could be something beyond presbycusis, and if they refer for an audiometric evaluation based on an elevated suspicion, it's OK. But the physician should not refer based on a suspicion of presbycusis only.
Beck: To me, the Medicare rules and regulations appear to almost inspire patients and physicians to exaggerate claims in order to "rule out" medical or surgical conditions. We know that presbycusis in and of itself, without further medical involvement, leads to a lesser quality of life, depression, anxiety, and feelings of worthlessness and that presbycusis is the probably the largest hearing loss diagnosis category, and it probably does more damage than all other hearing loss categories combined, yet Medicare doesn't really want us to find and treat it. Seems a little weird to me!
White: I understand, and I cannot disagree with your opinion, but of course providers need to adhere to the rules and guidelines for Medicare patients. The rules state that Medicare will not pay for, and should not be used to pay for routine tests or tests to determine the need for a hearing aid. We all sort of dance around this issue, but the Medicare statute is clear, no hearing aids and no tests related to hearing aids. However, some progress has been made. In years past, Medicare wouldn't pay for the test if the final result was determined to presbycusis with hearing aids recommended. However, at this time, if everything is ruled out and if the result is presbycusis with hearing aids recommended, Medicare should pay for the test, because the tests have provided the physician with diagnostic information to help manage the patient.
Beck: Agreed, that's definitely going in the right direction. So if you can support the rationale for doing a test, such as "rule out" this or that, and if the test has been referred by a physician, you should be OK, even if the patient has presbycusis?
White: Again, the physician should not be ordering tests unless they suspect a medical problem, but if the suspect a medical problem, and if the final diagnosis is determined to be presbycusis, there's a pretty good chance it will be paid...but that's not a guarantee. The individual situation and process matters, and the rationale matters too. If the physician writes on a prescription note..."evaluate for hearing aids," that's not good as far as billing and getting reimbursed through Medicare. If the physician writes "rule out asymmetric sensorineural loss" or "rule out retrocochlear" or perhaps "rule out conductive hearing loss," those would better support a Medicare claim.
Beck: OK Steve, thanks. What can you tell me about the new CPT codes for cochlear implants?
White: As of January, 2003, there are four new codes for cochlear implants, including CPT codes 92601 through 92604. The new procedure codes are the result of a three-year effort by the ASHA Health Care Economics Committee. These codes allow the audiologist to report analyzing and programming cochlear implants. Previously, because programming was not diagnostic, the audiologist could not bill Medicare for these services....but now that the CPT code specifies diagnostic analysis and programming, Medicare will pay for it.
Beck: That really is a major step forward. But I wonder...Is it presumed that because the patient has a cochlear implant, that follow-up tests are "by default" ordered by the physician, or do you need a unique referral for each visit?
White: I think it would be best to have a unique referral, but that's probably a bit of a grey area at this time.
Beck: What about cerumen removal? Is there a CPT code that the audiologist can bill against?
White: Audiologists may be permitted to perform cerumen removal based on their state license, but as far as Medicare is concerned, audiologists cannot bill Medicare for cerumen removal if it is the only procedure performed by the audiologist because it is not a diagnostic procedure. If cerumen removal is performed during a visit where a number of other procedures are performed, Medicare believes that the cost is factored into the relative value of each diagnostic test.
Beck: Steve I know we can go on for hours and hours, but I suspect the best way for audiologists to get information about Medicare is to get the new book?
White: Yes, I agree. The new book does cover all of these issues and lots more. One major topic which we haven't spoken about today, but is a big issue for many audiologists is the issue of "accepting assignment" and that's covered in the book too, and again, it can be acquired by ASHA members and non-members, too.
Beck: OK Steve, you've been very generous with your time, and I really do appreciate it. Thanks so much for your time and energy this morning.
White: You're welcome Doug. Thanks to you too, for getting this information out.
------------------------------------------
For More Information on These Topics...
Go to https://www.asha.org/shop/reimbursementproducts.htm and scroll down to the links for for:
Medicare Handbook for Audiologists
Negotiating Health Care Contracts and Calculating Fees
Health Plan Coding and Claims Guide
Getting Your Services Covered: A Guide for Working with Insurance and Managed Care Plans
White: Hi Doug. Thanks for having me.
Beck: Steve, I think many of the folks reading this interview will be familiar with your name from various coding, CPT and billing issues. However, before we get to those same issues, would you please tell me about your professional education and your early career positions?
White: Sure Doug. I earned my bachelor's degree in 1966 and my master's in 1969 in Speech Pathology and Audiology from Ithaca College.After that, I worked three years at the Upstate Medical Center in Syracuse. I earned my Ph.D. in audiology in 1974 at Wayne State University. Following my doctoral studies, I taught and did clinical work at Michigan State University for 7 years. I was the clinical coordinator for audiology and an assistant professor from 1974 until 1981. From there I went to ASHA as the director of the Reimbursement Policy Division, and have been here ever since.
Beck: Oh my...24 years with the same employer! I guess you're starting to learn your way around the building?
White: Yes, but the learning never stops!
Beck: Steve, tell me, what does your office do on a day-to-day basis regarding
health care economics and advocacy?
White: Well, that's a great question. We work on everything to do with third party reimbursement, private health plans, HMO, PPO, Fee-For-Service, whatever! If a member needs information on these programs, we handle it. We've also assembled handbooks, pamphlets and guidelines to help our members obtain reimbursement for their services.
Beck: I thought the pamphlets were available to ASHA members and non-members, too?
White: Yes. They're available via the ASHA website and I think they're very practical. For example, we have one handbook called "Getting Your Services Covered" and another titled "Health Plan Coding and Claims Guide" and "Negotiating Health Care Contracts and Calculating Fees." I also recommend "Appealing Health Plan Denials." We also have a few free publications available on the ASHA web site, and in particular, I recommend the Medicare physician fee schedule (www.asha.org/NR/rdonlyres/7304CDC4-FA4E-4AEB-8AA4-1010DAFE83AD/0/2005MFS_Aud.pdf)- that's very useful, too. So, as you can see, there are quite a few, and, except for the fee schedule, they're all listed under PUBLICATIONS and SALES on the ASHA website.
Beck: Another major publication for you is the recently released "Medicare Handbook for Audiologists."
White: Yes, you're right. That one is really important. It's specific to audiology, and covers everything related to billing, coding and reimbursement related to Medicare issues, rules and regulations. Additionally, Medicare is administered by many different local and regional offices across the USA, and sometimes what is true at one Medicare office is not true elsewhere. So it's important to make sure the audiologist is knowledgeable about the local rules and regulations, as well as the national standards. It also addresses skilled nursing facilities and Medicare Parts A and B too.
Beck: And for those not familiar with Parts A and B, can you please give us a quick tutorial?
White: Sure. Once you're eligible for Medicare and Social Security, which has generally occurred at age 65, you are automatically eligible for Medicare Part A of Medicare. Then, you can elect to enroll in Part B, and almost everyone does. There is a monthly premium for Part B, and you do have to pay 20 percent of the approved fees. Part A primarily covers hospital stays and related expenses and Part B is looked on as covering physicians' office fees and physicians' surgical expenses. So everyone is automatically enrolled in Part A, and again, you might think of Part B, essentially as "outpatient" services. Private practice audiologists have their Medicare diagnostic services covered under Part B.
Beck: I know I've heard of Part C, but I have no idea what that is?
White: Part C, better known as Medicare Advantage, was created in 1997 and is the latest iteration of Medicare managed care. It is provided through such entities as HMOs and PPOs. Congress and the administration believe that managed care will save money so they are providing financial incentives to managed care organizations to become Medicare providers..
Beck: And lastly, what is Part D?
White: Part D is the new term used to describe the prescription drug benefit. The "D" stands for drugs, and these benefits are not covered under Parts A or B or C.
Beck: For professionals not familiar with Medicare protocols, I'd like to cover a few basic issues. First, patients are not supposed to "self refer." In other words, even though some audiology services have CPT codes and are billable to Medicare, simply having Medicare is not enough...the patient is only allowed to use their Medicare benefits if their physician has referred them...is that correct?
White: Yes, you're correct. Medicare beneficiaries need to have a referral from a physician before seeing an audiologist. The patient is supposed to contact their physician first, and after the patient has been referred by their physician because of a diagnostic or treatment question, the patient can be seen by the audiologist and Medicare can be billed. But, it must be documented in the physician's chart and in the audiology office chart. In other words, it must be documented at the source, and at the audiologist's office, too. Then, the patient can be seen and Medicare can be billed for audiology services.
Beck: And so the goal of Medicare is not to provide hearing tests or audiometric evaluations for their members - right?
White: Exactly. We audiologists may not like the way that Medicare has designed this part of its program but Medicare's goal is for the audiologist to support the physician in their diagnosis and treatment plan, not to provide audiometric evaluations for each Medicare beneficiary. Medicare basically does not want to pay for evaluations if the reason for the testing is to determine the need for a hearing aid or is a "routine test.". Medicare reimbursement is only available to help diagnose the patient, if the physician believes there is a medical issue to be considered.
Beck: But in reality, it often seems like Medicare presumes we know the answer before we ask the question. In other words, if the patient's chief complaint is bilateral hearing loss, and indeed, it is determined to be presbycusis and the only viable option is hearing aid amplification -- Medicare says they don't want to pay for that test, but how can we know the test result if we haven't yet performed the test?
White: Yes, well that's the problem in a nutshell! The Medicare system was never intended to provide hearing tests for patients who have presbycusis. However, if the physician believes the hearing loss could be something beyond presbycusis, and if they refer for an audiometric evaluation based on an elevated suspicion, it's OK. But the physician should not refer based on a suspicion of presbycusis only.
Beck: To me, the Medicare rules and regulations appear to almost inspire patients and physicians to exaggerate claims in order to "rule out" medical or surgical conditions. We know that presbycusis in and of itself, without further medical involvement, leads to a lesser quality of life, depression, anxiety, and feelings of worthlessness and that presbycusis is the probably the largest hearing loss diagnosis category, and it probably does more damage than all other hearing loss categories combined, yet Medicare doesn't really want us to find and treat it. Seems a little weird to me!
White: I understand, and I cannot disagree with your opinion, but of course providers need to adhere to the rules and guidelines for Medicare patients. The rules state that Medicare will not pay for, and should not be used to pay for routine tests or tests to determine the need for a hearing aid. We all sort of dance around this issue, but the Medicare statute is clear, no hearing aids and no tests related to hearing aids. However, some progress has been made. In years past, Medicare wouldn't pay for the test if the final result was determined to presbycusis with hearing aids recommended. However, at this time, if everything is ruled out and if the result is presbycusis with hearing aids recommended, Medicare should pay for the test, because the tests have provided the physician with diagnostic information to help manage the patient.
Beck: Agreed, that's definitely going in the right direction. So if you can support the rationale for doing a test, such as "rule out" this or that, and if the test has been referred by a physician, you should be OK, even if the patient has presbycusis?
White: Again, the physician should not be ordering tests unless they suspect a medical problem, but if the suspect a medical problem, and if the final diagnosis is determined to be presbycusis, there's a pretty good chance it will be paid...but that's not a guarantee. The individual situation and process matters, and the rationale matters too. If the physician writes on a prescription note..."evaluate for hearing aids," that's not good as far as billing and getting reimbursed through Medicare. If the physician writes "rule out asymmetric sensorineural loss" or "rule out retrocochlear" or perhaps "rule out conductive hearing loss," those would better support a Medicare claim.
Beck: OK Steve, thanks. What can you tell me about the new CPT codes for cochlear implants?
White: As of January, 2003, there are four new codes for cochlear implants, including CPT codes 92601 through 92604. The new procedure codes are the result of a three-year effort by the ASHA Health Care Economics Committee. These codes allow the audiologist to report analyzing and programming cochlear implants. Previously, because programming was not diagnostic, the audiologist could not bill Medicare for these services....but now that the CPT code specifies diagnostic analysis and programming, Medicare will pay for it.
Beck: That really is a major step forward. But I wonder...Is it presumed that because the patient has a cochlear implant, that follow-up tests are "by default" ordered by the physician, or do you need a unique referral for each visit?
White: I think it would be best to have a unique referral, but that's probably a bit of a grey area at this time.
Beck: What about cerumen removal? Is there a CPT code that the audiologist can bill against?
White: Audiologists may be permitted to perform cerumen removal based on their state license, but as far as Medicare is concerned, audiologists cannot bill Medicare for cerumen removal if it is the only procedure performed by the audiologist because it is not a diagnostic procedure. If cerumen removal is performed during a visit where a number of other procedures are performed, Medicare believes that the cost is factored into the relative value of each diagnostic test.
Beck: Steve I know we can go on for hours and hours, but I suspect the best way for audiologists to get information about Medicare is to get the new book?
White: Yes, I agree. The new book does cover all of these issues and lots more. One major topic which we haven't spoken about today, but is a big issue for many audiologists is the issue of "accepting assignment" and that's covered in the book too, and again, it can be acquired by ASHA members and non-members, too.
Beck: OK Steve, you've been very generous with your time, and I really do appreciate it. Thanks so much for your time and energy this morning.
White: You're welcome Doug. Thanks to you too, for getting this information out.
------------------------------------------
For More Information on These Topics...
Go to https://www.asha.org/shop/reimbursementproducts.htm and scroll down to the links for for:
Medicare Handbook for Audiologists
Negotiating Health Care Contracts and Calculating Fees
Health Plan Coding and Claims Guide
Getting Your Services Covered: A Guide for Working with Insurance and Managed Care Plans
