Kim Cavitt, AuD Audiology Resources, Inc.

Compliance, Coding, Reimbursement, and Practice Management for the Audiology Practice
Kim Cavitt, AuD Audiology Resources, Inc. Live Streamed from Chicago, IL February 23-24, 2017

Learning Outcomes Attendees will be able to:
…list Federal regulations applicable to audiology. ....identify the FDA warning signs of ear disease. …describe the differences between bundling and unbundling. ...list the CPT and HCPCS codes to be used when fitting a hearing aid. ...define managed care terms.

A Bit of Housekeeping… We will be utilizing Poll Everywhere throughout the event. The only attendees that are eligible for CEUs are those who paid to attend this event. The only attendees able to ask questions during and after the event are the paid attendees themselves. You will have until March 10 to complete the course evaluation. This is required for CEUs to be processed. This will come as a separate on Monday.

Things to Know As We Start
I will say things that are unpopular… You decide what you do with the information presented over the next two days. I want everyone to make informed decisions. I try to document myself as much as possible though the inclusion of links. I try to keep politics out of this as much as possible but it is not always possible. Healthcare reform is a moving target…what I tell you today may not apply tomorrow. I ALWAYS err on the conservative side of the laws and regulations. Many laws and regulations are too broadly written not to take this stance. I am NOT an attorney and am not providing legal advice. I consulted a healthcare attorney in preparing this boot camp. I strongly suggest every practice retain counsel for legal questions and concerns.

Do you believe your practice is currently HIPAA compliant?

HIPAA Health Insurance Accountability and Portability Act of (HIPAA) Civil and criminal penalties Covers: Standard Transaction and Code Sets National Provider Identifier National Employer Identifier HIPAA 5010 Security HITECH (Breach Notification) Privacy Marketing Business Associates

HIPAA Audits HIPAA is now being audited by HHS.
As a result, it is very important that you follow the requirements set forth. professionals/compliance- enforcement/audit/

Standard Transaction and Code Set
This aspect of HIPAA requires that the following code sets be utilized for documenting and billing all medical items and services: CPT (Current Procedural Terminology) ICD 10 (International Classification of Diseases-10th Revision) HCPCS (Healthcare Common Procedure Coding System)

National Provider Identifier (NPI)
Requires that each individual provider utilize their own distinct, unique individual provider identification number for all payers. This number stays with the provider as they move from employer to employer. National Provider Identifier (NPI) National Plan and Provider Enumeration System (NPPES)

National Employer Identifier (EIN)
Requires that each individual practice or facility utilize their own distinct, unique practice or facility identification number for all payers. This is required for every practice or facility except a sole proprietorship. The EIN is issued by the Internal Revenue Service (IRS). Each practice also needs a facility or practice National Provider Identifier (NPI). National Plan and Provider Enumeration System (NPPES)

HIPAA 5010 This was a systems update that went into effect January 1, 2012 (enforcement began ion March 31, 2012) on that required systems updates to allow for transition to ICD-10. Affected software vendors, payers, and clearinghouses much more than providers. Administrative- Simplification/Versions5010andD0/Version_5010.html

837 Claims Format 837 Claims submission format set forth in HIPAA 5010. You should ask your office management vendor or EMR about this format. CMS 1500 Paper claim form learning-network-mln/mlnproducts/downloads/837p-cms pdf

Protected Health Information (PHI)
Names Street number and name, city, and last two digits of the zip code Dates directly related to the individual (birth date) Phone number Fax number address Social security number Medical record number

Health insurance member number Account numbers Certificate or license numbers Vehicle identifiers and serial numbers Device identifiers and serial numbers Hearing aid serial numbers URLs

IP addresses Biometric indicators Finger, retinal, and voice prints Photos Any unique identifying number, characteristic or code

Security The Security Rule is an extension of the Privacy Policy.
Went into effect April 20, 2005. Applies to electronic formats. Providers need to have: Administrative Safeguards. Physical Safeguards. Technical Safeguards. You also need policies and procedures related to operations and documentation. professionals/security/index.html

Security Rule Covered entities must:
“Ensure the confidentiality, integrity, and availability of all e-PHI they create, receive, maintain or transmit. Identify and protect against reasonably anticipated threats to the security or integrity of the information. Protect against reasonably anticipated, impermissible uses or disclosures. Ensure compliance by their workforce.”

Security Rule: Risk Assessment
“A risk analysis process includes, but is not limited to, the following activities: Evaluate the likelihood and impact of potential risks to e- PHI. Implement appropriate security measures to address the risks identified in the risk analysis. Document the chosen security measures and, where required, the rationale for adopting those measures. Maintain continuous, reasonable, and appropriate security protections.”

Security Rule: Risk Assessment
What do audiologists need to think about? Computers Phones Tablets Fax Machines Answering Machines Audiometers Test Suites OMS/EMR NOAH

Security Rule: Administrative Safeguards
Security Measures To reduce risks of breaching protected health information. Need a Security Officer Information Access Management Regulate who has access to protected health information. Minimum necessary access Training and Accountability Authorize access to PHI. Train staff on policies and procedures. Sanction staff who do not comply.

Security Rule: Physical Safeguards
Facility access and control Limiting and controlling physical access. Workstation and device security Proper use and access to workstations and electronic devices. Policies and procedures related to: Transfer. Removal. Disposal. Re-use.

Security Rule: Technical Safeguards
Control of access Passwords to protect access. Audit Safeguards to record and examine access. Integrity control Ensure that PHI is not improperly altered or destroyed. Transmission security Protections against “hacking.”

Security Rule: Policies, Procedures and Documentation
You must develop policies and procedures to comply with the security rule. If need guidance, consult an IT consultant who specializes in HIPAA. Must have written policies and procedures. Need to document staff training, actions, activities, and risk assessments.

Business Associate “A business associate is a person or organization, other than a member of a covered entity's workforce, that performs certain functions or activities on behalf of, or provides certain services to, a covered entity that involve the use or disclosure of individually identifiable health information. Business associate functions or activities on behalf of a covered entity include claims processing, data analysis, utilization review, and billing.” “Business associate services to a covered entity are limited to legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services.” Providers are responsible for the actions of their business associates. professionals/privacy/guidance/business-associates/index.html

Common Audiology Business Associates
Hearing aid manufacturers Earmold manufacturers Accountant Lawyer OMS vendor IT consultant Buying/management group

HITECH-Breach Notification
Effective date of February 17, 2010. Applies to paper and electronic formats. Breach: An “impermissible” or unauthorized use or disclosure of PHI. Must do a risk assessment. Breach notification: Must occur within 60 days. Providers and business associates have burden of proof that notifications have been made. Business Associates must notify the covered entity. Notify the individual. Oftentimes provide identity theft protections. Notify the Media: If breach is of more than 500 individuals. Notify Secretary of Health and Human Services:

Privacy Rule Protections of patient’s health information and PHI.
Effects both paper and electronic records. Effective April 14, 2003 and updated in January 2013. Protects “Individually identifiable health information” is information, including demographic data, that relates to: The individual’s past, present or future physical or mental health or condition, The provision of health care to the individual, The past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number).

Privacy: Disclosures That Do Not Require Authorization
Treatment Ordering/referring physician. Physician/provider you are referring to. Coordination of care. Payment Insurance carrier. Health Care Operations “Certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business”

Privacy Rule Specifics:
Keep disclosures to “minimum necessary.” Need a Privacy Officer. Need training on privacy and that training must be documented. New hires. Annually Must have a complaint process. Must have record safeguards: Storage. Disposal. HIPAA: 7 years Need though to consult state and payer record retention requirements as they can exceed HIPAA. Access.

Privacy Rule Specifics:
Texting Both can be done with patients through encrypted/secured service providers. papers/ensure- -ephi-hipaa-compliant/

Use and Disclosure The HIPAA version of a medical release.
Could also list who can be disclosed to on intake form. This is a specific, HIPAA form. Allows the patient to list who can be disclosed to and what can be disclosed. Can also restrict disclosures here.

Do you market to your database?

Privacy Rule: Marketing
The Privacy Rule defines “marketing” as making “a communication about a product or service that encourages recipients of the communication to purchase or use the product or service.” Applies to marketing sent to your database only. “An arrangement between a covered entity and any other entity whereby the covered entity discloses protected health information to the other entity, in exchange for direct or indirect remuneration, for the other entity or its affiliate to make a communication about its own product or service that encourages recipients of the communication to purchase or use that product or service.” professionals/privacy/guidance/marketing/

Marketing versus Education
Requires authorization Is a third-party paying for the communication? Are you trying to get a patient to purchase an item or service? Are you “marketing”: Price Product Promotion

Marketing versus Education
Does not require authorization. Talks about technology, not product No mention of specific products or price. No promotions.

Privacy Rule: Marketing Decision Matrix Poll
Do you co-op marketing with a third-party? Are you an equity member of a buying group whose products you market? Do you have a lease or loan from a third-party vendor? Do you have a business development fund for products you market? Do you go on vendor-funded trips? Do you offer discounts, promotions, offers, or discounts? Do you participate in Medicaid, Medicare, Worker’s Compensation, or TriCare?

Long Form vs. Short Form Marketing Authorization
No remuneration, in cash or in kind, exchanges hands in any form for products you market. You pay for all of your own marketing communications, in full, that are sent to your database. Example: By initialing this section and signing below, I authorize _________________________ to send me educational and/or marketing information on the products and services offered by ____________________________. No remuneration is involved in this communication. I understand that I may revoke this authorization, in writing, at any time.

Long Form vs. Short Form Marketing Authorization
Remuneration, in cash or in kind, occurs regarding a product or service you are marketing. The vendor is paying in whole or in part for the communication. One page document.

Omnibus Rule Effective September 23, 2013.
Business associates (any entity that creates, receives, maintains, or transmits PHI on behalf of a provider who supplied this information to them) and their contractors and subcontractors, are required to comply to the updated HIPAA Privacy and Security Rules, including breach notification. Patients have the right to request that a copy of their electronic medical record be supplied to them in an electronic format. regulations/combined-regulation-text/omnibus-hipaa- rulemaking/

Omnibus Rule Patients who are paying privately for an item or service have the right to restrict any disclosure about this item or service to their health plan. “Marketing” has been redefined as any patient communication where the provider receives financial remuneration from a third-party whose products or services are being marketed. When “marketing” is being performed using PHI, a patient authorization must be in place prior to sending this marketing communication. The sale of PHI is prohibited. There must be a defined breach notification process where a situation is presumed to be a breach until the provider, business associate, contractor, or subcontractor determines that there is a low probability that the patient’s privacy has been compromised. A risk assessment must be performed anytime there is a breach of PHI.

Omnibus Rule Allows for broader use of PHI for fundraising opportunities. Allows for a streamlined authorization process for use of PHI for research purposes. Penalties have increased to up to $1.5 million maximum per calendar (many fines range between $100 and $50,000 per violation and degree of culpability) and up to 10 years in jail.

What Every Practice Needs:
2013 or newer revised Notice of Privacy Practices 2013 or newer revised Business Associate Agreement 2013 or newer revised Breach Notification Policy 2013 or newer revised Marketing Authorization Providers with individual NPIs Facility NPI Use and Disclosure form Acknowledgement of Receipt of Notice of Privacy Practices Can be added to your intake form. Security Policy and Process Breach Notification Policy and Process

What Every Practice Needs:
Risk Assessment Process for breaches. Independent Contractor Agreement that includes HIPAA Language Documentation of Staff Training Employee Confidentiality Form

Do you still feel as though you are HIPAA complaint?

Office of the Inspector General
Also known as OIG. They are the “policemen” and “auditors” of Medicare and Medicaid.

We Are NOT Immune…. materials/2016/takedown.asp facilities.pdf /05/13/lovelace-et-al.pdf

The Importance of Codes of Ethics
Please be aware of : The ethical guidelines outlined in your State licensure law. Failure to comply can result in the loss of your license. Ignorance is not a defense. The Codes of Ethics of organizations which you are a member. Failure to comply can result in you being removed from this organization and/or losing your credentialed status. Also, some of the aspects of a Code of Ethics can also protect you from violating legal statutes, laws, rules, or regulations.

Professional Codes of Ethics
AAA deofethics.aspx ASHA

Ethical Quandary? Would you feel comfortable telling your patient about your: Vendor funded trip? May have OIG implications. Business Development Fund? Vendor Payment Arrangement? Gifts from vendors?

Would you feel comfortable if you patients knew of these types of relationships?

