Otolaryngology Coding Alert

Although audiology technicians may assist audiologists in audiologic and vestibular function tests, you must understand the aides' role and applicable guidelines or risk improper reporting.

"Technicians perform audiograms [92552-92557], electronystagmograms [92541-92545], and can make swim molds [99070]," says Janet Agemian, administrator, Professional Otolaryngology Assoc., MDPA, Voorhees, N.J. In addition, assistants may also perform tympanometry (92567) and duties involving hearing aids, such as hearing aid examinations (92590-92591), checks (92592-92593) and evaluations (92594-92595), Agemian says.

In a survey on the role of audiology technicians, many respondents "believe technicians can help reduce current appointment backlogs," says John T. Berardino, author, The Role of Audiology Technicians in the VA System.

Training the assistant to do hearing tests and ENGs "frees the audiologist to see more hearing aid patients," adds Edie Scully, Baton Rouge Ear, Nose & Throat in Louisiana. This extra time benefits the practice monetarily and provides the patient with faster service.

"The biggest benefit of using technicians is the salary difference between a tech and an audiologist, which is quite significant," Agemian says.

The American Association of Audiology (AAA) is sympathetic to the financial plight of otolaryngology practices and understands that "audiologists are using support personnel ... to ensure both the accessibility and the highest quality of audiology care while addressing productivity and cost-benefit concerns," according to an AAA position statement.

Practices must understand that audiologists are highly qualified personnel. The Social Security Act establishes that a qualified audiologist is an individual with a master's or doctoral degree in audiology who:

A. is licensed as an audiologist by the state in which the individual furnishes such services; or
B. in the case of an individual who furnishes services in a state that does not license audiologists, has:

1. successfully completed 350 clock hours of supervised clinical practicum (or is in the process of accumulating such supervised clinical experience),

2. performed not less than nine months of supervised full-time audiology services after obtaining a master's or doctoral degree in audiology or a related field, and

3. successfully completed a national examination in audiology approved by the secretary.

In comparison, technicians are not regulated by any federal statute. Instead, states may choose whether to recognize or regulate their services. Thirty-seven states now recognize support personnel, and 31 regulate conduct, according to the American Speech-Language-Hearing Association (ASHA). Regulation ranges from licensure to registration. Education requirements vary by state. The highest standards, such as New Mexico's, require a bachelor's degree and enrollment in a master's program. Other states, such as Florida, stipulate a high school diploma plus additional training. Some states are silent on the issue.

Scully's practice hires part-time audiology students who are accumulating practice hours, which ensures high-quality, interested assistants.

States may also regulate other areas to ensure technicians do not supersede their level of expertise. Regulations include how many aides an audiologist may supervise, how much time the audiologist must directly supervise the technician, and the duties the assistant may perform. For a breakdown of state requirements visit www.professional.asha.org/resources/states/state_licensure .cfm#support or research your state's laws by going to www.professional.asha.org/resources/states/index.cfm and scrolling down to your state.

"The tech never performs any test without the audiologist either directly supervising or reviewing the results before the patient leaves," Scully says.

CMS designates many of the vestibular function tests and audiologic function tests with a supervision requirement of "5". This level of diagnostic test supervision means the physician supervision policy does not apply when a qualified audiologist personally furnishes the procedure; otherwise the procedure must be performed under the general supervision of a physician, according to Program Transmittal B-01-28.

The memorandum establishes that audiologists may perform the listed diagnostic tests without an otolaryn-gologist supervising the service. The audiologist bills the applicable service under the physician's unique personal identification number. For Medicare to cover these services, the patient must first see the doctor. The audiologist renders the tests based on the physician's order.

For instance, suppose a patient who has dizzy spells presents to an otolaryngologist. After conducting an examination, the doctor orders a positional electronystag-mography (ENG), and is called out of the office. The audiologist performs the test.

The otolaryngologist should report the ENG and an E/M service. For the ENG, she assigns 92542 (Positional nystagmus test, minimum of 4 positions, with recording). For the E/M, she reports the appropriate new patient office visit codes (99201-99205) appended with modifier -25 to indicate a separate, distinct procedure from the diagnostic test.

Medical necessity would not support the audiologist ordering and performing the test without the physician's examination. This justifies billing the examination as a separate, necessary service. The supervision rule does not apply to the audiologist, so despite the doctor's absence, the audiologist's services are still covered.

The diagnostic supervision rules do not exempt the assistant from physician supervision. Instead, they enforce general physician supervision, which have broad allowances. Section 410.32(b) of the Federal Code of Regulations states, "General supervision means the procedure is furnished under the physician's overall direction and control, but the physician's presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician."

This means that when the doctor leaves the premises, the assistant may perform the test. "General supervision does not require you to be physically present on-site when the service is provided, but the service must be provided under your overall supervision and control," the American Academy of Family Physicians explains.

However, "An audiologist must always be present in the office when using a tech," Agemian says. And Scully adds, "The tech never performs any test without the audiologist either directly supervising or reviewing the results before the patient leaves."

Regardless of payer, the otolaryngologist must order the test before the audiologist sees the patient. For doctors who prefer to see the patient after the audiology tests are conducted, the physician must still sign off that he ordered the test prior to the audiologist's seeing the patient. Without this documentation, the carrier will deny payment for the test.

Heads up: The AAA is working on frequently asked questions on using audiology assistants, which will be available as a quick fax sheet. Otolaryngology Coding Alert will let you know when it's available.