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The Fundamentals of the Role of Medicare in Audiology

The Fundamentals of the Role of Medicare in Audiology
Kim Cavitt, AuD
March 18, 2013

This text-based course is a transcript of the recorded seminar presented by Kim Cavitt, Au.D. This course is part of a series of courses that Dr. Cavitt has recorded for AudiologyOnline.  The title of this series is, “Billing, Coding, Reimbursement, and Compliance Bootcamp” and is designed to provide everything you need to know about billing, coding, reimbursement, and compliance for audiology and hearing care practices.  Browse the courses at  It is recommended to download and review supplemental course materials prior to reading this transcript.

Today we are going to talk about the fundamentals of Medicare in the world of audiology.  We are going to start first with the basics.  Medicare is governed and managed by the Centers for Medicare and Medicaid Services.  Please note that it is Medicare and Medicaid.  CMS, for short, governs both programs while Medicaid is administered at the state level, and at the state level has its own rules and regulations.  The rules of engagement of Medicare typically cover Medicaid beneficiaries as well.  The Centers for Medicare and Medicaid Services are part of the U.S. Department of Health and Human Services.  Both this section and their subsidiary, CMS, govern the federal Medicare and Medicaid programs.  Claims for Medicare are paid by Medicare Area Contractors.  That is the fiscal intermediary that manages Medicare claims throughout the United States.  There are fiscal intermediaries for part A or hospital claims, and separate fiscal intermediaries for part B which are outpatient claims.  Also Medicaid programs are paid separately by states and their individual state Medicaid program. 

There are different types of Medicare.  Medicare part A is inpatient or hospitalization care.  Medicare part B is what is most common in audiology, which is outpatient or physician services, or diagnostic services outside the inpatient/hospital arena.   Part C is the Medicare Advantage programs or the privatization of Medicare.  Part D does not really have a lot of implication to audiology because that is the Medicare Drug program.  Audiologists who work within a hospital system are billing under part A which has its own in-facility rates and has its own in-facility system called OPPS.  The vast majority of audiologists in the country are billing out under part B which is the outpatient system with the Medicare fee schedules you typically see posted.  Part C governs those private Medicare Advantage programs that are put forth by Blue Cross/Blue Shield, Aetna, Humana, and United Healthcare. 

Medicare Enrollment

Providers need to be enrolled as an individual and their facility needs to also be enrolled as the practice.  Before you can enroll, you need to have an established clinic that is enrolled to link the enrolled providers to, and vice versa.  Before you can initiate the individual Medicare enrollment or the 855-I, an audiologist must have a national provider identifier or NPI, a state license to practice audiology, and a clinic address or enrolled Medicare practice, one who has created an 855-B and it has been approved.  You can enroll online to PECOS (  It is really the best way to enroll.  It will help you avoid paper applications.  Paper applications are the way that people have difficulties in the Medicare system.  On paper, you can make mistakes in enrollment that the online enrollment does not allow you to do.  The online enrollment takes you step-by-step through questions.  If you are about to answer the questions incorrectly, it will stop you and guide you to finding the right answer.  In the end, when performing online enrollment, it is very difficult to have made mistakes. 

In the Medicare system you can be enrolled as a provider in more than one way.  Your options include being a participating provider.  Participating providers are enrolled in Medicare.  They accept assignments.  This means they accept the Medicare allowable as payment in full.  You would be listed in the provider directory.  The claims that you submit to Medicare will automatically roll over for payment to a secondary payer and Medicare outlays for the system for this particular claim 5% more than a nonparticipating provider.  This will make more sense I continue.

You can also be enrolled in Medicare but be a nonparticipating provider.  I want to stress that nonparticipating providers are enrolled in Medicare.  They have completed an 855-I and they are linked to a clinic who is enrolled with an 855-B.  They can accept assignment, or accept the allowable as payment in full on a claim by claim basis or charge the patient the limiting charge, which is 115% of the allowed amount.  The patient can pay up to that 115% allowed amount on the date of service to the provider.  The provider will get their money upfront.  The patient will then receive a check directly from Medicare for 95% of the allowed charge.  In the end, the patient is not going to receive what they paid.  They will receive 95%of the allowed charge.  Typically Medicare Area Contractors do not roll nonparticipating claims over to the secondary.  This means once Medicare processes your claim, you would need to take that explanation of benefits and then resubmit to the secondary for additional payment for the patient.  You are filing these claims on behalf of the patient as a Medicare nonparticipating provider.  Typically Medicare does not list nonparticipating providers in a directory. 