Ethical Practice Guidelines on Financial Incentives from Hearing Instrument Manufacturers
Created by AAA and ADA in 2003 and updated by AAA in July 2011. web.s3.amazonaws.com/migrated/ _EPC_I ndustryGuideline.pdf_5382ed0f4cb pd f Arrangements you must avoid: Prid Pro Quo An exchange of goods or services where one transfer is contingent on another.

Ethical Practice Guidelines on Financial Incentives from Hearing Instrument Manufacturers
Conflicts of Interest Ownership interests in company’s whose products you dispense. Disclosure of any commercial interests to patients. Disclosure of consulting relationship to patients. Acceptance of gifts of any value from manufacturers. Disclosure of remuneration for research. Incentive trips (rewarded for conducting business). Business Development Funds. Lease arrangements. Cash rebates. Sales quotas with manufacturer in order to receive an incentive.

When Ethics Violations Can Turn Into Legal Problems
Anti-Kickback legislation: education/roadmap_web_version.pdf Criminal penalties. It is a felony to knowingly and willfully solicit or receive any remuneration, directly, or indirectly, overtly or covertly, in cash or in kind, in return for purchasing, leasing, or(or recommending the purchase, lease, or ordering ) of any item or service reimbursable in whole or in part under a federal health care program. Medicare Medicaid Tricare They create an incentive to overutilize particular goods and services, impinge upon the patient care process, and create an unfair competitive environment to those who refuse to provide remuneration.

When Ethics Violations Turn Into Legal Problems
Some examples from Audiology An audiologist furnishes hearing tests to a physician’s patients at less than fair market value (or free) in exchange for hearing aid referrals where some of these referrals may be for instruments covered under a Federal health program. When an audiologist purchases X number of products and gets X free from a manufacturer and bills a federal payer for any of these products once they have been provided to the patient and does not disclose the “buy one, get one” deal

What Can I Give Patients?
Anything that is less than $10 in value per item or less than $50 per year. andInducements.pdf and-potential-referral-sources/ referral-sources-and-patients.html

What Can I Give Physicians?
Gifts of “nominal value” (although they do not define this). It is better to give nothing! referral-sources-and-patients.html and-potential-referral-sources/

What Gifts Can I Receive from Industry?
Nominal value only. Education is allowed. html referral-sources-and-patients.html

Relationships to Vendors
Sunshine Act: The Sunshine Act requires manufacturers of pharmaceuticals, medical devices, biological and medical supplies covered by Medicare, Medicaid or SCHIP to collect, track and report all financial relationships with physicians and teaching hospitals to CMS. sunshine-act-means-for-health-care-transparency/272926/ There, as a result, is precedent in health care.

Relationships to Vendors
Is your relationship with the vendor benefiting: The patient or consumer? Your business or practice? You, personally? The vendor? We all need to be more careful and aware of these relationships and have them vetted by our own, personal legal counsel.

As a result you want to avoid: Free hearing tests Providing free hearing tests when you are a Medicare provider appears to be a clear violation of Medicare rules and regulations. Medicare prohibits offering free services such as hearing testing as an inducement to generate other services such as diagnostic audiologic services. ology-medicare-prohibitions-FAQs/ You need your own legal counsel to help you work through the ramifications of providing free testing given your specific situation.

Use of referral pads. Write-offs of co-pays and deductibles. Unless meets established, documented indigent policy. Reminder mailing for annual hearing tests where you are seeking third-party coverage. All could be construed as a solicitation of a Medicare covered service.

Anti-Kickback “Section 1128B(b) of the Social Security Act (42 U.S.C a-7b(b)), previously codified at sections 1877 and of the Act, provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit or receive remuneration in order to induce business reimbursed under the Medicare or State health care programs. The offense is classified as a felony, and is punishable by fines of up to $25,000 and imprisonment for up to 5 years.” This provision is extremely broad. The types of remuneration covered specifically include kickbacks, bribes, and rebates made directly or indirectly, overtly or covertly, or in cash or in kind. In addition, prohibited conduct includes not only remuneration intended to induce referrals of patients, but remuneration also intended to induce the purchasing, leasing, ordering, or arranging for any good, facility, service, or item paid for by Medicare or State health care programs.

When Ethics Violations Turn Into Legal Problems
False Claims Act Criminal penalties. downloads/SMDL/downloads/SMD032207Att2.pdf Do not submit fraudulent claims to any entity. Claims for services not performed. Including hearing aids that have not yet been dispensed. Billing under someone else’s provider number.

False Claims Act Upcoding
Billing for a comprehensive test when all you did was air conduction. Billing for a comprehensive test and not adding a modifier when you only tested one ear. All codes but imply two ears were tested. 52 modifier Billing for services known to not be covered and not adding the appropriate modifier. Hearing aids. Aural rehabilitation. Evaluation and Management codes. GY Modifier

False Claims Act Submitting claims for services which were not medically necessary and not adding the appropriate modifier. Annual hearing tests. Tests solely for the sale of a hearing aid. Presence of a physician order does not guarantee medical necessity. GY Modifier

FDA Requirements Requirements:
R/CFRSearch.cfm?fr= FRSearch.cfm?FR= Receive a User Brochure Medical Clearance or Medical Waiver Needed for each fitting of a child under the age of 18 years of age. If over 18 years of age, may sign a medical waiver. The FDA will NOT be policing the lack of use of a medical waiver. Either needs to be in FDA language.

FDA Requirements “The U.S. Food and Drug Administration today (December 7, 2016) announced important steps to better support consumer access to hearing aids. The agency issued a guidance document explaining that it does not intend to enforce the requirement that individuals 18 and up receive a medical evaluation or sign a waiver prior to purchasing most hearing aids. This guidance is effective immediately. Today, the FDA is also announcing its commitment to consider creating a category of over-the-counter (OTC) hearing aids that could deliver new, innovative and lower-cost products to millions of consumers”. m htm

FDA Requirements Many state laws reference the FDA Referral Red Flags:
Active drainage within previous 90 days. History of sudden or rapidly progressive hearing loss. Unilateral hearing loss. Conductive hearing loss or air-bone gap. Impacted cerumen or foreign body in the ear canal. Pain or discomfort. Visibly congenital or traumatic deformity of the ear. Acute or chronic dizziness.

FDA and State Dispensing Laws
Just because the FDA has indicated that they will not enforce the medical waiver or medical clearance requirement does NOT mean that your state will immediately remove it from your state dispensing laws. It is IMPORTANT that, before you discontinue use of the medical clearance and medical waiver for adults, that you contact your state dispensing and/or audiology licensure boards and determine if the requirement remains in your state.

When in Doubt… Hire legal counsel which specializes in health care and/or Medicare law. Do not enter into contractual relationships with others parties, including physicians, healthcare facilities, buying groups, or management services, without legal advice. Can find an attorney via your state bar association or Google.

The Role of State Licensure
It is this that dictates your scope of practice. National Associations do not dictate this. Payers do not dictate this. Payers do not have to cover all items and services in your scope of practice. YOU cannot interpret this alone. It is very important that you are aware of the requirements of both the hearing aid and/or audiology licensure boards in your state and the scope of practice limitations.

The Role of State Licensure
Audiology Assistants, Technicians, and Support Staff. Cannot perform testing on Medicare beneficiaries and legitimately receive payment. Be careful of: Scope of practice issues. Lack of licensure. You may be allowing them to practice audiology without a license.

Managed Care Terms Accountable Care Organization (ACO): A healthcare payment model that seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of patients; care is typically directed and managed by the PCP, similar to that of an HMO. Allowed Charge (approved charge, allowable): Payment for an item or service under the customary and current system outlined on the payer fee schedule; inclusive of the payment from the primary payer, secondary payer, deductible, co-pay and co-insurance.

Managed Care Terms Alternative Payment Model (APM): APMs give Medicare and Medicaid new ways to pay health care providers for the care they give Medicare beneficiaries. The programs are based upon cost savings, patient outcomes, and quality. Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. Appeal: A request for a health insurer or plan to review a coverage decision or payment again.

Managed Care Terms Assignment of Benefits: A procedure where the member/beneficiary authorizes the payer to make payment of allowable benefits directly to the rendering provider. Bad Debt: The amount that a practice must write off due to a patient’s failure to meet their financial responsibilities. Balance Billing: Billing the patient for any amount in excess of the allowed by the payer; billing the difference between what the payer allows and your usual and customary rate to the patient. Beneficiary: A person eligible to receive benefits under a health plan; the insured.

Managed Care Terms Benefits: The health care items or services covered under a health insurance plan. Billed Charges: The amount the provider bills to the payer for a specific item or service; same as “submitted charges.” Bundled Payments: payers compensate providers with a single payment for an episode of care, which is defined as a set of services delivered to a patient over a specific time period. This model aims to incentivize providers to improve care coordination, limit costly and unnecessary services, and reduce variations in care not tied to patient care quality and outcomes. By providing one single payment for various providers, bundled payments seek to promote a team- based approach to care.

Managed Care Terms Bundling: Billing for multiple, distinct items or services to a payer under a singular code. Care Coordination: The organization of your treatment across several health care providers. HMOs and ACOs are common ways to coordinate care through a PCP. Carrier: The insurance company which writes and administers the health insurance policy; the payer. Claim: A demand to the payer, by the patient, for payment of benefits under an insurance policy. Clinical Improvement Activity: An activity associated with care coordination, beneficiary engagement, healthcare system efficiency, beneficiary access and patient safety. Co-insurance: A provision of an insurance plan by which the beneficiary shares in the cost of certain covered expenses with the payer on a percentage basis; cost-sharing.

Managed Care Terms Coordination of Benefits: A provision in an insurance plan that, when a patient has coverage by multiple insurance plans, benefits paid by all of the plans will never exceed 100% of the usual and customary fee. Co-payment: The provision of an insurance plan by which the beneficiary is required to pay a fixed portion of the cost of their healthcare expenses. Contractual Adjustment: The difference between your usual and customary fee and the amount allowed by the payer; same as “write-off.” Credentialing: The process by which managed care organizations and payers determine that a provider is competent to provide services to their beneficiaries.

Managed Care Terms Customary Charge: The provider’s standard charge for a given item or service. Date of Service: The date the service is performed or the item is dispensed. Deductible: A stipulated amount which the beneficiary must pay toward the cost of their healthcare before the benefits and coverage of the plan go into effect; usually a set dollar amount that must be satisfied within a given calendar year. Discount Benefit: This is a benefit that negotiates discounts for their members for non-covered items or services. There is no third-party coverage in this instance. This is the same as an unfunded benefit.

Managed Care Terms Durable Medical Equipment (DME): Equipment, items, goods, and supplies ordered by a health care provider for everyday or extended use; a cochlear implant and hearing aid are considered to be DME by some payers. Electronic Claim: A claim form completed, processed, and transmitted from one computer to another. Electronic Medical Record (EMR): A computerized, digitally stored and transmitted medical record. Eligible Expenses: Same as “allowable” and “negotiated rate.”

Managed Care Terms Explanation of Benefits (EOB): A form included with your payment/denial from the payer which explains the specifics of coverage, denial and/or payment for a specific patient for a given date of service; it also outlines the patient’s financial responsibilities. Excluded services: Health care items and services that a health insurance plan doesn’t pay for or cover; same as “non-covered service.” Exclusions: Specific services or conditions which the insurance policy will not cover or which are covered at a limited rate. Fee for Service: Refers to reimbursing healthcare providers for the individual items and services provided.

Managed Care Terms Fee Schedule: The fixed dollar amount which is billed or allowed for a specific item or service. Funded Benefit: This is a benefit where a third-party payer is paying in whole or in part of a given item or service. Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO; care is usually coordinated by a PCP.

Managed Care Terms Incident to: Services defined as are defined as services or supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness. These services are furnished under the supervision of the attending physician and, as a result, billed under the NPI of this physician as the rendering provider. In-Network (participating): The provider has been credentialed by a specific payer and has agreed to the terms of their payer agreement/contract; the provider must accept the allowable as payment in full.

Managed Care Terms Insured: The individual who represents the family unit in in relation to the insurance benefits and coverage; usually the employee who holds the insurance provided by their employer. Insurer: Payer. Medicare Access & CHIP Reauthorization Act of 2015 (MACRA): MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes: Create Quality Payment Program (QPP) End the Sustainable Growth Rate (SGR) formula for determining Medicare reimbursement for provider services. Create a new system for rewarding health care providers for giving better, more affordable care and producing better outcomes and eliminate the incentives for providing more care and services. Combine the existing quality reporting programs into one new system.

