Otolaryngology Coding Alert

Question: Our audiologist performed testing without a physician’s order and billed the applicable codes (all in Appendix A of CR 13055) with modifier AB. A few weeks later, the patient returned for additional testing without an order. The codes for those tests are also on the Appendix A list, but when billed with -AB, the claim was denied. Why? Can you explain the rules surrounding billing Appendix A audiology codes and offer ways to strengthen these claims?

AAPC Forum Participant

Answer: The denial was likely due to frequency limitations — a patient may only have one visit to an audiologist without a physician or non-physician practitioner (NPP) order every year, and an audiologist can only bill the testing codes in Appendix A of CR 13055 with modifier AB (Audiology service furnished personally by an audiologist without a physician/npp order …) once every 12 months.

Background: During the CY 2023 Medicare Physician Fee Schedule (MPFS) rulemaking, the Centers for Medicare & Medicaid Services (CMS) finalized a regulation allowing audiologists to provide certain diagnostic tests without a physician order and bill those 36 CPT^® codes with modifier AB. Stipulations for these tests include:

• Covered once per patient per 12-month period
• Limited to assessment of non-acute hearing conditions
• Excludes services related to:
  • Disequilibrium
  • Hearing aids
  • Exams for prescribing, fitting, or changing hearing aids

Key: “You may only bill using modifier AB once every 12 months, regardless of the number of applicable CPT^® codes billed with the modifier on that date of service. For example, if you bill one CPT^® code with the AB modifier on a certain date, none of the codes on the list of 36 applicable CPT^® codes will be payable under the PFS for another 12 months without a qualifying order,” explains MLN Matters article #MM13055 (www.cms.gov/files/document/mm13055-audiologists-may-provide-certain-diagnostic-tests-without-physician-order.pdf).

Update: CMS added two new CPT^® codes for use with modifier AB effective Jan. 1, 2024:

• 92622 (Diagnostic analysis, programming, and verification of an auditory osseointegrated sound processor, any type; first 60 minutes)
• 92623 (… each additional 15 minutes …)

Modifier AB billing tips:

• Use it with any of the codes in Appendix A of CR 13055, but only when the patient has come directly to the audiologist without a physician or NPP order.
• Document in the medical record the actual tests provided and their results for purposes of medical review.
• Document good faith efforts were made to provide services for non-acute hearing conditions so that the claim won’t be denied if the audiologist unexpectedly discovers an acute condition.

“After getting care from an audiologist they accessed directly, the patient needs to wait 12 months before getting additional diagnostic tests from an audiologist without a physician or NPP order. During this interim period, the patient may seek care from their treating physician or NPP that could result in a referral to an audiologist for diagnostic testing,” per MM13055.