The third option is that you are not enrolled in Medicare, but audiologists cannot opt out of Medicare.  This means we do not have the ability to enter into private contracts with Medicare beneficiaries.  Because of mandatory claims submission requirements that are part of the Medicare system, if you are seeing Medicare eligible beneficiaries, you must either be enrolled in Medicare as a participating provider, be enrolled in Medicare as a nonparticipating provider, or provide all of your testing free to Medicare beneficiaries, and really to all patients.  From my experiences, private insurance contracts say that you cannot charge one patient for something that you are giving to everyone else for free.  You cannot charge a Medicare beneficiary privately for something that Medicare would have covered.  This is a very important note.  You cannot charge one patient for something that you are giving away to others for free.  If you are providing testing at no charge, you need to be providing testing at no charge to all your patients regardless of their payer or their payer situation. 

I would like to give an example of how Medicare would pay differently in different scenarios.  There are three situations in this example. 

The first situation is as the participating provider.  The billed amount would be $125. This is our usual and customary charge billed out on a claim.  For the participating provider, Medicare allowed $100.  That was the Medicare allowed rate.  This means between Medicare and the secondary or the patient (if they have no secondary,) $100 is the maximum amount that you can collect on this claim for this patient if you are a participating provider.  Medicare pays 80% of all claims or all allowed amounts.  The beneficiary (patient) or the co-insurance pays 20%.  The total payment to the provider would be $100.  You accepted the Medicare allowed amount as payment in full. 

The second situation is the Medicare provider who is nonparticipating, but decides to accept assignment on this particular claim.  You may do this for a patient who has limited financial resources or is in a scenario where their health care costs are ballooning, and you want to be of assistance.  In this case, the Medicare allowed amount is $95, because you are nonparticipating, which is 5% less.  Medicare would pay 80% of that which is $76.  The beneficiary or co-insurance would pay 20% which is $19.  Because you are nonparticipating and you agreed to accept assignment, your total payment would be $95. 

The last case, which is the most common case for those who are nonparticipating, would be that you are not accepting assignment on this claim.  The billed amount would be the limiting charge.  The patient would pay you the limiting charge of $109.25 on the date of service.  Medicare has allowed $95 and they will send the patient a check privately for that $95.  Either the beneficiary or the secondary payer will pay either you (if you are a participating provider) or the patient (if you are not enrolled as a provider in the secondary’s plan) $19.  In the end, you received $109, but the patient received $95.  The patient does not get the same amount of benefit.  They had to pay $14.25 difference out of their own pocket that will never be reimbursed to them because you are a nonparticipating provider. 

For this reason, some audiologists determine that it is in their best interests to be participating because they want the patients to come in directly.  They want to be listed in provider manual and they are willing to take a little less money in order for that to happen.  It all depends on what you choose based upon your clinic mix, your referral source mix, how your referral sources perceive participation versus nonparticipation, and finally the socioeconomics of your area. 

CMS Audiology Policies

Audiology has very defined policies in the Medicare system.  They are defined by the Update to Audiology Policies that went into effect October 1, 2008; the Revisions and Re-Issuance of Audiology Policies that went into effect September 1, 2010; the ABN Guidance that was just updated for January 1, 2012; and the Physician’s Quality Reporting System, which has been in effect since 2010.  We will talk about each of these independently. 

The Update to Audiology Policies and the Revisions and Re-Issuance of Audiology Policies are very important for audiologists to read.  I am providing you with the links to the actual documents at the end of this course.  The Revisions and Re-Issuance just clarifies some of the points of the Update to Audiology Policies from 2008.  These rules we are going to talk about are in effect currently and these are the guidelines that audiologists are being asked to adhere to. 

