Medicare Compliance & Reimbursement

Ensure physician’s order to prevent having to write off claim.

Bear in mind that audiological diagnostic tests are a separate benefit and not an incident-to service.Heed the following advice if your practice includes an audiologist.

Only Schedule Audiology with a Physician Order

Although an audiologist can submit claims under her own name, a physician must order the test.

“Medicare patients have to have a doctor’s referral,” says Catherine Tinkey of ENT Medical Services in Iowa City. “Some commercial insurers don’t require it, but most do.”

“Our rule of thumb is, ‘if we are submitting a medical claim, there has to be a physician involved,’” adds Gloria Sikora with Trinity Mother Frances Hospitals and Clinics in Tyler, Tx. “And I would get that order in writing and keep it in the patient’s medical file.”

From CMS: All audiological diagnostic tests must be ordered. Most orders should be from a physician, but a non-physician provider (NP or PA) may order and perform audiological testing when the order and testing are within their state scope of practice, per CMS Transmittal 84.

Look at Professional and Technical Components

According to CMS Transmittal 84, audiological diagnostic tests are not covered as an incident-to service because they are a separate benefit. Because of this, the Centers for Medicare & Medicaid Services’ (CMS) only allows audio technicians to perform procedures that include both professional and technical components. The audio technician’s service is considered the technical component. A physician, audiologist, or non-physician practitioner provides the test supervision and clinical judgment of the professional component.

The physician, audiologist or qualified non-physician practitioner bills the directly supervised service as a diagnostic test.

Possible change: If an audiological diagnostic test is not broken into two parts (professional and technical components), CMS says that only the audiologist, physician or non-physician practitioner can provide the service and bill with his or her individual NPI. For example, 92553 (Pure tone audiometry [threshold]; air and bone) does not have both a technical and professional component. Therefore, an audio technician cannot bill for any part of this test. Only the audiologist, physician, or non-physician practitioner can complete the test (assuming that audiologic testing is within the NPP’s state scope of license).

If an audio technician performs the technical component of a service that does not require the skills of an audiologist such as 92540 (Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording), the physician, audiologist, or NPP shall provide and document his or her work related to the professional component of the service. This would include clinical decision making and other active participation in the delivery of the service.

Caution: Do not bill this participation as evaluation and management or as part of other billed services. The sum of the work performed by the audio technician and the audiologist, physician, or NPP will equal the service defined by the code with no modifier. In this case, 92540 would cover the work of a technician and an audiologist under the audiologist’s NPI number.

Get Familiar With the Codes

The CMS Physician Fee Schedule allows a professional and technical component for many CPT® codes in Audiology section. Refer to CPT® for a complete listing, but a few common examples (in addition to 92540 listed above) include the following:

• 92541 — Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording,
  
• 92544 — Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording,
  
• 92585 — Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive,
  
• 92588 — Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report.
  

Exceptions: When coding these procedures, you’ll find one exception to the technical/professional component requirement, for 92567 (Tympanometry [impedance testing]). CMS states in Transmittal 84 that since tympanometry is mostly automatic, the procedure may be performed by an audio technician and still be billed under the supervising audiologist’s, physician’s, or NPP’s NPI.

Resource: To read CMS Transmittal 84, visit www.cms.gov/Transmittals/Downloads/R84BP.pdf.