Managed Care Terms Medically Reasonable and Necessary: Health care services, items, or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine. Member: Same as “beneficiary.” Merit-Based Incentive Payment System (MIPS): MIPS is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Based Modifier (VM) and the Electronic Health Record incentive program into a single program in which eligible professionals will be measured on defined metrics. Audiology is ineligible for MIPs in 2017.

Managed Care Terms Negotiated Rate: Same as “allowable” and “eligible expenses.” Network: The facilities, providers, and suppliers a health insurer or plan has contracted with to provide health care services and care. Non-Covered Service: An item or service that is not a covered benefit under a specific insurance plan; same as “excluded services.” Order: A request from one healthcare provider to another healthcare provider requesting that they perform a specific item or service to a given patient; same as “referral” or “prior authorization.”

Managed Care Terms Organization Predetermination: The Medicare Advantage process of advanced beneficiary notification. This process varies payer by payer and must occur prior to the provision of care. Out of Pocket Expense: Limitation on the amount a beneficiary must contribute to their healthcare costs in a given year; can affect co-insurance. Out-of-Network: The provider has not been credentialed by a specific payer and has not agreed to accept the terms of the payer agreement/contract; can bill the patient your usual and customary rate; patient’s coverage and benefits often reduced.

Managed Care Terms Patient Centered Medical Home: The patient centered medical home (PCMH) model facilitates the coordination of care through a patient’s primary care physician. The PCMH model integrates mental health and specialty services, and involves a team-based approach consisting of physicians, nurses and medical assistants, pharmacists, nutritionists, social workers and care coordinators. Right now, this model is primarily being applied to chronic care conditions such as diabetes and cardiac care. Patient Responsibility: The amount the patient owes for a given item or service once the payer has processed the claim.

Managed Care Terms Pay for Performance (P4P): This is a term used to refer to those payment models aimed at improving the quality, efficiency and the overall value of health care. In P4P arrangements, providers are reimbursed based on whether they achieve a pre- determined set of quality metrics. Payable Amount: The amount paid by the payer for a given item or service; excludes co-insurance, co-payments and deductibles. Predetermination: The process of obtaining a written estimate of what a payer will pay for specific items and services before the item is dispensed or the service is performed; not a guarantee of payment.

Managed Care Terms Primary Insurance: The payer who has the primary responsibility for payment under the coordination of benefits provisions of the patient’s insurance agreement. Prior Authorization: A requirement by the payer that coverage for a given item or service is dependent on the item or service being approved by the payer or another healthcare entity before the item or service is provided to the beneficiary. Provider: The individual who provides items and services to beneficiaries.

Managed Care Terms Referral: Same as “order.”
Secondary Insurance: The payer who has the secondary responsibility for payment under the coordination of benefits provisions of the patient’s insurance agreement. Submitted Charges: Same as “billed charges.” Third-Party Administrator (TPA): A middle-man between the provider and the payer/employer group who negotiates discounts, coverage, and benefits for the payer/group and administers the benefit offerings. Unbundling: The process of coding, billing, and requesting payment for items and services that are typically billed under a single procedure code.

Managed Care Terms Unfunded benefit: The payer has negotiated a discount program for its members but does not pay any payment towards the costs of items or services. This is the same as a discount benefit. Utilization Review: The process of reviewing items and services provided by a specific provider or facility to determine if the items and services provided were reasonable and necessary; a provision included in most third-party contracts. Verification: The act of predetermining eligibility, coverage, and benefits for a specific patient for specific items and services. Write-Offs: The amount that is not paid by the payer but cannot be billed to the beneficiary; same as “contractual adjustment.”

Have you read all of your managed care contracts?

Coverage versus Reimbursement
Coverage is when a third-party is paying all or part of the cost of the item or service. Lack of coverage does NOT mean a lack of reimbursement. Reimbursement is when you, the provider, receive payment for the cost of the item or service. WE NEED TO CARE MORE ABOUT REIMBURSEMENT AND LESS ABOUT COVERAGE!

Facts Other than Medicare, you are a VOLUNTARY participant in managed care. Participation is a business decision. Must be credentialed before you can bill a payer as an in- network provider. Otherwise, you are an out-of-network provider and patient should pay in-full for any item or service they receive on the date the item or service is provided. The patient should be informed of your network status (as it pertains to their insurance) prior to making an appointment and be informed of their financial obligations.

Medicare Enrollment Audiologists CANNOT opt out of Medicare.
Need enrollment as an individual (855-I) and practice (855- B). Must have an NPI, license, and address before proceeding with enrollment. Can enroll online through: Best way to enroll; avoid paper applications. Read the tutorials

What Is the Medicare Opt Out?
You enter into private contracts with Medicare beneficiaries for Medicare covered services. Services will not be covered by Medicare. Collect payment from patients. You do not file claims to Medicare. Opted out for two years Certification/MedicareProviderSupEnroll/OptOutAffidavits.html Audiologists cannot opt out!

Medicare Enrollment Determined on 855-R. Options Participating:
Accept Assignment. Listed in provider directory. Rolls-over to secondary. Medicare pays 5% more.

Medicare Enrollment Non-Participating:
Accept assignment on claim by claim basis or charge patient limiting charge (115% of allowed amount). Patient pays provider on date of service. Patient receives 95% of Medicare allowed charge from Medicare/secondary payer. Typically does not roll-over to secondary carrier.

Medicare Enrollment Free Audiologists cannot opt out of Medicare.
If charge $X to one person, you must charge $X to all.

Medicare Enrollment Options
Par Non-Par who accepts assignment Non-Par who do not accept assignment (Limiting Charge) Billed Amount $125 $115 Medicare Allowed Amount $100 $95 80% of Medicare Allowed $80 $76 Beneficiary Co-Insurance $20 $19 Total Payment to Provider $115 (95 x 1.15 limiting charge); patient paid $20 difference

Medicare Revalidation
This is Medicare’s attempt to update your enrollment. ONLY do it online via PECOS at

Initial Steps to Contracting: Who?
Need to do a market analysis. What insurers represent the major employers in your area? What insurances do your referral sources and local hospitals accept? Some referral sources cannot, by contract, refer to out of network providers. What insurers offer lucrative hearing aid benefits?

Request Information Begin the process with a Google search.
Most payers have excellent websites that contain useful information regarding provider enrollment and guidance. Take a look at their provider manual or administrative guidance. You can often begin the application request/enrollment process directly from the payer website. Provider/healthcare professional section of the website.

Payer Reply Once your application/enrollment request is completed, you will receive a reply from the payer. This can include: Rejection: Closed Network. They can and do say “no.” Provider Agreement and Payer Fee Schedule.

Rejection Periodically, attempt to re-enroll if participation with this payer is lucrative for your business. Have data to illustrate how many of their members are seeking your services, how underserved your community is (if a patient has to drive more than 5 miles to see an in-network provider), or how your practices offers services or products not provided by other in-network providers (such as auditory processing, vestibular or tinnitus evaluation or management, pediatrics or implants).

Rejection Reach out to the human resources department of the employer providing these benefits to their employees. Have data to illustrate how many of their members are seeking your services, how underserved your community is (if a patient has to drive more than 5 miles to see an in-network provider), or how your practices offers services or products not provided by other in-network providers (such as auditory processing, vestibular or tinnitus evaluation or management, pediatrics or implants).

Rejection Have your patients advocate for your inclusion in the plan.
Encourage them to contact customer service or the human resources department of their employer.

Rejection Purchase a practice that is in-network with the payer in question.

CAQH Credentialing clearinghouse. Free. http://www.caqh.org/
To participate: Must be a contracted provider with a least one of the CAQH participating payers. Must be invited by CAQH once registered.

Receive Provider Agreement
Read the entire agreement and review the fee schedule. Things to consider: You want these answers IN WRITING ONLY! What products am I participating with: Medicare Advantage? Medicaid? HMOs? If Medicare Part C, what are the organizational pre-determination requirements? Does it allow for balance billing or patient upgrades for hearing aids? Is there a required waiver process? Does it require patients complete notices of non-coverage before non-covered services are provided? Can student externs or technicians see members of this plan? Can hearing aid dispensers see members of this plan? Can certain services be carved-out of the contract? What are the termination terms? Renegotiation terms? For hearing aids, am I required to supply a manufacturer’s invoice? What are the renewal terms? “Evergreening” of contract.

Receive Provider Agreement
Things to consider: You want these answers IN WRITING ONLY. How is medical necessity defined? What are the requirements for standard processes and procedures for all patients? What are the means of provider notification of substantive changes to the agreement? What are the requirements for standard fee schedule/charge master? What are the timely claims filing requirements? Are there any other claims filing requirements. Can I file paper claims? Are there clinic hour requirements? What are the medical record retention requirements? How does it address evaluation and management services provided by audiologists? Do they require hearing aid patients be referred to a third-party administrator for dispensing? Does the fee schedule address all of the items and services you provide? HCPCS and CPT How are unlisted codes processed?

Fee Schedule What the payer allows, per contract, for each specific item and service you provide for each specific product you are contracted to provide. Never accept less than you can afford. Need to know your breakeven plus profit amount per hour to properly analyze this. Do the benefits outweigh the costs? Be careful of: Inclusive hearing aid coverage benefits. Large hearing aid discounts (percentages of dollars billed). “Fitting fee only” or Invoice plus arrangements. Requirements to provide the manufacturer invoice. Sometimes you do not buy the aid in this equation. Sometimes it is a better business decision to be out-of-network providers as patients pay you in full on the date of service.

Third-Party Administrators
They exist to: Allow payers a single point of contact and payment for hearing aid related items and services. Defined risk for the payer. Cost containment for the member. An established standard of care for the member. Audiologists helped create the need for these programs and help maintain their existence through their participation.

Considering a TPA TPAs (third-party administrators) are becoming more and more prolific in the audiology space. Before you agree to join, please consider the following: Is the plan offering a funded or unfunded (discount) benefit? Is your practice bundle or unbundled? Can you create a competitive product offering? What is my responsibility in informing the patient of their benefits, either funded or unfunded? How many patients do you stand to potentially lose if you do not enroll in the program? What products does the plan offer? What if the member wants a product that is not in the program?

Considering a TPA Before you agree to join, please consider the following: Can I charge the patient or their healthcare insurer for a hearing test? What items and services are included in the fitting fee? If it is not included in the fitting fee, are their limits to what I can charge? Do I have to notify patients of these costs, in writing, upfront? Do I receive a greater fitting fee if I am a member of a specific buying group or membership organization? How long is the trial period? What do I receive if the patient returns the aids for credit? How long do I have to manage the patient for the fitting fee? Are their limits as to what I can charge for service outside of the fitting fee window?

Before You Initially Sign…
Make a copy of the entire contract and fee schedule and SAVE IT. Ask questions when you lack answers. Don’t sign until you get your answers! Do not be afraid to negotiate. The worse they can do is say “no.” What are the pros versus cons of contracting with each payer? If unsure of some of the contract terms, hire an consultant and/or attorney to review.

If You Have Already Signed: Renegotiation
It is NOT the payers responsibility to have a copy of your contract. If you cannot locate it, request, in writing, a copy of their current agreement and review any administrative guidance or provider manuals on their websites. Request, in writing, a copy of the current fee schedule.

Renegotiation Know what you want and defend why you deserve it.
Have a knowledge of your current agreement and your Medicare fee schedule for your area. Follow the guidance in the contract on termination but, instead of sending a termination letter, send a request for renegotiation. You must also be willing to walk away in negotiation or you have no power or leverage.

Renegotiation Follow the same contract evaluation process you would follow if you were signing up for the first time.

Non-Participation Again, other than Medicare, you are a voluntary participant in managed care. It is an option to not participate in third-party, managed care plans and be an out of network provider. In this situation, the patient pays in full on the date of service. Your office can submit claims to the payer as a courtesy to the patient. The patient is reimbursed, from the payer, their out of network benefits. You often see this in mental health, dental and optometry offices.

Two Separate Business Entities
This option is often selected when a practice has a large physician referral base or a large diagnostic practice. An option that many physician practices choose is to spin their hearing aid or auditory rehabilitative practice off into a separate business, with a separate legal structure and separate tax identification number. As a result, this second entity would not be encumbered by the managed care obligations of the original business. This new, second business could be strategically enrolled in various managed care enterprises, while avoiding those with poor coverage and benefits for treatment, including haring aids. This is becoming more common in audiology practices as well. In order to do this, you will need to hire an attorney and an accountant to evaluate this option for your situation and effectively and legally create this new business entity.