First and foremost, we have to remember “Incident to” billing.  Prior to 2008, audiologists who worked in an otolaryngology clinic typically billed the services they provided and the testing to payers under the National Provider Identifier or provider number of the physician of which they were employed, or the supervising physician.  Medicare put a stop to that in 2008 by saying that audiology services provided by an audiologist must be billed out under the NPI and Medicare PTAN of the rendering audiologist.  They cannot be billed “Incident to” a physician, unless performed by a technician.  If an audiologist performs the testing, it needs to be billed out under the NPI of the audiologist who performed the service.  Audiology services provided by an audiologist cannot be billed under the NPI of a physician.  If physicians perform the service, they can bill for them; but if an audiologist performs the service, it needs to be billed under the NPI of the audiologist who actually performed the service.  When someone goes on vacation, you cannot bill things out underneath who has not physically performed the testing. 

The Update to Audiology Policies also stresses that for an audiology diagnostic service to be covered, it must be ordered by a physician.  The audiologist needs to have a physician order in place before providing services that they are seeking coverage for.  Without an order, the patient is responsible for the cost of the testing. 

They also determined in this guidance that we are a diagnostic profession.  As a result, treatment or rehabilitative services are non-covered if provided by an audiologist.  If provided within your scope of practice or scope of care defined by your state, you can bill Medicare beneficiaries privately for treatment services such as cerumen removal, canalith repositioning, tinnitus management, vestibular rehab, and aural rehab, as long as you are functioning within the scope of your practice.  Medicare, under no circumstances, reimburses an audiologist for any treatment or rehabilitative services provided by an audiologist, but you can and should bill patients privately when you provide those services to Medicare beneficiaries.

 The Update also outlined the fact that computerized audiometry, otograms for example, are non-covered services, regardless of who performs the procedure.  Again automated audiometry is non-covered by Medicare.  If it is being provided in a clinic, it is the patient’s responsibility to pay for testing.  Diagnostic hearing testing requires the skills of an audiologist, a physician, or in very limited cases, a non-physician practitioner such as a nurse practitioners, licensed nurse practitioners, and physician’s assistants.  Those individuals must be practicing within their scope of practice for the state licensure.  A technician, an audiology assistant, and someone who is an ototech are not non-physician practitioners and as a result, hearing tests, automated hearing tests, or tests performed by them, unless they are specifically listed, are non-covered. 

Role of Technicians and Their Supervision Requirements

Let’s talk about the role of technicians in the Medicare system.  There are some procedures a technician can perform under the direct supervision of a physician.  A technician cannot function under the direct supervision of an audiologist.  You cannot bill services performed by a technician under the provider number of an audiologist.  It can only be billed under the provider number of the supervising physician.  That physician is someone who is in the office suite.  They are not in the operating room.  They must be in the office suite.  They do not need to be in the test suite.  They also need to be readily available and involved in the patient’s care.  As a result, technicians should be working underneath the supervising physician of that patient.  Technicians can only perform procedures that have a technical and professional component split with one exception.  Technicians can perform otoacoustic admissions, the vestibular family of codes, and auditory brain stem response testing under the direct supervision of the patient’s attending physician.  They can perform the technical component of those procedures.  They can also perform tympanometry under the direct supervision of the supervising physician.  Those are the only procedures that a technician can perform in the Medicare system.  Again this is OAEs, ABR, tymps, and vestibular.  Everything else requires the skills of an audiologist or a physician in order to have Medicare covered the procedure. 

Role of Students and Their Supervision Requirements

Students, including but not limited to, the final year extern require 100% personal supervision.  Personal supervision means that the supervising audiologist is in the test suite.  They are not seeing other patients.  They are not running another schedule.  They are not doing paperwork in another room.  They are in the test suite with the student directly involved in the provision of services.  It is that audiologist who is supervising that student’s work that the testing is billed out under.  Without 100% personal supervision, the testing provided by the student is non-covered by Medicare and is the financial responsibility of the patient. 

Medical Necessity

Another thing that is important is medical necessity.  Medicare pays for items and services that are medically necessary to diagnose, treat, or monitor a medical or surgical condition.  They do not pay for routine or annual hearing tests, and they do not pay for testing for the sole purpose of purchasing a hearing aid.  They will cover diagnostic testing where the only outcome is a hearing aid, but they do not cover testing that was for the sole purpose of purchasing a hearing aid.  For example, a patient loses their hearing aid and the state licensure law requires that you have a hearing test within six months to give them a replacement.  If the patient notices no change in history or symptom, and none is documented in the medical record, the test for the replacement hearing aid is the financial responsibility of the patient.  That test specifically was for the sole purpose of getting a hearing aid.  There was no medical, surgical, or monitoring reason to provide that testing.  When medical necessity is not met, the patient is financially responsibility for the cost of the test. 

