Otolaryngology Coding Alert

Before billing, double-check which practitioner performed the service

If your practice employs a speech pathologist or audiologist, you can ensure swift reimbursement for your  post-cochlear implant services if you know the following three expert-recommended requirements.

1.  Use Stand-Alone Code for Employee

You don't need a modifier when you report diagnostic analysis and aural rehabilitation services for your cochlear implant patients, as long as your otolaryngologist employs the audiologist or speech pathologist and you perform the service in a nonfacility environment (such as your practice office).

When your practice employs these practitioners, you should bill programming (92601, Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming; or 92603, Diagnostic analysis of cochlear implant, age 7 years or older; with programming), reprogramming (92602 "pediatric" ... subsequent reprogramming; or 92604 "adult" ... subsequent reprogramming) and rehabilitation (92507, Treatment of speech, language, voice, communication, and/or auditory processing disorder [includes aural rehabilitation]; individual; or 92508, ... group, two or more individuals) under the physician's name or "incident- to" the ENT, says Debi Irwin, CPC, coding specialist at the four-otolaryngologist Nashville Ear, Nose & Throat Clinic in Tennessee.

Append -GN for SLP in Facility or Independently

Be careful: If you're coding for a speech pathologist who provides services in a facility or independently, Medicare will reject post-cochlear implant services unless you append modifier -GN (Services delivered under an outpatient speech language pathology plan of care) to the appropriate code, says a reimbursement specialist at Cochlear Americas in Englewood, Colo.

Example: Your otolaryngologist performs a cochlear implant on an adult, and then your in-office audiologist programs the aural device. In this case, you should report 92603 incident-to the otolaryngologist.

But suppose you code for a speech-language pathologist who provides aural rehabilitation to a Medicare patient at an outpatient rehabilitation facility. To indicate that the speech-language pathologist performed the service at an outpatient facility, you should append modifier -GN to 92507.

Omit -GN and Lose More Than $62

Medicare will deny your aural rehabilitation claim if you omit modifier -GN, an error that will cut $62.36 from the claim, based on a national average. But if you append the modifier when your ENT's audiologist performs programming in the office (such as 92603), the carrier may confuse the charge and deny the $85.88 service.

2. Reserve Device Adjustments for Audiologist

Medicare restrictions dictate that only audiologists  may provide the cochlear implant diagnostic analysis and subsequent reprogramming. Medicare only reimburses aural rehabilitation when a speech-language pathologist provides the service.

Snag: Your audiologist provides aural rehabilitation to a Medicare patient. You properly report the service as 92507, but Medicare denies the $62.36 charge.

Documentation Will Reveal Who Performed Service

Why: Medicare doesn't cover 92507-92508 when an audiologist provides the service. You should reserve 92507-92508 for a speech-language pathologist to perform and 92601-92604 for an audiologist.

News: New legislation, however, may soon change this rehab coverage restriction. An audiologist is qualified to provide aural rehabilitation, says Steven C. White, PhD, the healthcare economics and advocacy director at the American Speech-Language-Hearing Association in Rockville, Md. If it passes, the Medicare Audiologic Rehabilitation Act of 2003, H.R. 3464, will amend the statute to make audiologists Medicare providers of aural rehabilitation services, he says.

3. Temporarily Ignore Therapy Cap

There's good news for otolaryngologists who provide in-office diagnostic and aural rehab services: 92507-92508 and 92601-92604 are not subject to the therapy cap because Medicare removed 92601-92604 from the list. The therapy cap doesn't include audiologists, says Debbie Abel, AuD, chair of the American Academy of Audiology's Coding and Practice Management Committee. That's why you don't need to use modifier -GN on audiologists' incident-to claims.

Cap Is High, But Moratorium Lasts Through 2005

Watch out: The aural rehab codes are still subject to the therapy cap, which is now set at $1,640. "Physical therapy, occupational therapy and speech-language therapy comprise the therapy cap specialties," Abel says.

Grace: The Medicare Prescription Drug Modernization Act of 2003 placed a two-year moratorium on the therapy cap, so your claims are safe from the limit until Dec. 31, 2005.