Billing 101: The Facts It is ALL about PROCESS and POLICIES.
Providers complete the testing, write the report, and fill out the superbill. Data is power!!! Complete a superbill (or OMS encounter) on every patient you see, even no-charge visits. Someone has to collect patient responsibility on the date of service. Billing costs YOU money!!! Office staff takes the superbill information, submits the claim, and monitors payment.

Billing 101: The Facts Claims should be posted within two business days. Payments should be posted daily. No one should be able to write-off sums over $100 other than the manager or owner. Stop seeing patients who owe you money.

Billing 101: The Facts You must invest in staff training and materials. Office management or billing software. The days of paper claims are almost over! Manuals. You will have to make an investment in ICD-10. Training. You must have consistent, no-exceptions financial policies STOP GIVING IT AWAY!! Should be in writing and available.

Billing Checks and Balances:
Owners and managers, regardless of your work setting, must monitor accounts receivable (especially that outside of 90 days) and accounts payable. Monthly, at a minimum. Collect patient responsibility on date of service.

How You End Up in Insurance Hell
YOU put yourself there, not the Insurer! You do not ask the right questions at scheduling and intake. You sign ANYTHING without reading or negotiating it. You do not have a working knowledge of the agreement YOU agreed to. You do not verify an individual patient’s coverage and benefits EVERY time. You insist everyone needs top of the line products.

How You End Up in Insurance Hell
YOU put yourself there, not the Insurer! You insist on remaining in a bundled delivery model. You do not charge patients privately for non-covered services and to notify them in writing of their out of pocket expenses. You do not collect patient responsibility (co-pays, deductibles and co-insurance) at the time of the visit.

How Do You Get Out of Insurance Hell
Have a strong scheduling and intake process. Run your practice like your dentist, optometrist, chiropractor, or podiatrist runs theirs. All business is not good business. Third-party administrators exist because you sign up. KNOW your contracts! Nothing is free! Collect payment at time of visit. Fit the patient, with something audiologically appropriate, within their benefit.

Third-Party Coverage Know the terms of your third-party contracts and fee schedules. Good reimbursement begins and ends with you. Starts from the minute the patient calls. Accountability is key. Verification is required EVERYTIME! Have to ask the right questions. Hearing aids. BAHA. Cochlear implants.

Third-Party Coverage Third-party coverage of diagnostic and hearing aid services is the result of an agreement between the PATIENT and the INSURER. Sometimes patients have out of pocket expenses and financial responsibility for non-covered or denied coverage for services. Sometimes the fight for payment is a fight between the patient and the payer and NOT you!

Insurance Verification
KNOW YOUR CONTRACTS!!! Do as much as possible online. Who did you call? At what number? Do they have a reference number?

Who did you call? At what number? Do they have a reference number? Is the benefit or discount only available through a specific third-party administrator? Does the patient have a hearing aid benefit? Allowance? Can the patient have out-of-pocket expense? Can they upgrade? Is this a funded (the payer is covering all or a portion of the costs of the device) or unfunded (discount) benefit? Do they have out-of-network benefits? (You ask this if you are an out-of-network provider). What services are covered? Literally, provide the codes 92591, 92593, 92595, V5011, V5020, and V5160. Are they eligible today? Know your deductibles! They can sometimes be larger than the cost of the hearing aids.

What are the coverage/benefit specifics? Does the HL have to be related to accident., illness or injury? Is this an inclusive benefit? Does the benefit include all services related to the evaluation and fitting of the device? How frequent? X number of months or years Dollars? A fixed defined dollar amount or an “up to” amount “Up to” generally means your allowable fee for the device itself

So I Verified Benefits? Now What?
You must treat managed care patients as you would treat a private pay patient. The date you bill is the date you fit! Date of service is the day the item is dispensed or the service is provided. Can the patient upgrade? If no, you must fit within the benefit. Itemization can help in these situations. If yes, you need to offer them a product within their benefit. If they choose to “upgrade”, then they need to be notified in writing, prior to fitting, of the fact that they could have received a product at no-charge (except for co-pays, co-insurance and deductibles) but, instead, they have opted to upgrade and their financial responsibility is X. Is it an “up to” benefit or a fixed dollar amount? “Up to X” does not mean “X” Fit a entry level product. You will need to fit within the benefit.

If the patient does NOT have an inclusive hearing aid benefit, consider unbundling the charges, even if you remain bundled to your private pay patients, as it may push about $ to patient responsibility. You unbundled total needs to equal your bundled total. Restrict the level of product provided. If a carrier states that they pay a “maximum of x dollars” or “up to” X dollars but do not specifically define a benefit amount, assume the $500 rule as, on many occasions, they will not actually pay the maximum (the maximum would typically apply to a digital CIC). “Up to X” does not mean you will receive “X” It means they cover the allowable rates.

Hearing Aid Verification Scenarios:
Scenario 1: You contact the third-party payer and complete the insurance verification form in full. Per the third-party payer, you are allowed to balance bill the patient for the difference between the insurance coverage/allowable amount and the your usual and customary charge. This one is easy!

Scenario 2: You contact the third-party payer and complete the insurance verification form in full. Per the third-party payer, you are not allowed to balance bill the patient for the difference between the insurance coverage/allowable amount and your usual and customary charge. You must restrict product cost to an aid whose invoice cost is less than $ per aid maximum. The patient has no out-of-pocket expense in this scenario (except for unmet co-pays or deductibles). You must accept the negotiated rate as payment in full.

Scenario 2: Continued I strongly encourage you to be honest with the patient about the situation (i.e. “the negotiated rate is less than my cost for more advanced products”). The patient then has four options: Get a more basic hearing aid paid in full by their third-party payer. This is what most patients prefer. Refer the patient to a third-party administrator you are contracted with that IS a contracted provider for this plan, is allowed to bill the funded portion of their plan, and is also allowed to balance bill the patient. Go elsewhere and try to find another provider who will do this for them (in many cases out of network providers would be allowed to balance bill the patient). Have the patient sign a completed insurance waiver. In this case, they are waiving their insurance coverage and you, as the provider, will not be submitting a claim to their carrier. Please ensure that the patient gets an original copy of their bill or sale and the insurance waiver in the event they attempt to bill their carrier themselves. If the patient proceeds with the first bullet, the patient should pay any co-insurance amounts (based upon usual and customary rates) and deductible amounts (up to the usual and customary cost of the aids) on the date of the fitting.

Scenario 3: You contact the third-party payer and complete the insurance verification form in full. The carrier states that either the dispensing fee and/or hearing aid evaluation can be billed as a separate charge and/or they request that the claim be submitted unbundled. The patient should also pay any co-insurance amounts (based upon usual and customary rates) and deductible amounts (up to the usual and customary cost of the aids) on the date of the fitting. You need to unbundle the cost of the hearing aid in this situation. You can unbundle differently for different payers, based upon what is allowed in each contract, as long as the total package always equals the same amount!

Scenario 3: Continued Hearing aid (V5…)
Dispensing Fee (V5…, if allowed) Hearing aid evaluation (92590/1) Hearing aid check (92592/3) Electroacoustic analysis of aid (92594/5, if performed) Fitting and Orientation of aid (V5011) Conformity Evaluation (V5020, if performed) Earmold, if applicable (V5264) or dome (V5265) Earmold Impression, if applicable (V5275) Batteries (V5266) Accessories (V5267, if provided)

When Dealing with Hearing Aids in a Third-Party World, Please Consider:
The insurance verification form and process is completed prior to the hearing aid evaluation. If possible, the insurance information should be gathered at the time the hearing aid evaluation is scheduled. Please also make sure that the patient pays all outstanding deductibles, co-pays, and percentages of responsibility on the date of fitting, as well as any patient responsibility they may have. You want to be in a position to refund money and not trying to collect outstanding monies from the patient. These are all of the monies you can collect on the date of order or fit if you are an in- network provider. Do not discount hearing aids billed to third-party carriers. Have all marketing provide a disclaimer to this effect. You must get your cost of goods as low as possible. No manufacturer is irreplaceable.

Billing Hearing Aids via Third-Party Administrators
They each have their own processes. The general process is this: TPA refers patient to your practice. Your practice sees the patient and recommends amplification. You fax, or submit via their portal the required paperwork to order and/or acknowledge fitting of the device. The TPA pays for the device and, often, the earmold, if needed. After the end of the trial period, you are paid a fitting fee. You manage the patient, at no additional cost to the patient or the plan, for a fixed time period or number of visits.

The Down Low on Waivers/Patient Notification
CANNOT USE IF NOT ALLOWED BY CONTRACT!!! Otherwise, you will be in violation and, if a patient pushes back, you will have to refund them. Do they recognize S1001? Patient Notification Use to notify and bill patient for non-covered services.

The Down Low on Waivers/Patient Notification
Upgrade Waiver BCBS. Must provide an aid (standard) at no-charge to patient . Patient can upgrade if they so choose and pay the difference between the allowable and usual and customary.

The Down-Low on Waivers/ Patient Notification
Insurance Waiver Patient waives their insurance benefit. They do not bill their insurance and you do not bill their insurance. Rarely happens.

CMS 1500 Resources http://www.nucc.org
health-care-cms-1500-claim-forms-are-changing/ Guidance/Guidance/Manuals/downloads/clm104c26.pdf

CPT Basics CPT is the acronym for Current Procedural Terminology.
CPT is a listing of codes and their descriptions that outline medical services and procedures. CPTs are added, deleted, and modified annually (first Monday in November) by their creator, the American Medical Association. As of October 2003, HIPAA requires that all insurance carriers, including Medicare and Medicaid, use CPT codes. CPTs are five digit, numeric codes. Most codes that apply to audiology begin with the numbers 92xxx. Audiology can be involved in this code creation through ASHA and AAA.

Vestibular Testing: Without Recording
92531: Spontaneous nystagmus, including gaze 92532: Positional nystagmus test 92533: Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests) 92534: Optokinetic nystagmus test Non-covered by Medicare

Vestibular Testing: With Recording
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 or peripheral stimulation, with recording, and oscillating tracking test, with recording 92541: Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording 92542: Positional nystagmus test, minimum of 4 positions, with recording 92544: Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording 92545: Oscillating tracking test, with recording Add the -59 modifier if bill two or three of 92541, 92542, 92543, or on the same patient on the same date of service.

Vestibular Testing with Recording
Both replace in 2016. 92543 was eliminated. 92537: Caloric vestibular test with recording, bilateral; bithermal (i.e. one warm and one cool irrigation for each ear for a total of four irrigations) Add -52 modifier if only perform three irrigations and -22 modifier if perform more than four irrigations 92538: Caloric vestibular test with recording, bilateral; monothermal (i.e. one irrigation in each ear for a total of two irrigations) Add –52 modifier if only complete one irrigation

Vestibular Testing: With Recording
92546: Sinusoidal vertical axis rotational testing NOT for vHIT or headshake 92547: Use of vertical electrodes (List separately in addition to code for primary procedure) ENG only (except Florida MAC) 92548: Computerized dynamic posturography

Audiology Codes 92551: Screening test, pure tone, air only
92552: Pure tone audiometry (threshold); air only 92553: Pure tone audiometry (threshold); air and bone 92555: Speech audiometry threshold 92556: Speech audiometry threshold; with speech recognition 92557: Comprehensive audiometry threshold evaluation and speech recognition (92553 and combined) Add 59 modifier if bill two of 92552, 92553, 92555, or on the same patient on the same date of service.

Immittance Codes 92550: Tympanometry and reflex threshold measurements
92567: Tympanometry (impedance testing) 92568: Acoustic reflex testing, threshold 92570: Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing Reflex thresholds should be established both ipsilateral and contralateral test conditions at at least two to three frequencies

CAPD Codes 92620: Evaluation of central auditory function, with report; initial 60 minutes 92621: Evaluation of central auditory function, with report; each additional 15 minutes Need to have spent 31 minutes or more to bill 92620

CAPD Codes 92571: Filtered speech test
NOT for QuickSIN or speech in noise testing 92572: Staggered spondaic word test 92576: Synthetic sentence identification test Code individually only when performed in isolation. Is still in PQRS measures?

