Audiology - JE Part B

The term "audiology services" specifically means hearing and balance assessment services furnished by a qualified audiologist. Hearing and balance assessment services are termed "audiology services" regardless of whether they are furnished by an audiologist, physician, Non-Physician Practitioner (NPP), or hospital.

Audiologists are authorized to furnish diagnostic and balance assessment services under section 1861(ll)(3) of the Social Security Act (the Act). Hearing and balance assessment services, termed audiology services, are generally covered as "other diagnostic tests" under section 1861(s)(3) of the Act. Audiology services may also be provided by physicians and NPPs, including Physician Assistants (PAs), Nurse Practitioners (NPs), and Clinical Nurse Specialists (CNSs) when authorized by state law and scope of practice.

Coverage

• A physician order is required for audiology services in all settings.
• Effective January 1, 2023, CMS allows a specific diagnostic test exception for non-acute hearing conditions personally furnished by audiologists.
  • Coverage for audiology services is determined by the reason the test is ordered or directly accessed, as appropriate, rather than by the patient's diagnosis or condition.
• Audiology services may be furnished and billed by audiologists; no physician supervision required.
• Interpretation and report shall be included in the medical record by the audiologist, physician, or NPP who furnished any audiology service, or, by the physician who supervised the service.
• Technicians shall not interpret audiology services but may record objective test results of those services they may furnish under direct physician supervision.
• Payment for the interpretation and report of the service is included in payment for all audiology services, and specifically, in the professional component if the audiology service has a professional component and/or technical component split.
• Audiology services furnished as outpatient services of a hospital, are covered as "diagnostic services" under section 1861(s)(2)(C) and payable under the hospital Outpatient Prospective Payment System (OPPS).

Noncoverage

• Medicare does not reimburse audiologists for therapy services (i.e., auditory rehabilitation), hearing aids, and auditory implants (see CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 100).
• Audiology services are not covered under the benefit for services "incident to" a physician's service (see CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60).
  • Medicare benefit that allows audiologist to submit audiology services they personally furnish.

Audiology Exception

Effective January 1, 2023

• CMS's exception to the physician order requirement for certain diagnostic testing services broadens patient access to services furnished by audiologists.
• Only for non-acute hearing conditions, the policy will allow beneficiaries direct access to an audiologist, without an order from a physician or NPP.
• For the directly accessed services, append modifier AB to the allowed codes available on the CMS Audiology Webpage in the resource section.
• The direct access policy allows beneficiaries to receive care for non-acute hearing assessments that are unrelated to disequilibrium, hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids.
  • Limits billing for these services to one visit to an audiologist without an order, every 12 months.
  • For example, if one CPT code is billed with the AB modifier on a certain date, none of the remaining codes on the list of applicable CPT codes will be payable under the PFS for another 12 months without a qualifying order.
• In the event of the unexpected discovery of an acute condition during a visit with an audiologist without the order of the treating physician or NPP, modifier AB may be billed with each of the services you provided. The presence of the acute condition won't be cause to deny the claim, provided that good faith efforts were made, as documented in the medical record, to avoid providing audiology services for acute conditions without the order of the treating physician or NPP.

Billing

• Modifier AB - long descriptor: Audiology service furnished personally by an audiologist without a physician or NPP order for non-acute hearing assessment unrelated to disequilibrium, or hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids; service may be performed once every 12 months, per patient.
  • Use it with any of the codes available on the CMS Audiology webpage in the resource section, only when the patient has come directly to you without a physician or NPP order.
  • Tests are limited to certain non-acute hearing conditions and diagnostic services related to implanted auditory prosthetic devices (including cochlear, osseointegrated, and auditory brainstem implants), but may not include audiology services that are related to disequilibrium, or hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids.
  • Don't use it when the patient presents an order or referral from a physician or NPP.
• Only append modifier AB to codes on the approved CPT codes eligible to be performed without a physician or NPP order.
  • Claims will be returned if AB modifier is appended to CPT codes that are not applicable for the exception.
  • Diagnostic tests can include components that are split into a Professional Component (PC) and a Technical Component (TC). Documentation in the medical record must include the tests provided and results for medical review.

Resources

• CMS Audiology
• CMS IOM, Publication100-02, Medicare Benefit Policy Manual, Chapter 15, Section 60
• CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 16, Section 100
• CMS Medicare Learning Network (MLN) Matters (MM) 13055
• Social Security Act, Section 1861 (II)(3)