Billing Medicare Without a Physician Referral

Question

Answer

Without a physician referral that is precipitated by medical reasons, audiologists cannot bill Medicare even if a pathologic condition is discovered. If you are audited by Medicare and the referral is not documented in your chart (and the referring physician's) you are at risk for returning payment in addition to penalties incurred.

You may use a relatively new form, the Notice of Exclusions from Medicare Benefits (NEMB). This specifically cites that hearing aids and hearing examinations are not covered services and notifies the patient of such exclusions. You also have the option of using an Advanced Beneficiary Notice (ABN). These are both downloadable from www.audiology.org/professional/members/medicare/ or the ABN at www.cms.hhs.gov/medicare/bni/CMSR1312.pdf.

A medical waiver is appropriate for hearing aid acquisitions in some states but not for Medicare billing. The ABN or NEMB would be necessary. By not having the patient sign the ABN prior to performing the audiologic procedure, you may be putting yourself at financial risk for a denied service.

It would be helpful if you would attend a Medicare 101 course that is offered by your carrier to learn the nuances of appropriate Medicare billing. In addition, the two above sites are invaluable in obtaining additional information.

Debbie Abel, Au.D., has been in private practice for 12 years, in practice for a total of 25. She served as Co-Chair of the Coding and Practice Management Committee (previously Reimbursement Committee) of AAA for 6 months before becoming the Chair in July, 2003.