Pediatric Codes 92579: Visual reinforcement audiometry (VRA)
“Is a test technique that can be performed using either loudspeakers or earphones, which uses flashing lights, moving toys, or video to reinforce a head-turn response to sound stimuli, and it may be used with either tonal or speech stimuli” Four frequencies The procedure is repeated with speech, warble tones, narrow tone noise, and frequency specific noisemakers 92582: Conditioning play audiometry “Is a test technique in which the patient is taught a game that requires a response to tonal stimuli. A variety of play responses can be used with CPA, such as dropping a toy in a container or putting pegs in a board. It is typically done using earphones.” 92583: Select picture audiometry These are NOT method codes. Is still in PQRS measures?

Evoked Potential Codes
92516: Facial nerve function studies (e.g. ENoG) Can be billed “incident to” 92584: Electrocochleography (e.g. ECoG) or for CI NRT 92585: Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive 92586: Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited

OAE Codes 92558: Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis 92587: Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3–6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report 92588: Comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report

Hearing Aid Codes 92590: Hearing aid examination and selection; monaural 92591: Hearing aid examination and selection; binaural 92592: Hearing aid check; monaural 92593: Hearing aid check; binaural 92594: Electroacoustic evaluation for hearing aid; monaural 92595: Electroacoustic evaluation for hearing aid; binaural

Cochlear Implant Codes
92601: Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming 92602: Diagnostic analysis of cochlear implant, patient under 7 years of age; subsequent reprogramming 92603: Diagnostic analysis of cochlear implant, age 7 years or older; with programming 92604: Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming Add 59 modifier if performed on the same day at

Audiology Codes 92575: Sensorineural acuity level test
In some PQRS measures 92596: Ear protector attenuation measurements 92625: Assessment of tinnitus (includes pitch, loudness matching, and masking) 92626: Evaluation of auditory rehabilitation status; first hour 92627: Evaluation of auditory rehabilitation status; each additional 15 minutes (List separately in addition to code for primary procedure) 92630: Auditory rehabilitation; prelingual hearing loss 92633: Auditory rehabilitation; postlingual hearing loss 92640: Diagnostic analysis with programming of auditory brainstem implant, per hour

Other Audiology Related Codes
69209: Removal of impacted cerumen using irrigation/lavage, unilateral 69210: Removal impacted cerumen, with instrumentation, unilateral Technically, a surgical code While can be billed with a -50 modifier, it typically only is reimbursed as one unit 95992: Canalith repositioning procedure(s), per day

99366: Medical team conference with interdisciplinary team of health care professionals, face to face with patient and/or family, 30 minutes or more, participation by non-qualified health care professional 99368: Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more, participation by non- qualified health care professional

96110: Developmental screening (e.g. developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.

Use of 92700 To classify procedures that do not have CPT codes.
Individually reviewed. ABN required. If reporting 92700, submit report with: Copy of Patient Report Description of procedure Clinical Utility of the Procedure Time Skills of Tester Equipment used Benefit to patient Usual and Customary Fee ABN Required or Voluntary?

Common Uses of 92700 VEMPs High-frequency audiometry
Sensory organization test Audiometric Weber Head shake testing Eustachian tube function testing Speech in noise testing Tinnitus management ASSR Removal of incidental cerumen Middle/late latency response Fistula testing Use of goggles VHit Saccade testing

Codes to Use with Caution
You need to ensure that you have actually performed the service. 92504: Binocular microscopy 92560: Bekesy audiometry, screening 92561: Bekesy audiometry, diagnostic 92562: Loudness balance test, alternate binaural and monaural 92564: Short increment sensitivity index

CPT Tips Always have the coding legitimately represent all of the procedures that were completed on each individual patient on a given date of service. Always ensure you actually performed the specific procedure billed. COVERAGE and PAYMENT does not mean COMPLIANCE. Make sure you are using the most up to date codes. Make sure you have a 2016 or newer CPT Manual in your office. It is legitimate to bill for attempted procedures with the appropriate documentation. Use modifiers when needed.

Modifiers -22: Increased procedural service -32: Mandated Service
Some examples to consider are threshold search ABR or functional hearing assessment (extensions of another procedure). -32: Mandated Service -33: Preventative service When billing for follow-up newborn hearing screening only.

Modifiers -50: Bilateral Procedure -52: Reduced service
Only tested one ear. Did not meet all of the components of a code. -59: Distinct Procedural Service Used in situations where you are unbundling parts of a bundled code. 92540 92552 Used when performing and 92626/7 on the same patient on the same date of service.

Modifiers -RT: Right ear -LT: Left ear
Only modifiers that can be used with HCPCS codes.

Modifiers -GA: Waiver of liability on file
Used when an ABN was completed for required reasons, such as the use of or the existence of a local coverage determination. -GY: Item or service statutorily excluded or does not meet the definition of a Medicare benefit. You want a Medicare denial. Used with –GX modifier only. -GZ: Item or service expects to be denied as not reasonable or necessary. Used when an ABN was required but not obtained.

Do you provide services outside your office setting?

Place of Service Codes These are two-digit codes placed on claims to indicate the setting in which a service was provided. You change your setting, you change your place of service code. Education/Medicare-Learning-Network- MLN/MLNMattersArticles/downloads/MM7631.pdf

Place of Service Code Examples
11: Office 12: Home 13: Assisted Living Facility 14: Group Home 15: Mobile Unit 21: Inpatient Hospital* 22: Outpatient Hospital* 31: Skilled Nursing Facility* 32: Nursing Facility 34: Hospice* 62: Comprehensive Outpatient Rehabilitation Facility** * The facility must submit the claim. Your practice will need a contract with the facility to provide care. ** Audiologic testing is non-covered by Medicare.

Home Visits You have to reflect the place of service as HOME (12).
If you provide diagnostic services in the home, certain, specific criteria must be met for Medicare COVERAGE. The patient needs to be homebound. Guidance/Guidance/Manuals/downloads/bp102c07.pdf

Skilled Nursing or Hospice
Medicare Part B coverage is dependent on the status of the patient, on the specific date of service, within the Medicare system. You also have to be careful if they are living in these facilities and are seen in your office. If they are covered within the Part A time frame, the facility must bill and receive payment from Medicare and the audiologist will receive payment from the facility. You will need a contract with the facility that outlines the responsible party.

Skilled Nursing or Hospice
Learning-Network- MLN/MLNProducts/Downloads/SNFSpellIllnesschrt.pdf Payment/SNFPPS/ConsolidatedBilling.html

Hospital OPPS Billing “Bundling” is the name of the game.
This is how many hospital outpatient claims are paid, but does not effect how they are billed. ment/2017-hospital-outpatient-prospective-payment- system-opps-final chedule/ HOPPS.pdf Certain services are not reimbursed separately if provided on the same date of service as other services. You are reimbursed a “package” price for a given date of service. The reimbursement can often be higher. This is also a system that is sometimes mandated by a payer.

Evaluation and Management Code Basics
These are the codes physicians and non-physician practitioners (such as nurse practitioners and physician assistants) utilize to bill for office visits. Per the CPT manual, these codes can be used by “qualified health professionals who are authorized to perform such services within the scope of their practice.” So, can an audiologist in your state “evaluate” and ”manage”? Only your state licensure board can determine that.

Evaluation and Management Code Basics
Common codes to be considered by audiologists are (new patient) and (established patient). Avoid and as inappropriate for audiologists as this level of code requires a high risk of morbidity and mortality (which otologic issues do not contain).

Evaluation and Management Codes: New Patient
99201 Requires these key components: a problem focused history, examination (screenings) and straightforward medical decision making. Usually, the presenting problem(s) are self limited or minor. 99202 Requires these key components: an expanded problem focused history, examination (screenings) and straightforward medical decision making. Usually, the presenting problem(s) are of low to moderate severity.

Evaluation and Management Codes: New Patient
99203 A detailed history, examination (screening) and medical decision making of low complexity. Usually, the presenting problem(s) are of moderate severity.

Evaluation and Management Codes: Established Patient
99211 May not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. 99212 Requires a problem focused history, examination (screenings) and straightforward medical decision making. Usually, the presenting problem(s) are self limited or minor.

Evaluation and Management Codes: Established Patient
99213 An expanded problem focused history, examination (screenings) and medical decision making of low complexity. Usually, the presenting problem(s) are of low to moderate severity.

The Do’s of E/M Confirm that your state licensure laws allow for evaluation and management services. Is it in your state defined scope of practice? Consult your payer contracts and fee schedules to determine if they allow for the use of E/M codes by audiologists. If they do not AND it is allowed by state licensure, can the patient be held financially responsible for the costs? They do not have to allow their use by audiologists.

The Do’s of E/M If you bill one payer for E/M codes, you must bill all payers and patients (including patients when non-covered, such as Medicare). Can have it solely apply to specific test scenarios only as long as it applied to every patient. Auditory prosthetic device candidacy Vestibular assessment Tinnitus evaluation CAPD evaluation You must meet the documentation requirements of E/M codes or you shouldn’t use them. Read the E/M section of your CPT Manual at: Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide- ICN pdf before proceeding.

The Don’ts of E/M Do not utilize these codes for hearing aid visits.
These are only for use in diagnostic test situations. Do not accept payment from traditional Medicare for these codes. Use these codes with caution if you work in an ENT or hospital setting. Risks can be great if billing two E/M codes from the same facility for the same patient on the same date of service.

Evaluation and Management Codes
New patient versus established patient: They are established if they have seen you or another audiologist in your practice within the last three years. Outpatient versus inpatient. Examination: Typically paid separately, except for the screenings. As a result, ignore the time designates on the code and focus on the complexity of the visit.

Type of history: problem focused, expanded problem focused, detailed, comprehensive. Chief complaint History of present illness (brief or extended) Review of systems (none, problem pertinent, extended, complete) Past, family, and/or social history (none, pertinent, complete)

Problem focused: Chief complaint Brief history of present illness or problem Expanded problem focused: Problem pertinent system review

Detailed: Chief complaint Extended history of present illness or problem Problem pertinent system review expanded to include a limited number of additional, appropriate systems Problem pertinent past, family, and/or social history Comprehensive: Review of all 14 body systems Complete past, family, and/or social history

Medical decision making: Straightforward, low complexity, moderate complexity, high complexity. Number of diagnoses or management options: minimal, limited, multiple, extensive. Amount and complexity of data to be reviewed: none, minimal, limited, moderate, extensive. Risks of significant complications, morbidity, or mortality: minimal, low, moderate, high.

Utilizing E and M Codes For evidence based evaluation and management beyond audiometric assessment. Consider applying them uniformly, but only to specific clinical situations such as: Vestibular assessment Auditory prosthetic device candidacy assessment Central auditory processing assessment Tinnitus assessment

Pediatric Testing Can bill for testing that is attempted if documentation of: What happened? Why you were unable to complete the testing? Did you spend at least half of the typical test time attempting the procedure? Documentation is key!

Examples of Pediatric Test Situations: Child Less Than Two Years
VRA (92579) in soundfield or headphones, includes tones and/or speech Tympanometry and reflexes (92550) OAEs (92587) ABR (92585)

Examples of Pediatric Test Situations: Child Two to Five Years
Conditioning play audiometry (92582) Select picture audiometry (92583) Tympanometry and reflexes (92550) OAEs (92587)

CAPD Very hard to do, if participating with third-party payers.
CAPD evaluation (92620/1). First minutes, please report writing Treatment 92633 versus 92700 Team meeting with patient (99366) and team meeting without patient (99368). Evaluation and management codes?

Vestibular Assessment
Basic vestibular evaluation (92540): Gaze (92541). Positionals, minimum of four positions (92542). Hallpike testing is a position. Optokinetic (92544). Oscillating tracking (92545). Caloric testing (92537) Evaluation and Management codes?

Vestibular Assessment
Positional testing, without recording (92532) Could be used for Hallpike in isolation. Rotational testing (92546) Must have a rotational chair. Use of vertical electrodes (92547) For ENG only (except in Florida). Dynamic posturography (92548) Need a platform. Saccades, VEMPs, SOT, and/or use of goggles (92700) Ends up being private pay in most cases.

Auditory Osseointegrated Device
Need pre-determination in writing, if not clearly listed as a benefit on the patient’s contract. Never call a BAHA a BAHA Call it an “auditory prosthetic device”. Candidacy testing, if completed (92626). Evaluation and Management codes? Fitting (L9900). Patient pays this amount on the date of the device fitting. Troubleshooting/service (L9900). Suggest patient be billed and pay privately.

CI Candidacy Audiogram (92557) Tymps and reflexes (92550) ABR (92585)
OAEs (92587 or 92588) Caloric testing, per irrigation (Calorics x 2) Evaluation of A/R status (92626/7) Team meeting with patient (99366) versus team meeting without patient (99368) Evaluation and Management codes?

CI Surgery NRT (92584)

CI Initial Tune-up Programming (92601 if less than 7 years or if 7 years or older) Could bill as two line items, with RT/LT modifiers or add -50 modifier for bilateral implants Testing (92626) Add -59 modifier NRT (92584)

CI: Everything Else Re-programming (92602 or 92604) NRT (92584)
Testing (92626) Must spend at least 31 minutes. Troubleshooting/service (L9900) Suggest patient be billed and pay privately. Recommend you send patients to manufacturer for supplies. More time to bill and collect than you actually receive. L codes exist.

Cerumen Removal Impacted (69209 or 69210):
Use if you used lavage or irrigation or use for use of any other form of instrumentation. Can bill Medicare patients privately. Voluntary ABN. Consult your contract for guidance with other payers. 50 modifier for binaural, although they may only pay for one ear. Non-impacted (92700): Inclusive to audiogram if performed on same date of service for Medicare. Can bill Medicare patients privately if done on a separate date of service.

Tinnitus Management What does your typical patient look like in terms of test battery, case history, and counseling??? 92625 Evaluation and Management? This will help you determine the codes you use and the prices you set. Will need to screen for depression, as allowed by state licensure, for PQRS. Very hard to do, if participating with third-party payers. Medicare does not cover tinnitus maskers. Medicare patients are financially responsible for costs. Consult payer guidance for private insurers. V5299. Tinnitus rehabilitation (92700 versus 92633).

Aural Rehabilitation 92630 or 92633
Medicare beneficiaries are financially responsible for the costs. Consult payer guidance for private insurers.

VA, Workers Compensation and Medicaid Coding
These entities follow their own, defined coding conventions Following the coding recommendations and requirements outlined by these specific payers

ICD-10-CM ICD-10-CM is an acronym for the International Classification of Diseases, 10th Revision. ICD-10s are a listing of codes designed to classify diagnoses and symptoms. Created by the World Health Organization and Centers for Disease Control. These codes typically consist of up to seven characters. Changed on October 1 of each year. Went into effect October 1, 2015.

Fundamentals of ICD10 Code what the patient, their family and/or their physician report in your case history. Case histories need to focus on the whole patient, not just the auditory system Code co-morbidities that support medical necessity. i.e. cancer, vascular disorders, autoimmune diseases, diabetes, MS Code what you, the audiologist, measure. i.e. hearing loss Code what you, the audiologist, personally visualize. i.e. exotoses, cauliflower ear Do not code merely for coverage. This could be VERY important with the repeal of ACA.

Importance of Documentation
Documentation of comprehensive case history, test results, and plan of care is key to successful ICD 10 coding, especially if working with certified coder at your facility and they are coding for you

Meaning of “Unrestricted”and “Restricted” in ICD 10
Unrestricted means “normal” in ICD 10 Restricted means “abnormal” in ICD 10

What the Numbers Mean A “3” as the last number means bilateral.
A “2” as the last number means left ear. A “1” as the last number means right ear.

Local Coverage Determinations
A Local Coverage Determination (LCD) is a decision by a Medicare Administrative Contractor (MAC) whether to cover a particular service on a MAC-wide, basis.

Local Coverage Determinations
Vestibular and Auditory Testing Novitas Evoked Potentials Intraoperative Monitoring First Coast Wisconsin Physician Services Tympanometry Vestibular Testing Only Vestibular Testing Also affects 92557 Palmetto Noridian

ICD-10 Examples H93.293 Abnormal auditory perception, bilateral
H Abnormal auditory perception, left ear H Abnormal auditory perception, right ear H93.3X3 Acoustic nerve disorder, bilateral H93.3X2 Acoustic nerve disorder, left ear H93.3X1 Acoustic nerve disorder, right ear H Acquired stenosis of external ear canal, bilateral H Acquired stenosis of external ear canal, left ear H Acquired stenosis of external ear canal, right ear

ICD-10 Examples Z Adjustment and management of implanted bone conduction device Z Adjustment and management of cochlear implant H Auditory recruitment, bilateral H Auditory recruitment, left ear H Auditory recruitment, right ear Q16.1 Aural atresia G51.0 Bell's Palsy

ICD-10 Examples D33.3 Benign neoplasm of cranial nerves
H81.13 Benign paroxysmal vertigo, bilateral H81.12 Benign paroxysmal vertigo, left ear H81.11 Benign paroxysmal vertigo, right ear M95.12 Cauliflower ear, left ear M95.11 Cauliflower ear, right ear H93.25 Central auditory processing disorder

ICD-10 Examples H90.0 Conductive hearing loss, bilateral
H90.12 Conductive hearing loss, left ear, unrestricted hearing in right ear H90.11 Conductive hearing loss, right ear, unrestricted hearing in the left ear H90.A11: Conductive hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral side H90.A12: Conductive hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral side

ICD-10 Examples R62.0 Delayed milestone in childhood
F81.89 Developmental disorder of scholastic skills, other H Diplacusis, bilateral H Diplacusis, left ear H Diplacusis, right ear R42 Dizziness This is a symptom, not a diagnosis. Z51.11 Encounter for antineoplastic chemotherapy

ICD-10 Examples H69.81 Eustachian tube disorders, other specified, right ear H69.82 Eustachian tube disorders, other specified, left ear H69.83 Eustachian tube disorders, other specified, bilateral H Exostosis, bilateral H Exostosis, left ear H Exostosis, right ear

ICD-10 Examples Z82.2 Family history of hearing loss
Z46.1 Fitting and adjustment of hearing aid T16.2XXA Foreign body in left ear, initial encounter T16.2XXD Foreign body in left ear, subsequent encounter T16.1XXA Foreign body in right ear, initial encounter T16.1XXD Foreign body in right ear, subsequent encounter

ICD-10 Examples Z01.12 Hearing conservation and treatment
Z Hearing examination following failed hearing screening Z01.10 Hearing/vestibular examination without abnormal findings H Hematoma of pinna, bilateral H Hematoma of pinna, left ear H Hematoma of pinna, right ear Z91.81 History of falling

ICD-10 Examples H93.233 Hyperacusis, bilateral
H Hyperacusis, left ear H Hyperacusis, right ear H61.23 Impacted cerumen, bilateral H61.22 Impacted cerumen, left ear H61.21 Impacted cerumen, right ear

ICD-10 Examples F70 Intellectual disabilities, mild
F71 Intellectual disabilities, moderate F72 Intellectual disabilities, severe F73 Intellectual disabilities, profound F78 Intellectual disabilities, other F79 Intellectual disabilities, unspecified

ICD-10 Examples H83.13 Labyrinthine fistula, bilateral
H83.12 Labyrinthine fistula, left ear H83.11 Labyrinthine fistula, right ear Z79.2 Long term (current) use of antibiotics Z79.82 Long-term use of aspirin Z76.5 Malingering H81.03 Meniere's disease, bilateral H81.02 Meniere's disease, left ear H81.01 Meniere's disease, right ear

ICD-10 Examples H90.6 Mixed hearing loss, bilateral
H90.72 Mixed hearing loss, left ear, unrestricted hearing in right ear H90.71 Mixed hearing loss, right ear, unrestricted hearing in left ear H90.A31: Mixed conductive and sensorineural hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral side H90.A32: Mixed conductive and sensorineural hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral side Z96.22 Myringotomy tube(s) status H83.3X3 Noise effects on inner ear, bilateral H83.3X2 Noise effects on inner ear, left ear H83.3X1 Noise effects on inner ear, right ear

ICD-10 Examples H55.00 Nystagmus
Z0.58 Observation and evaluation of newborn for other specified suspected condition ruled out H92.03 Otalgia, bilateral H92.02 Otalgia, left ear H92.01 Otalgia, right ear Can represent pressure and fullness as well. H92.13 Otorrhea, bilateral H92.12 Otorrhea, left ear H92.11 Otorrhea, right ear

ICD-10 Examples H91.03 Ototoxic hearing loss, bilateral**
H91.02 Ototoxic hearing loss, left ear** H91.01 Ototoxic hearing loss, right ear** ** Code poisoning or adverse effect T36.5X5A Poisoning, adverse effect, aminoglycosides, initial encounter T36.5X5S Poisoning, adverse effect, aminoglycosides, long term follow-up T36.5X5D Poisoning, adverse effect, aminoglycosides, subsequent encounter

ICD-10 Examples T37.2X5A Poisoning, adverse effect, antimalarials, initial encounter T37.2X5S Poisoning, adverse effect, antimalarials, long term follow-up T37.2X5D Poisoning, adverse effect, antimalarials, subsequent encounter T45.1X5A Poisoning, adverse effect, antineoplastic, initial encounter T45.1X5S Poisoning, adverse effect, antineoplastic, long term follow-up T45.1X5D Poisoning, adverse effect, antineoplastic, subsequent encounter

ICD-10 Examples T39.015A Poisoning, adverse effect, aspirin, initial encounter T39.015S Poisoning, adverse effect, aspirin, long term follow-up T39.015D Poisoning, adverse effect, aspirin, subsequent encounter T50.1X5A Poisoning, adverse effect, loop diuretic, initial encounter T50.1X5S Poisoning, adverse effect, loop diuretic, long term follow-up T50.1X5D Poisoning, adverse effect, loop diuretic, subsequent encounter

ICD-10 Examples T36.3X5A Poisoning, adverse effect, macolides, initial encounter T36.3X5S Poisoning, adverse effect, macolides, long term follow- up T36.3X5D Poisoning, adverse effect, macolides, subsequent encounter T46.7X5A Poisoning, adverse effect, vasodilators, initial encounter T46.7X5S Poisoning, adverse effect, vasodilators, long term follow-up T46.7X5D Poisoning, adverse effect, vasodilators, subsequent encounter

ICD-10 Examples H93.A1 Pulsatile tinnitus, right ear
H93.A2 Pulsatile tinnitus, left ear H93.A3 Pulsatile tinnitus, bilateral H93.A9 Pulsatile tinnitus, unspecified ear Z97.4 Presence of external hearing aid H90.3 Sensorineural hearing loss, bilateral H90.42 Sensorineural hearing loss, left ear, unrestricted hearing in right ear H90.41 Sensorineural hearing loss, right ear, unrestricted hearing in left ear H90.A21: Sensorineural hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral side H90.A22: Sensorineural hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral side

ICD-10 Examples I Sequealae following unspecified cardiovascular disease, other F80.4 Speech and language delay due to hearing loss F80.1 Speech-language disorder, expressive F80.2 Speech-language disorder, expressive/receptive F80.89 Speech-language developmental disorder, other F80.0 Speech-language disorder, phonological

ICD-10 Examples H91.23 Sudden idiopathic hearing loss, bilateral
H91.22 Sudden idiopathic hearing loss, left ear H91.21 Sudden idiopathic hearing loss, right ear H Threshold shift, temporary, bilateral H Threshold shift, temporary, left ear H Threshold shift, temporary, right ear H93.13 Tinnitus, bilateral H93.12 Tinnitus, left ear H93.11 Tinnitus, right ear

ICD-10 Examples H93.013 Transient ischemic deafness, bilateral
H Transient ischemic deafness, left ear H Transient ischemic deafness, right ear H82.3 Vertiginous disorder of vestibular function, bilateral* H82.2 Vertiginous disorder of vestibular function, left ear* H82.1 Vertiginous disorder of vestibular function, right ear* *Code first underlying disease H Vertigo, aural, bilateral H Vertigo, aural, left ear H Vertigo, aural, right ear

ICD-10 Examples H81.43 Vertigo, central, bilateral
H81.42 Vertigo, central, left ear H81.41 Vertigo, central, right ear H Vertigo, peripheral, other, bilateral H Vertigo, peripheral, other, left ear H Vertigo, peripheral, other, right ear H81.8X3 Vestibular function disorder, other, bilateral H81.8X2 Vestibular function disorder, other, left ear H81.8X1 Vestibular function disorder, other, right ear

Different Hearing Losses in Different Ears
H90.A11: Conductive hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral side H90.A12: Conductive hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral side H90.A21: Sensorineural hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral side H90.A22: Sensorineural hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral side H90.A31: Mixed conductive and sensorineural hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral side H90.A32: Mixed conductive and sensorineural hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral side You would need to select two of the above codes to reflect different hearing losses in different ears.

Toxicity from Viagra H91.02 Ototoxic hearing loss, left ear
T46.7X5A Poisoning, adverse effect, vasodilators, initial encounter First date you diagnose an ototoxic loss.

“Routine” Hearing Test
There is no CPT or HCPCS code for a “routine” hearing test. The best option is ICD 10 code Z0.110. Sometimes, again, it is the patient’s responsibility to fight for coverage.

Normal Hearing with No Other Symptoms or Co-Morbidities
Z01.10 Hearing/vestibular examination without abnormal findings Or H Abnormal auditory perception If they report communication difficulties.

Normal Vestibular Z91.81 History of Falling or R42 Dizziness
H Vestibular function disorder, unspecified, bilateral Comorbidities that drove medical necessity.

Newborn Hearing Screening Follow-up
Code pre and post natal conditions or symptoms. Code any co-morbidities. Code anything you see or measure. If they previously failed a hearing screening, code Z Add the -33 modifier to all of the procedures. Consider Z0.58 (Observation and evaluation of newborn for other specified suspected condition ruled out).

ICD 10 Tips We code what we learn and find, not for coverage.
You could be giving someone a pre-existing condition. Do not use rule out diagnoses once you know they do not exist. Can code up to 12 diagnoses per claim. Can link diagnosis to procedure (diagnosis pointer; 24e). Field can accommodate up to four pointers. Use the most specific code possible whenever possible. Can be denied over lack of specificity. We have NO IDEA the impact of use of a Z code on reimbursement as this varies payer to payer. As a result, use other codes whenever possible. Avoid these codes being a primary or only diagnosis.

ICD 10 Resources Online Look-up (free options): Manuals/Software
database/staticpages/icd-10-code-lookup.aspx Manuals/Software assn.org/store/catalog/subCategoryDetail.jsp?category_id=cat &navAction=push

HCPCS Basics HCPCS is the acronym for Healthcare Common Procedure Coding System. HCPCS is a listing of codes and their descriptions that outline items and supplies and the services that surround them. HCPCS are added, deleted, and modified annually by the Centers for Medicare and Medicaid Services (CMS). As of October 2003, HIPAA requires that all insurance carriers, including Medicare and Medicaid, use HCPCS. HCPCS are a letter followed by four numbers. Most codes that apply to audiology begin with the letters L (cochlear implants or BAHA) or V (hearing aids). Anyone can submit an application for HCPCS codes but need some form of vendor support as you need their data. It is now about products only.

HCPCS “L” Codes L9900: Orthotic/prosthetic supply, accessory and/or service component of another HCPCS L code (can be used for an abutment revision) I do not think audiology practices should be in the auditory prosthetic device replacement part business (due to DME requirements). Patients should work directly with device manufacturers.

HCPCS “S” Codes S1001: Deluxe item, patient notified
Need to determine how each private payer recognizes and reimburses this code before you use any of the codes. Not appropriate for Medicare or Medicaid. Sometimes these codes may be used to represent a service for productivity and not billing. S1001: Deluxe item, patient notified It is listed in addition to the code for the basic item. May help with upgrades. S0618: Audiometry for hearing aid evaluation to determine level and degree of hearing loss Some payers may consider this the code to be used for a routine hearing test.

HCPCS “S” Codes S5165: Home modifications, per visit
Home falls hazard assessment and modification. S9445: Patient education, not otherwise classified, non- physician provider, individual, per session S9446: Patient education, not otherwise classified, non- physician provider, group, per session S9476: Vestibular rehabilitation program, non-physician provider, per diem

HCPCS “S” Codes S9981: Medical records copying fee, administrative
S9982: Medical records copying fee, per page State medical records policies dictate what can be charged. S9999: Sales tax

HCPCS Codes V5008: Hearing screening V5010: Assessment for hearing aid
Same as V5010: Assessment for hearing aid Same as 92590/1. V5011: Fitting/orientation/checking of hearing aid “Checking” aspect same as 92592/3. V5014: Repair/modification of hearing aid Repairs Reprograming Recase Replate V5020: Conformity evaluation Verification.

HCPCS Codes V5050: Hearing aid, monaural, in the ear
V5060: Hearing aid, monaural, behind the ear V5130: Binaural, in the ear V5140: Binaural, behind the ear These are without technology.

HCPCS Codes V5170: Hearing aid, CROS, in the ear
V5180: Hearing aid, CROS, behind the ear V5210: Hearing aid, BICROS, in the ear Receiver and transmitter V5220: Hearing aid, BICROS, behind the ear Transmitter and hearing aid/receiver

HCPCS Codes V5254: Hearing aid, digital, monaural, CIC
V5255: Hearing aid, digital, monaural, ITC V5256: Hearing aid, digital, monaural, ITE V5257: Hearing aid, digital, monaural, BTE

HCPCS Codes V5258: Hearing aid, digital, binaural, CIC
V5259: Hearing aid, digital, binaural, ITC V5260: Hearing aid, digital, binaural, ITE V5261: Hearing aid, digital, binaural, BTE

HCPCS Codes V5200: Dispensing fee, CROS V5240: Dispensing fee, BICROS
V5090: Dispensing fee, unspecified hearing aid V5110: Dispensing fee, bilateral V5160: Dispensing fee, binaural V5241: Dispensing fee, monaural hearing aid, any type What encompasses the ordering, programming, and fitting that is not represented by another code.

HCPCS Codes V5268: Assistive listening device, telephone amplifier, any type V5269: Assistive listening device, alerting, any type V5270: Assistive listening device, television amplifier, any type V5271: Assistive listening device, television caption decoder V5272: Assistive listening device, TDD V5273: Assistive listening device, for use with cochlear implant V5274: Assistive listening device, not otherwise specified

HCPCS Codes V5281: Assistive listening device, personal FM/DM system, monaural (1 receiver, transmitter, microphone), any type V5282: Assistive listening device, personal FM/DM system, binaural (2 receivers, transmitter, microphone), any type V5283: Assistive listening device, personal FM/DM neck, loop induction receiver V5284: Assistive listening device, personal FM/DM ear level receiver

HCPCS Codes V5285: Assistive listening device, personal FM/DM, direct audio input receiver V5286: Assistive listening device, personal Bluetooth FM/DM receiver (streamer) V5287: Assistive listening device, personal FM/DM receiver, not otherwise specified V5288: Assistive listening device, personal FM/DM transmitter assistive listening device

HCPCS Codes V5289: Assistive listening device, personal FM/DM adaptor/boot coupling device for receiver, any type V5290: Assistive listening device, transmitter microphone, any type

HCPCS Codes V5264: Ear mold/insert/not disposable, any type
V5265: Ear mold/insert/disposable, any type V5275: Ear impression, each

HCPCS Codes V5267: Hearing aid or assistive listening device/supplies/accessories, not otherwise specified V5266: Battery for use in hearing device V5298: Hearing aid, not otherwise classified V5299: Hearing service, miscellaneous

V5299 Examples Extended warranty Loss and damage deductible
Tinnitus device Earmold service Service plan PSAP Noise ear plug/filter

HCPCS Tips Medicaid and the VA see HCPCS code use differently.
Follow their specific requirements. Available on their websites. No code for tinnitus devices or maskers. Use V5299.

HCPCS Tips There are some “duplicates” across CPT and HCPCS codes.
V5010 vs /1 V5014 vs /3 and 92594/5 Use the code covered in your insurance contract, which has the highest reimbursement in your fee schedule, or which is required by the insurance benefit. Remember, there is one code for each type of aid (digital BTE, monaural) and it does not take into account level of technology.

CMS Audiology Policies
Update to Audiology Policies: Effective October, 2008. Guidance/Guidance/Transmittals/downloads//R84BP.pdf Revisions and Re-Issuance of Audiology Policies: Effective September, 2010. Learning-Network- MLN/MLNMattersArticles/downloads//MM6447.pdf

Addresses: “Incident to” billing. Not allowed except for cerumen removal, canalith repositioning, ENoG and tympanometry. Required physician orders. No order…no coverage. Treatment Services Medicare never covers treatment provided and billed by an audiologist. Computerized audiometry. Not covered. Role of technicians and their supervision requirements. Require training and 100% direct supervision of the treating physician. Audiologists cannot supervise technicians and bill the services they provide under the NPI of an audiologist.

Addresses: Role of students, including but not limited to, the final year extern and their supervision requirements. Students require 100% personal supervision for Medicare coverage. Medical necessity. No medical necessity…no coverage. Billing of technical and professional components. Audiologists should bill the global fee for the services they provide. Documentation. An audiogram in and of itself does not constitute sufficient documentation if audited. 92700 You use this code to bill for procedures and services that have no CPT code. “Opt Out” (audiologist cannot opt out of Medicare).

Documentation and Medicare
“Documentation for Orders (Reasons for Tests): The reason for the test should be documented either on the order, on the audiological evaluation report, or in the patient’s medical record. (See subsection C of this section concerning reasons for tests.) Documenting skilled services. When the medical record is subject to medical review, it is necessary that the record contains sufficient information so that the contractor may determine that the service qualifies for payment. For example, documentation should indicate that the test was ordered, that the reason for the test results in coverage, and that the test was furnished to the patient by a qualified individual. Records that support the appropriate provision of an audiological diagnostic test shall be made available to the contractor on request”.

Medicare and Medical Necessity
“Under any Medicare payment system, payment for audiological diagnostic tests is not allowed by virtue of their exclusion from coverage in section 1862(a)(7) of the Social Security Act when: The type and severity of the current hearing, tinnitus, or balance status needed to determine the appropriate medical or surgical treatment is known to the physician before the test; or The test was ordered for the specific purpose of fitting or modifying a hearing aid.” Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs- Items/CMS html (Chapter 15, section 80.3)

Medical Necessity “Examples of appropriate reasons for ordering audiological diagnostic tests that could be covered include, but are not limited to: Evaluation of suspected change in hearing, tinnitus, or balance; Evaluation of the cause of disorders of hearing, tinnitus, or balance; Determination of the effect of medication, surgery, or other treatment; Re-evaluation to follow-up changes in hearing, tinnitus, or balance that may be caused by established diagnoses that place the patient at probable risk for a change in status including, but not limited to: otosclerosis, atelectatic tympanic membrane, tympanosclerosis, cholesteatoma, resolving middle ear infection, Meniere's disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, acoustic neuroma, demyelinating diseases, ototoxicity secondary to medications, or genetic vascular and viral conditions; Failure of a screening test (although a screening test is non-covered); Diagnostic analysis of cochlear or brainstem implant and programming; and Audiology diagnostic tests before and periodically after implantation of auditory prosthetic devices.”

Physician Order Requirements
Needed for each incident of care. Needs to be in place before testing is performed. Does not guarantee medical necessity. Should state “audiologic and/or vestibular evaluation.” Should avoid the term “hearing aid.” For audiologists, tests do not need to be individually listed. Delivery methods: Submitted via EMR. Hand delivered, faxed, or mailed. ed. Telephone. Avoid this option. Only-Manuals-IOMs-Items/CMS html (Chapter 15, section 80.6)

Advanced Beneficiary Notices
ABN Information/BNI/ABN.html Applicable to traditional Medicare only. Has required and voluntary (notice of non-coverage) uses. Must be completed prior to rendering care. Mandatory claims submission. If they select Option 1.

Advanced Beneficiary Notice (ABN)
Required ABN Use of or L9900 Local Coverage Determination in place in your locality For traditional Medicare ONLY. GA Modifier required. Waiver of liability on file.

ABN Voluntary ABN When item is statutorily excluded from coverage or does not meet the definition of a Medicare benefit. Serves as a Notice of Non-Coverage for when an item or service is never covered. GX Modifier required. Can use with a GY modifier.

Voluntary ABN Uses Routine or annual audiologic testing where medical necessity was not met. Hearing aids or testing for the sole purpose of obtaining a hearing aid. Treatment services such as cerumen removal, canalith repositioning, tinnitus management, and aural rehabilitation. Tinnitus maskers and devices. Evaluation and Management codes. Audiologic and/or vestibular testing where a physician order was not obtained prior to testing. Audiologic evaluations that were the result of solicitation (e.g. reminder cards, marketing events). Audiologic and/or vestibular testing that was completed by a student in the absence of 100% personal supervision by an audiologist or physician. Audiologic testing that requires the skills of an audiologist or physician but was completed by a technician. Screenings.

Medicare Advantage Advanced Beneficiary Notices are not applicable.
May need pre-service organization determination from the payer prior to perform the service or dispensing the item. You need to consult each payer for their guidance on pre-service organization determination process. 92700 L9900 V5298 V5299 Some require this process for all non-covered services as well.

Who Can Order Testing? As allowed by their state licensure.
Certified Nurse-Midwives Clinical Nurse Specialists Clinical Psychologists Clinical Social Workers Interns, Residents and Fellows Nurse Practitioners Physician Assistants Doctors of Medicine or Osteopathy Doctors of Dental Medicine or Surgery Doctors of Podiatric Medicine Doctors of Optometry Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html

Ordering Physicians Medicare requires a physician order for coverage of audiologic and vestibular services. The ordering physician MUST be enrolled in Medicare as either a participating, non-participating or opt out provider. You need to ensure this prior to submitting the claim or your claim will be denied. If the claim is denied, the patient cannot be financially responsible for the costs. Certification/MedicareProviderSupEnroll/MedicareOrderingandRe ferring.html

Medicare Advantage (Part C)
Most (except HMOs) do not require a physician order. Need to consult each plan to determine requirements. Many Medicare Advantage plans are reimbursing audiology and vestibular services consistently with Local Coverage Determinations where they exist.

Medicare Data on YOU Google yourself and many of you will find that your Medicare claims data is available online to consumers systems/statistics-trends-and-reports/medicare-provider- charge-data/physician-and-other-supplier.html

Physician Compare Allows patients to find, choose, and compare physicians and other health care providers who are enrolled in Medicare. A provision of the Affordable Care Act. Audiologists are currently listed. Your PQRS participation will be noted as well.

Medicaid Varies greatly state by state.
Managed programs may be GREATLY affected by repeals in ACA so make sure to check eligibility at every visit. Know the guidelines and follow them! Medical necessity always applies here. Managed Medicaid can differ greatly from state Medicaid programs. Ask yourself: Why are you participating???? Medicaid is generally NOT a revenue generating business unless doing volume! You would need volume to make money. Know how to handle non-covered services and do not provide them for free! There may be notification requirements prior to providing care.

Audiology Physicians Quality Reporting System (PQRS)
PQRS was retired on December 31, 2016. Your practice can still be penalized in both 2017 and for failure to appropriately report in 2015 and 2016. The penalty is 2%. The replacement program, the Merit-Based Incentive Payment System (MIPS) went into effect on January 1, Audiologists are ineligible for the MIPS program in 2017. As a result, we have no required reporting responsibilities in Audiologists have the opportunity to improve both the profession of audiology and quality of care provided to patients by participating in the Medicare Physician Quality Reporting System (PQRS) program.

Have you received a PQRS penalty?

Audiology Physicians Quality Reporting System (PQRS)
The audiology community is strongly encouraging folks to keep doing the actions, although not necessarily reporting on claims because the data will not be maintained or reported by CMS, because: It differentiates us in the marketplace, It is evidence based care, and This system and these measures will return and be required again, with even greater consequences. Audiologists have the opportunity to improve both the profession of audiology and quality of care provided to patients by participating in the Medicare Physician Quality Reporting System (PQRS) program.

Merit Based Incentive Payment System (MIPS)
The Merit-based Incentive Payment System (MIPS) consolidates three existing quality reporting programs: the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBPM), and meaningful use (MU). The system also adds a new performance category, called improvement activities (IA).

Merit Based Incentive Payment System (MIPS) and Audiology

Merit Based Incentive Payment System (MIPS): What We Do Know
PQRS like measure reporting will be back. There will be clinical improvement reporting requirements. Registry reporting only? Likely… ASHA is developing an audiology registry as we speak. Slated for September 2018. Details are yet to be released. Electronic medical record requirements? Maybe….we need to start to prepare for this.

Clinical Improvement Activities
Expanding practice access Population management Care coordination Beneficiary engagement Patient safety and practice assessment Achieving health equity Integrating behavioral and mental health Emergency Response and Preparedness

Clinical Improvement Activity Examples
Expanded hours Telehealth Patient satisfaction surveys Data registry participation Reports to physicians Timely communication to physicians Electronic health records Peer led support groups Enhanced websites Falls risk screening and assessment Humanitarian work Depression screening Tobacco screening

Facts About Documentation
Think beyond the ear… If it is not documented, it did not happen. An audiogram in and of itself does not constitute sufficient documentation, specifically as it relates to medical necessity. Does the testing result in payment? Was the testing ordered? Needs to be complete and legible. It needs to be dated. Must document name and professional identity. Learning-Network- MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf

Case History This is the first step to strong documentation of patient history and medical necessity. Components History of chief complaint(s) Right ear, left ear, or binaural. Acute, chronic, progressive, fluctuating, or sudden. Detailed description of chief complaint(s). Congenital versus acquired.

Case History Components Family history:
Health status or cause of death of parents, siblings, and children. Specific disease history of parents, siblings, and children. Hereditary medical conditions.

Case History Components Past history:
Prior major diseases, illnesses, injuries, or accidents. Surgical history. Current medications or treatments. Allergies (specifically latex).

Case History Components Social history:
Marital status, including domestic partners. Employment history. Recreational history. History of drug, alcohol, and tobacco use.

Case History Components Review of systems: Neurological. Psychiatric.
Endocrine. Constitutional symptoms. Hematologic/lymphatic. Weight loss, fever, chills, fatigue Allergic/immunologic. Non-specific Eyes. Ears, nose, mouth, and throat. Cardiovascular. Respiratory. Gastrointestinal. Genitourinary (urinary/genital). Musculoskeletal. Integumentary (skin and breast).

Results Need to outline results and explain why you did what you did.
Otoscopic inspection. Comprehensive hearing test (air, bone, speech and discrimination). Immittance testing. OAEs. Other tests.

Recommendations Make sure to take into account test results and case history findings. Don’t forget: Medication management. Tinnitus. Amplification. Maybe not just hearing aids. Assistive devices. Aural rehabilitation. Ear protection. Referral information.

SOAP Notes All documentation should contain these components.
S= Subjective O=Objective A=Assessment P=Plan All documentation should contain these components. These components can be flipped to focus on assessment and plan at the outset. Useful link:

Notes versus Report Documentation, in the medical record, is what is needed to document patients’ history, results, plan of care and medical necessity. A report to the ordering and/or attending physician can replace the notes (in the medical record you would indicate to see reported dated X) IF the report is comprehensive.

Example Dan Brown was seen at the Northwestern University Hearing Clinic on May 21, 2014 for a comprehensive audiologic evaluation. His primary care physician, Ed Jones, MD, ordered the testing.

Example Mr. Brown reported hearing loss in his left ear, dizziness that is accompanied by nausea, and tinnitus in his left ear. The patient does not report any ear deformities, ear drainage, ear pain, sudden or rapidly progressive hearing loss or foreign bodies in the ear. The patient does report a history of cardiac issues, high blood pressure, smoking and occupational noise exposure. Currently, Mr. Brown is taking Lasix, Lipitor and aspirin daily.

Example Otoscopic inspection revealed evidence of non-occluding cerumen in both ears. This cerumen was removed, using a headlight and curette, prior to testing. Following cerumen removal, otoscopy was unremarkable.

Example A comprehensive hearing test was completed to determine the patient’s hearing sensitivity and speech recognition abilities. Pure-tone audiometry revealed a mild-to- moderate, sensorineural hearing loss in the right ear and a mild-to-severe, sensorineural hearing loss in the left ear. Speech reception thresholds were in good agreement with the pure-tone findings. Speech recognition scores were excellent for the right ear and fair for the left ear at elevated presentation levels. Significant asymmetries were noted between ears throughout the testing, with the left ear being significantly poorer.

Example Immittance testing, which accesses the integrity and function of the outer and middles ear systems, revealed normal, Type A tympanograms bilaterally. Acoustic reflex thresholds were established due to the asymmetries between ears and to assist in the differential diagnosis. Acoustic reflex thresholds were within normal limits for the right ear but were elevated or absent for the left ear.

Example Mr. Brown’s test results revealed a binaural sensorineural hearing loss, with the left ear being significantly poorer. The tests results are consistent with possible retrocochlear pathology in the left ear.

Example Recommendations:
Comprehensive otologic evaluation with Michael Shinner, MD. I have already contacted Dr. Shinner’s office and I have scheduled Mr. Brown to see him on May 24. Hearing aid evaluation and selection once the cause of the patient’s hearing loss has been determined, a medical plan of care has been developed and implemented and the patient has been medically cleared for amplification. Consistent use of ear protection in noisy settings. I have provided Mr. Brown with a set of disposable earplugs and have instructed him on their use and purchase. I have cautioned Mr. Brown about the risks of driving or operating heavy machinery while experiencing dizziness. Gave Mr. Brown literature regarding smoking cessation.

The Importance of Data The purpose of coding is not just reimbursement; it is data collection. Every patient needs to generate an encounter. You need to collect, via your OMS or EMR.

Data You Need (at a minimum)
Number of patients seen Number of no charge visits Dollars billed Number of hearing aid repairs Dollars collected In-house Number of hearing aid evaluations completed Manufacturer Number of aids fit

Pricing Strategies Most pricing strategies I see in this industry are based on NOTHING. You CANNOT be afraid to charge for your time and services.

Pricing Strategies All prices should reflect:
An understanding of your personal breakeven analysis. An understanding of your third-party payer fee schedules. An understanding of the prevailing rates in the area.

Do you know what your practice needs to breakeven per hour?

Breakeven Analysis Breakeven analysis is what does your practice needs to bring in, per hour, per full-time equivalent provider to cover your expenses (salary, overhead, calibration, fixed costs, benefits, annual fees, etc.). Hearing aid procurement costs are not here as they are variable. zingUrProfeServices.pdf You want to add a “profit” amount to this. This is the minimum you can charge. You base your fees for items and services where no fee schedule exists. Based upon the time required to complete the procedure.

Breakeven Analysis and QuickBooks
Print a Quickbooks Expense Report for a 12 month period of time. Take a Black Sharpie and mark through any line item that accounts for goods that are sold (i.e. hearing aids, earmolds, ALDs). Add up the remaining expenses (including salaries) from the Report. These are your expenses for the year.

Breakeven Analysis and QuickBooks
Divide this amount by 12. This is the amount you need to breakeven per month. Divide this amount by the number of full-time equivalent, revenue generating providers. Divide this amount by the number of available hours your providers are available to see patients in an average month. No one should see patients 40 hours a week.

Third-Party Fee Schedules
Be aware of the third-party fee schedule amounts. You do not want to charge less than you could have collected. Must have a standard fee schedule for all patients . If you charge one, you must charge all.

Prevailing Rates Least important aspect, as you must charge what you need to cover your overhead and you do not want to charge less than you could have collected. Just because your competitors are idiots does not mean you have to be one too!

Pricing Diagnostic/Treatment Services
Compare break-even rate plus profit to that of your highest third-party payer for each code. Consider how much time you schedule each procedure for. NEVER charge what you expect to receive unless instructed to do so by the payer!!

Pricing Hearing Aid Services
What is your breakeven plus profit amount? How much time do you schedule for each hearing aid procedure? What is the prevailing third-party reimbursement rate?

Is your practice currently unbundled or itemized?

What is Bundling? Billing all items and services associated with the evaluation, fitting, and management of a hearing aid, as well as its related goods, under one code on the date of fitting.

Why do the Majority of Practices Bundle Their Hearing Aid Pricing?
Honestly, because that is how hearing aid pricing has always been; long before audiologists began dispensing hearing aids in 1978

Why Bundle??? Despite changes in medical and retail sales, the influx of audiologists into the delivery paradigm, and changes in technology, hearing aids are delivered in essentially the same manner as they were 50 years ago

Do You Buy “Commodities” the Same Way Today as You Did in 1970?

Do you personally purchase items online?

The Answer…. Has to be “No” for Most of Us…but we are forcing our patients into the same delivery and pricing model we have always had.

What is this Bundled Pricing Strategy Actually Based On?
Typically, nothing tangible. Rather it is typically a rudimentary calculation of invoice times X

Why we Need to Move Past 1970: The New Norm and Why We Need to Re-Evaluate our Pricing Models
The “status quo” may no longer suffice. We have to differentiate ourselves and our services from these disruptive forces that now exist in the marketplace. How do we price the product and value the service? How do we provide care and services not offered or available through these disruptive entities? How do we embrace these patients who have procured their devices by “disruptive” means? Do we turn them away? Do we engage the “price shoppers”? How do we expand our focus from just selling a “widget” or a “commodity”?

Who is your competition?

Your “Real” Competition
Your Manufacturers You Work With: Sonova (Phonak), William Demant, (Oticon), Widex, Starkey, