Even in the world of billing and reimbursement, where fluidity and change are commonplace, 2008 has already yielded some of the most significant guideline, policy, and coding updates ever seen in the world of audiology or hearing healthcare. As a result, it is vital that professionals all keep abreast of these changes and learn how they affect their practices. All of these updates can have a significant effect on hearing care practices and, ultimately, on professionals' compliance status and revenues. This paper will highlight these changes, provide links and related resources for audiologists, provide tips for best practices in coding and reimbursement, and present frequently asked questions regarding coding and reimbursement for hearing care professionals.
ICD-9-CM Codes
2008 began with new diagnosis codes being introduced that relate specifically to audiology. ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes are written by the World Health Organization. The codes classify diseases and symptoms for documentation and billing purposes. HIPAA (Health Insurance Portability and Accountability Act) requires the use of these codes (as part of the Standard Transaction and Code Set Rule) to describe the diagnoses that result from medical decision making, procedures and testing. The recent coding changes relate specifically to the diagnosis of hearing loss, speech-language delay related to hearing loss, hearing conservation, and auditory processing disorders.
The 2008 ICD-9-CM codes went into affect October 1, 2007 and are listed in any 2008 ICD-9-CM coding manual. They can be purchased from the American Medical Association (catalog.ama-assn.org) and cost $55.00+ each. Failure to use the most specific, update to date diagnosis code will result in a denial of third-party insurance claims.
Centers for Medicare and Medicaid Services
The Centers for Medicare and Medicaid Services or CMS originally proposed significant reductions in reimbursement for 2009. The United States Congress overrode a presidential veto and increased Medicare payments by 1.1% for 2009. The only possible reductions could be related to the Medicare Advantage program and it recipients. Also, the Medicare Bill added audiology to the Physician Quality Reporting Initiative (PQRI). Information on PQRI is located on the CMS website at www.cms.hhs.gov/PQRI/. Audiologists are advised to read this information to stay current on this initiative. Medicare has held claims for the first two weeks of July 2008 in anticipation of the funding cuts. These claims will now be paid in accordance with the 2008 fee schedule.
Medicare providers who have not updated their enrollment status since 2003 now need to update their information with Medicare. Please consult the CMS website at www.cms.hhs.gov for the application and additional information.
Advanced Beneficiary Notice (ABN)
On September 1, 2008, another new update will go into effect. CMS has revised the Advanced Beneficiary Notice (ABN) that is to be used with Medicare Beneficiaries. There are instances where Medicare denies certain goods or services that are typically meet the definition of a Medicare benefit but in this instance are not deemed "medically necessary". It is in these instances where it is possible that Medicare may not cover this good or service that an ABN is required prior to delivery of service. In this instance, Medicare beneficiaries must be informed of the type of good or service, its associated costs, and the reasons you suspect that the good or service may not be covered. They then, through the use of the ABN, must accept financial responsibility for this good or service in the event of a Medicare denial. Without a signed ABN in place prior to the good or service being provided, a Medicare beneficiary cannot be billed for a Medicare-denied good or service (that meets the definition of a Medicare benefit). The ABN and Notice of Exclusions from Medicare Benefits (NEMB) are mandated by CMS as part of the Beneficiary Notices Initiative. The revised ABN (CMS-R-131) is intended to take the place of both of the old ABN and NEMB forms. The new form allows audiologists to collect all monies upfront and refund patients in the event that Medicare ultimately pays. The new form, and information surrounding its use, can be found at www.cms.hhs.gov. This new form cannot be significantly modified from its original format and has very specific font requirements. The new form must be used by all audiologists by September 1, 2008.
Notice of Exclusions from Medicare Benefits (NEMB)
Notice of Exclusions from Medicare Benefits (NEMB) forms is still optional. These forms can be used to notify Medicare beneficiaries of their financial responsibility in instances where the good or services that is being recommended or requested by the patient does not meet the definition of a Medicare benefit or is statutorily excluded. An audiologist can now use the new ABN form (www.cms.hhs.gov) or the existing NEMB form (www.cms.hhs.gov/BNI). This is an optional form. Medicare does not require that an NEMB be used. I though find it to be extremely useful as it does an excellent job of notifying patients of their rights and responsibilities.
Update to Audiology Policies
Probably the most significant changes in audiology guidelines were introduced by CMS as part of the Update to Audiology Policies (CMS Manual System, Pub 100-02 Medicare Benefit Policy, Transmittal 84, Change Request 5717, February 29, 2008). This document outlines the policies surrounding billing audiological services to Medicare. Per Medicare, Medicare Audiology Policies have not been updated since 2003. The goal of this document is to clarify the language contained within the existing Medicare policy, as well add new guidelines to the policy. Also, a main component of this policy change is that audiologists are to bill under their own National Provider Identifier (NPI) and not under the NPI of a physician. The Update to Audiology Policies becomes effective on April 1, 2007 (with an implementation date of October 1, 2008).
The main aspects of the Update on Audiology Policy (as indicated in the CMS Manual System, Pub 100-02 Medicare Benefit Policy, Transmittal 84, February 29, 2008) are:
- "Audiological Evaluations include tests of the auditory and vestibular systems, tinnitus, auditory processing and osseointegrated devices."
- "Audiological tests are covered and payable when performed by qualified audiologists."
- "Medicare does not cover audiological treatment, including hearing aids."
- "Audiological tests may be ordered for a beneficiary when the reason for the test is not for the purpose of fitting or modifying a hearing aid."
- Audiological services are not to be billed "incident to" a physician or non-physician practitioner. Audiologists are to bill under their own NPI.
- Payment for audiological diagnostic tests cannot be based solely on the diagnosis or outcome or on the specialty of the person ordering the test.
- Medicare cannot deny payment for follow-up audiological testing if that testing is required to determine the appropriate medical or surgical treatment or to evaluate the success of any medical or surgical treatment.
- Medicare will not pay for computerized testing that does not require the skills and expertise of an audiologist.
- Medicare shall make coverage and payment decisions on an osseointegrated device (BAHA) based upon the Medicare Policy outlined in Publication 100-02, chapter 16, section 100.
- Medicare shall pay for both the technical and professional component (the global fee) of audiological testing when furnished by a qualified audiologist, physician or non-physician practitioner.
- Medicare will not pay for the technical component (-TC) of audiological tests performed by a qualified technician unless the documentation contains the name and professional identity of the technician who actually performed the service, the technician is directly supervised by the physician or nonphysician supervisor, and this supervisor is actively involved in the clinical decision making and test interpretation and this involvement is fully documented.
- Audiologists must document their names and professional identities in the medical record in order to bill Medicare for services rendered.
- Medicare will not pay for services that require the skills of an audiologist when furnished by an AuD 4th year student.
- Medicare will not pay for diagnostic audiological tests provided by a technician unless the physician referral specifies each test individually.
National Provider Identifier (NPI)
The National Provider Identifier (NPI) Rule finally went into effect on May 23, 2008. Audiologists must now begin using this code (in lieu of ALL other individual provider numbers) for all third-party insurance claims (with the exception of some State Medicaid and Worker's Compensation programs). An audiologist cannot complete the Medicare Provider Application process without first obtaining an NPI number. Failure to utilize this number (and the NPI number for referring physician) can result in third-party insurance claims being denied. Professionals can obtain this number or search the NPI database for other providers' NPI numbers at nppes.cms.hhs.gov/NPPES. Once this number is obtained, professionals need to notify all of the third-party insurance carriers that they are contracted with to notify them of the new provider number. Also, the Centers for Medicare and Medicaid Services (CMS) website (www.cms.hhs.gov/NationalProvIdentstand/) and the professional section of the Academy of Dispensing Audiologists website (www.audiologist.org) contain a great deal of useful information related to the NPI Rule and HIPAA.
Coding and Reimbursement - Best Practices
Office Forms, Documents and Processes
Audiology practices need to make sure to update all of their forms and documents as changes in coding, Medicare and state laws occur. The American Medical Association, who own and create the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) coding systems, update these codes at the end of each year (to go into effect January 1 of the following year). It is important to keep abreast of changes in these codes. Use of an incorrect or deleted code will result in the denial of a claim. As a result of these coding changes, each practice should update their superbill, computer systems, and pricing each December. In addition, third-party insurance contracts need to be updated annually in order to ensure that the pros of participation still outweigh the cons. There are times when it is better to be an out of network provider than an in network provider as it gives the professional more control over revenue.
Insurance Verification
Professionals who participate in third-party insurance and dispense hearing aids under those plans, must create and utilize an insurance verification form and process for their practice and ensure it is completed for every patient prior to the hearing aid consultation. Otherwise, there is a risk of dispensing hearing aids whose cost is greater than the reimbursement. Be mindful of contracts that require that large provider discounts be taken off of the usual and customary price or MSRP. In these cases, it can be detrimental to unbundle prices. Knowing the negotiated rate is not as important as knowing whether or not balance billing is allowed or whether or not the professional has to accept one of these large discounts. The answers to those two questions can help guide the professional's recommendations to the patient.
State Hearing Aid Dispensing Laws
It is also extremely important to keep abreast of changes in state licensure and dispensing laws. Most of the hearing aid bills of sale I review as part of my business are not legal for the state in which the audiologist or dispenser practices. This means that, in most cases, all hearing aids sold under the agreement are not legally binding. It is important to read and understand state laws and rules and to ensure that all office forms and processes follow the requirements of the law. Even if an audiologist is no longer licensed under a state hearing aid dispensing law, he or she still must follow the laws related to hearing aid dispensing.
AAA Draft Policy on Financial Incentives in Industry
Please be aware that the American Academy of Audiology (AAA) has recently released a Draft Policy on Financial Incentives in Industry. You can find this policy at www.audiology.org/membership/ethics. This policy, if enacted, could dictate your relationships with manufacturers.
Resources
The following are required reading for audiologists who are navigating the complex world of coding and reimbursement:
- The Current Procedural Technology (CPT) Manual
- The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)
- Health Care Financing Administration Common Procedural Coding System
Frequently Asked Questions
Question: After an insurance company has denied a claim, can an audiologist still charge the patient by giving the patient an Advanced Beneficiary Notice (ABN), regardless of which insurance?
Answer: ABNs only apply to Medicare beneficiaries. It is also important that, for an ABN to be valid, it must be completed and signed prior to any testing being performed. Also, when you submit the claim, you must also add the -GA modifier next to each procedure code, to indicate that an ABN is signed and is on file.
For all private insurance contracts, the patient is responsible for their financial responsibility, particularly their co-pays and deductibles. They do not need to have prior notification of their financial responsibility. It is important for audiologists to always read and understand the terms of insurance contracts as well as be aware of how to read and understand Explanation of Benefits (EOB) documents.
Question: When should you use an ABN? For example, when a chemotherapy patient receives monthly audiological evaluations for ototoxicity monitoring, should an ABN be signed?
Answer: Yes, that is a good example of when ABNs should definitely be in place. I would recommend having ABN's signed for anyone being monitored for ototoxicity or for patients who require frequent, subsequent audiograms. It is this type of atypical test pattern that can potentially yield a denial.
Question: Do you have to have an ABN signed for each audiologic evaluation performed or just a single ABN in the chart that applies to all audiologic evaluations?
Answer: First, it is important that you are familiar with the ABN form and its requirements. You need to have an ABN signed for each date of care and it must be completed in its entirety. Remember, you're not going to complete an ABN on every patient every day. You need to get an ABN signed in situations where you're using an unlisted code (such as 92700) or you are doing an atypical amount of testing on a given patient in a short or atypical time frame. Again, as always, documentation, especially of medical necessity, is important.
Question: When a professional is contracted with an insurance company, can he or she collect the entire amount due for hearing aids from a patient and then reimburse the patient once the insurance company pays the claim?
Answer: Typically, no. Most carriers only allow you to collect patient responsibility from the patient. You can collect what the patient responsibility is, or what you estimate it to be, but you cannot collect, in most cases, the entire amount. Participating providers typically agree to accept provider discounts and are ofetn not allowed to balance bill the patient the difference between usual and customary and the negotiated insurance rate. This is why it is so important to verify a patient's insurance coverage specifics prior to completing a hearing aid evaluation with the patient.
Question: Would it be ethical to bill insurance for a hearing aid to see what they will pay prior to issuing the hearing aid?
Answer: Generally, no. You cannot bill a carrier for a service that you have not provided. This would typically be a violation of your third-party insurance contract and possibly could be a violation of state insurance and/or dispensing laws. As I have previously mentioned, it is so important to be aware of the terms of each of your third-party insurance contracts.
Question: If your employer is an ENT and is ordering an audiologic evaluation, do you need an actual order in the chart? Or can the ENT dictate the order in the patient's report?
Answer: Medicare does not state that orders must be written, it just states that you have to have an order from a physician prior to performing any testing. If you do not obtain a written order, you are trusting another professional to consistently document their order to you in their medical record. I would not trust any professional with that responsibility. It is you who would be held responsible if the order is not documented. For this reason, I am an advocate of written orders, even if you work with the referral source. This will be especially important as audiologists in ENT settings begin billing services out under their own NPI number.
Question: Can you use two Hearing Loss ICD-9 codes on a single claim? For example, if a patient has a sensorineural hearing loss in one ear and a mixed loss in another ear?
Answer: Yes, in this example you would use one code "Mixed Hearing Loss Unilateral", and the other "Sensorineural Unilateral".
Summary
As we begin the second half of 2008 and enter the national election cycle, we will see healthcare, insurance and Medicare thrust to the forefront of our national debate. Billing, coding and reimbursement are fluid;the codes will start to change again between October and December, and professionals are advised to be ready. Keep abreast of changes in this arena through professional organizations, Medicare publications, and AudiologyOnline. As the Inspector General of Medicare states, "Ignorance is not a defense". Business and billing education is key to the creation of a successful, efficient and profitable audiology practice.