Billing of Technical and Professional Components

Medicare also indicated that audiologists could now bill both the technical and professional components of codes that contain the TC/PC split such as OAEs, ABR and vestibular as long as they were providing both the technical and the interpretation of the test.  Audiologists do not need to add modifiers to claims where they have both performed the test and interpreted the test. 

CPT Code 92700

Medicare indicated that when an item or procedure does not have a defined CPT code, that you use the unlisted otorhinological item or service code of 92700.  You will hear me talk about 92700 in other sections of this boot camp series.  You will need to supply documentation with that claim when you use 92700 to illustrate what service was provided, what its clinical utility is, how long it took you to perform the procedure, what equipment was required to perform the procedure, what the skill set of the provider is required to perform the procedure, and a usual and customary fee for that procedure that you have created for your clinic.  You will also want to send a copy of the patient’s report along with this claim and information.  Some examples of where 92700 would be appropriate are vestibular-evoked myogenic potentials (VEMPs), middle or late latency response, high-frequency audiometry, or an Audiometric Weber. 

Opting Out of Medicare

The Revisions and Re-Issuance of Audiology Policies made it clear that audiologists may not opt out of Medicare.  Audiologist may not charge Medicare beneficiaries privately for medically necessary items or services.  Audiologists either need to be enrolled as a participating provider, as a nonparticipating provider, or give all their testing away free to all of their patients.  Those are your options in Medicare.  There is not a fourth option to charge Medicare beneficiaries for testing that is being provided.  We cannot opt out of Medicare. 

Comprehensive Outpatient Rehabilitation Facility Billing

If you work in a comprehensive outpatient rehab facility, Medicare does not cover testing performed in that type of facility.  Those would be non-covered procedures.  The patient again would be responsible for the costs. 

Mandatory Claims Submission

Finally we are a mandatory claims submitter.  If a Medicare beneficiary requests that we submit a claim on their behalf, we need to do so.  If we need to submit a claim for an item or service that does not meet medical necessity or is statutorily excluded, there is a -GY modifier that you can add to the claim to indicate that. 

Local Coverage Determinations

Medicare Area contractors that manage claims also can dictate coverage in cases where they believe Medicare has been silent.  They can actually state that they only pay for a specific item or service if the patient exhibits or has a specific diagnosis.  Those are call local coverage determinations.  Three of the three Medicare Area contractors actually have local coverage determinations that affect audiology.  One is Trailblazer that is a Medicare Area Contractor in the western states.  One is Palmetto that covers states on both the eastern and western seaboards, and First Coast which is the Medicare Area Contractor for Florida.  All three of these Medicare Area Contractors have local coverage determination that influences or affects Audiology.  It is important, if any of these three are your Medicare Area Contractors, that you consult the guidance available on their website about local coverage determinations and read them very carefully as they will dictate care. 

Medical Necessity

The following information is in quotes because it was extracted directly from Chapter 15 of the Medicare Provider Manual as it pertains to audiology.  This is Chapter 15, section 80.3.  This contains all the rules and regulations that apply to audiology that are outlined in the Update to Audiology Policies and Revisions and Re-Issuance. 

“Examples of appropriate reasons for ordering audiological diagnostic tests that could be covered include, but are not limited to:

  • Evaluation of suspected change in hearing, tinnitus, or balance.  The patient reports a change in history or symptom;
  • Evaluation of the cause of disorders of hearing, tinnitus, or balance.  Once a cause is determined, medical necessity may not be met; but if you are still trying to determine etiology or cause, then that test would be covered;
  • Determination of the effect of medication, surgery, or other treatment.  Post-operative audiograms, monitoring ototoxicity would be where medical necessity has been met;
  • Reevaluation to follow-up changes in hearing, tinnitus, or balance that may be caused by established diagnoses that place the patient at probable risk for a change in status including, but not limited to: otosclerosis, atelectatic tympanic membrane, tympanosclerosis, cholesteatoma, resolving middle ear infection, Menie&lgrave; re’s disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, acoustic neuroma or vestibular schwannoma, demyelinating diseases such as MS, ototoxicity secondary to medications, or genetic vascular and viral conditions.  If your patient has a diagnosis of any of those items listed above and testing is warranted on a periodic basis to monitor those conditions, that testing would be covered as long as it ordered by a physician;
  • Failure of a screening test (although a screening test is non-covered) and a diagnosis has not already been established for their hearing loss.  The patient is for the first time having their hearing addressed and going to have their hearing screened.  If they fail that hearing screening and they have never had their hearing testing before, that subsequent hearing test would be medically necessary and covered;
  • Diagnostic analysis of cochlear or brainstem implant and programming; and
  • Audiology diagnostic tests before and periodically after implantation of auditory prosthetic devices.”  This means any candidacy determination testing or any verification testing or cochlear implant or auditory osseointegrated implant patient.  They do not cover testing related to a hearing aid.  They cover testing for candidacy determination and verification cases for cochlear implant and BAHA users. 


It is important your documentation supports why the test was performed.  Medicare does not pay for routine and they do not pay for protocol.  They pay for you to perform the testing that is medically necessary to diagnose or treat or monitor that particular patient.  It is important that the reason for the test be documented on the order, in the report or in the patient’s medical record.  If you perform tympanometry, you need to make sure that your documentation illustrates why tympanometry was warranted in that particular case.  If tympanometry was not medically necessary in that case, do not do it.  If you are performing tympanometry, immittance testing, and ABR or otoacoustic emmissions, you need to make sure that document in the record why you did the test; what its medical necessity was for this patient.  I cannot stress that enough. 

You also need to document skilled services.  “When the medical record is subject to medical review, it is necessary that the record contains sufficient information so that the contractor may determine that the services qualify for payment.  For example, documentation should indicate that the test was ordered, that the reason for the test results in coverage, and that the test was furnished to the patient by a qualified individual.  Records that support the appropriate provision of an audiological diagnostic test shall be made available to the contractor on request.”  You need to make sure that you can justify in the record why you performed this particular test individually on each individual patient. 

Physician Order Requirements

Physician order requirements are needed for each incident of care.  You cannot get an order once in a patient’s lifetime and mean that hearing testing is ordered.  You need this for each incident of care.  If a physician orders an audiologic testing and vestibular evaluation, you cannot do them on the same date of service.  That is okay; it is still one incidence of care.  If a physician wants someone monitored for ototoxicity and they want them monitored over time, whatever time frame is indicated in the order would be considered one incidence of care.  However if a physician sends you an order because they want someone followed up for Meniere’s, you would need an order the next time they needed to be followed up for Meniere’s.  There is no such thing as a standing order.  You need an order for each incidence of care, and even through you have a physician order, it does not guarantee medical necessity.  An example would be when a patient loses their hearing aid.  They go to their doctor for an order for a hearing test.  Even though they have an order, it does not make that test medically necessary.  You, as the audiologist who performed the procedure, are responsible for determining and justifying medical necessity. 

An order should very simply state audiologic and/or vestibular evaluation.  Testing that is performed by an audiologist does not need to be individually listed.  If a physician wants a technician to perform testing, each individual test must be listed individually.  If the testing is being performed by an audiologist, the audiologist gets to determine what testing is warranted.  As a result, you want to keep physician orders as simple as possible.  You want to avoid the use of the term “hearing aid” on the order.  Personally if I received an order for a hearing test and the order indicated that they were being referred for testing and hearing aid, I would send the order back and ask that they send me a new order for just the hearing test.  You do not want to have a situation where the test could be construed as for the sole purpose of obtaining a hearing aid. 

Physician orders should come in these different ways.  They can be hand delivered, faxed or mailed.  They do not need to be signed by the physician.  They just need to be an order for a particular patient with a particular date for a particular service.  The can be emailed from the physician or his office.  They can be called in, but I would avoid this option.  I would avoid this option because if they call in, you need to trust that the physician on the other side has documented that order in their medical record.  For someone who has worked with doctors for most of her career, I would never trust that.  In an audit or utilization review, if you do not have that physical order in your charts, they will pull from the ordering physician.   If it is not there, you will be the one paying the claim back.  I would avoid phone orders or orders delivered verbally by a patient at all costs. 

Advanced Beneficiary Notice (ABN)

The Advanced Beneficiary Notice of Noncoverage is a Medicare defined and regulated document that is used to notify Medicare beneficiaries of their potential financial responsibilities prior to the rendering of a service of dispensing an item.  An ABN must be signed before the procedure is performed to be valid.  You can find the current ABN form effective March of 2011 and its accompanying guidance in a link at the end of this course.  There is also great guidance on how to follow an ABN.  An ABN document is only appropriate for Medicare beneficiaries.  You want to consult your Medicare Advantage or Part C programs to determine if this form is allowed and applicable in Medicare Advantage scenarios.  This is really up to the contractor of the Medic are Advantage program, whether or not advanced beneficiary notices are utilized in their guidance.  Sometimes instead they want their own document, which they may or may not, define for you, which is a notice of non-coverage.  It can mean the same thing, but it is in a little different language.   It also does not have the word “Medicare” on it.  You want to consult your Medicare Advantage providers.  This document is only for Medicare patients.  The ABN is the alerting notice to the patient on their fiscal responsibility for Medicare diagnostic services has two roles.  As a required notification, it informs the beneficiary that the item or service may not meet the definition of medical necessity in this instance of care, or as a voluntary notification, or notification of non-coverage that informs the beneficiary that the item or service is statutorily excluded or does not meet the definition of a Medicare benefit.    

Let’s talk about some required use examples.  One example is that an order is in place from a physician but medical necessity has not been met in your determination.  Another is that testing frequency is outside the norm.  It is always better to be safe than sorry while typically this kind of testing would be covered because it says they monitor.  Let’s say a physician is ordering testing where they are monitoring.  They want you to do it three times in one day and you are doing three different claims for the same date of service.  Again, you want to have an ABN signed, to protective you if Medicare ultimately denies.  Any time you use the unlisted 92700 CPT code as they are individually reviewed, you would want to have an ABN signed, or any time a local coverage determination is in place in your locality because payment is determined by diagnosis.  You would not know what that diagnosis is until after you perform the testing.  It is always best if a local coverage determination is in place that you have an ABN signed before the provision of services. 

Some common situations where the use of a required ABN would be warranted are:

  • An audiologist has a physician order, but evidence of medical necessity may not have been met in this instance of care;
  • The code 92700 or the unlisted otorhinologic item or service is used;
  • Or an LCD is in place and the provider is performing a procedure that appears to not be covered by the LCD.

If a required ABN is completed and the beneficiary wants the claim submitted to Medicare for a coverage decision, that means they select the option 1, section G of the form, the provider should add the –GA modifier to the items or services that were listed on the ABN.  The –GA modifier means required waiver viability is on file.  You do not need to send the ABN with the claim.  The –GA will let them know that you have one signed on file. 

Again a physician orders an annual hearing test on a Medicare beneficiary.  The beneficiary has been previously diagnosed with a sensorineural hearing loss.  When the patient arrives in your clinic, they do not report a change in history or medical condition and do not have a medical condition that requires audiologic monitoring.  Instead, the patient is interested in amplification.  This is a perfect example of the beneficiary having an order, but medical necessity was not met. 

Another example would be a Medicare beneficiary is undergoing vestibular evoked myogenic potential (VEMP) testing.  As this procedure does not have a CPT code, the use of 92700 is warranted. 

The third example is a local coverage determination is in place in Texas.  A Medicare Beneficiary in Texas is about to undergo audiologic testing.  As the coverage of the audiologic testing in this case is dependent on the beneficiary having one of the approved diagnoses, the use of a required ABN is warranted.  This is the due to the fact that the resulting diagnosis may not one the diagnoses approved for payment by the LCD. You cannot shop a diagnosis that is not appropriate just to ensure coverage. 

ABNs can also be used for voluntary reasons.  I call a voluntary ABN more of a patient notification or patient communication.  I firmly support the use of voluntary ABNs to make sure that you and the patient are on the same page, so there is no misunderstanding or miscommunication, and they understand that this item or service is not covered and why it is not covered.  It is important that you put that in writing to them so they understand the situation and will not go to another healthcare provider and get different information.  Then they are angry with you because you did not tell them or you were not clear.  Oftentimes you are dealing with hearing impaired people, putting this information in writing is the best way to know that they understood. 

Some voluntary uses are:

  • Routine or annual audiologic testing where medical necessity was not met;
  • Hearing aids or testing for the sole purpose of obtaining a hearing aid;
  • Treatment services such as cerumen removal, canalith repositioning, tinnitus management and aural rehabilitation;
  • Tinnitus maskers and devices;
  • Evaluation and Management codes.  You should not utilize evaluation and management codes unless you are appropriately educated on their appropriate use and care.  There is module of this boot camp specifically over evaluation and management codes.; 
  • Audiologic and/or vestibular testing where a physician order was not obtained prior to testing;
  • Audiologic evaluations that were the result of solicitation (i.e. reminder cards, marketing events);
  • Audiologic and/or vestibular testing that was completed by a student in the absence of 100% personal supervision by an audiologist or physician;
  • Audiologic testing that requires the skills of an audiologist or physician, but was completed by a technician or a student was not appropriately supervised; or
  • Screenings.

When you use a voluntary ABN, the provider should add the –GY modifier that means the item or service statutorily excluded or does not meet the definition of a Medicare benefit, and the –GX modifier to the items or services that were listed on the ABN.  The –GX modifier means that a voluntary ABN was signed and is on file. 

PQRS (Physician Quality Reporting System)

The PQRS system has been worked on collaboratively in audiology through an organization or band of brothers called the Audiology Quality Consortium, which is made up of representatives of the 10 audiology stakeholder organizations.  All this work is collaborative.  I am directing you to the ASHA document because it is an example of one of the collaborative pieces that are available.  You can also find collaborative pieces on the American Academy of Audiology website, as well as the Academy of Doctors of Audiology website.  These websites will be listed at the end of the course. 

PQRS is the Physician Quality Reporting System.  It is a voluntary program designed to improve the quality of care of Medicare beneficiaries.  I am going to stress that it is voluntary today.  PQRS will be mandatory by 2015, and if you are not reporting in 2013, your 2015 Medicare claims will be deducted because you did not participate in 2013.  I would clarify this by saying PQRS is voluntary in 2012, but would consider it to be required if you do not want any penalties for 2013.  Beginning January 1, 2012, audiologists who bill Medicate part B and who participate in PQRS by reporting on approved quality measures are eligible for a 0.5% incentive payment.  In 2012, you are eligible for an incentive payment.  That incentive payment will start to diminish and will gone, but instead there will be penalties, starting in 2015. 

Audiologists have the opportunity to improve both the profession of Audiology and quality of care provided to patients by participating in the Medicare Physician Quality Reporting System.  The audiologist must be enrolled as a Medicare provider, either participating or nonparticipating.  This means that in addition to having one's own NPI number, the audiologist must have completed the Medicare form 855-I for formally registering with Medicare as a provider and, if necessary, an 855-R form to inform Medicare where regular payments should be directed.  The 855-R is your assignment of benefits to a business.  The PQRS is reported on a HCFA 1500 form. 

PQRS is a program that will apply to non-Medicare situations as well (for example, procedures or situations involving children).  But to be eligible to receive the 0.5% bonus at year end, the PQRS participant must be a Medicare provider and they are only going to give bonuses to those claims that were performed on adults.  Again, this will be mandatory by 2015. 

The current PQRS measures are:

  • Congenital or traumatic deformity of the ear;
  • A history of active drainage from the ear within the previous 90 days (for patients who have disease of the ear and mastoid processes);
  • A history of sudden or rapidly progressive hearing loss; and
  • Acute or chronic dizziness.

There will be a module in this boot camp specifically related to PQRS.  Today in the Medicare module I wanted to touch on it.  It is very important if you want to learn more to view the PQRS module independently, and/or go to the guidance that you will see available on the websites. 

I also want to stress that you will see the national associations of which you are a member actively talking about PQRS especially in the next 6 to 12 months.  Please be sure to read any information that you receive from an organization, which you are a member of, as it relates to PQRS.  This is very important for those of you enrolled in Medicare.  It could cost you money if you are not participating by 2013.  It is important for you to be educated on PQRS and you set up the process and procedures in order to report through it.  It can be reported very easily.  You just need to put those procedures in place in order to so. 

Medical Record Retention

There are guidelines in states, at the federal government, and in your contracts about how long you need to retain records.  For HIPAA, you need to retain your patient records for at least 6 years.  You also need to consult your state laws and your third party contracts.  I have seen state laws where it talks about records for children need to be maintained until that child turns 25.  If you first saw that child at the age of 1 and they are not 25 yet, you could be maintaining that record for 25 years.  I have seen managed care contracts where you need to maintain medical records for 13 years.  Again it is important to be aware of the record retention policies in your state and in your managed care contracts.  Pediatrics and hospitals often have very different policies.  I am giving you the link for a document that talks about the different medical record retention policies in each state at the end of this course.  I would also like to stress that medical record retention policies can be affected by what is in the record.  If you are putting in what I would deem as financial information, such as invoices and EOBs, those records can also have tax implications to them as well.  If they are an invoice, this is something that you paid, and you may need that for other purposes.  I do not recommend putting financial type documents in patient charts.  I think those should be batched and kept separately as they can have very different record retention policies that are governed by the IRS.  You need to be aware of what is in your records, what should and should not be in your records, either electronic or paper, and how long you need to maintain those records. 

Supplemental Links

Medicare Enrollment -

Update to Audiology Policies -

Revisions and Re-Issuance of Audiology Policies -

Medical Necessity -

Advanced Beneficiary Notice -   and

Physician Quality Reporting System -

Medical Record Retention Policies -

Cite this content as:

Cavitt, K. (2013, March). The Fundamentals of the role of Medicare in audiology. AudiologyOnline, Article #11438. Retrieved from


Signia Xperience - July 2024

kim cavitt

Kim Cavitt, AuD

Owner of Audiology Resources

Kim Cavitt, AuD was a clinical audiologist and preceptor at The Ohio State University and Northwestern University for the first ten years of her career.  Since 2001, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc.  Audiology Resources, Inc. provides comprehensive operational and reimbursement consulting services to hearing healthcare clinics, providers, organizations, buying groups, and manufacturers who want to be better equipped to compete in the managed care and healthcare arenas.  She currently serves on the Board of the Academy of Doctors of Audiology and the State of Illinois Speech Pathology and Audiology Licensure Board.  She also serves on committees through AAA and ASHA and is an Adjunct Lecturer at Northwestern University.

Related Courses

Fundamentals of Audiology Coding
Presented by Kim Cavitt, AuD
Recorded Webinar
Course: #37127Level: Intermediate3 Hours
This course discusses various coding options used by audiologists. Part one defines audiology CPT, Modifiers, HCPCS and Place of Service codes and discusses their appropriate use. Part two focuses on the basics of IC-10, the most common codes used by audiologists, and how to effectively integrate this new code set into an audiology practice.

ICD 10: Fundamentals and Appropriate Use in an Audiology Practice
Presented by Kim Cavitt, AuD
Recorded Webinar
Course: #29962Level: Intermediate1 Hour
This course will focus on the fundamentals of ICD 10 in an audiology practice, including coding scenarios, local coverage determination implementation, and code use.

2021 Coding and Reimbursement Update
Presented by Kim Cavitt, AuD
Recorded Webinar
Course: #35600Level: Intermediate1.5 Hours
This course will focus on the coding and insurance updates that are new for 2021. We will discuss the CPT changes, MIPS additions, and managed care medical policy and coverage updates.

Ethical and Legal Requirements of Audiology Practice - Staying Compliant
Presented by Kim Cavitt, AuD
Recorded Webinar
Course: #30065Level: Intermediate2 Hours
In this presentation, we will discuss the foundations of ethics and compliance in audiology, as well as U.S. regulations. We will explore the AAA and ASHA Codes of Ethics, state ethical guidelines contained in several state licensure laws, Medicare, HIPAA, the FDA Guidelines, Stark laws, and Anti-kickback laws and explain, in detail, how they relate to specific scenarios we encounter in audiology.

2020 Coding and Reimbursement Update
Presented by Kim Cavitt, AuD
Recorded Webinar
Course: #34179Level: Intermediate1.5 Hours
This course will focus on the coding and insurance updates that are new for 2020. We will discuss the CPT changes, MIPS additions, and managed care medical policy and coverage updates.

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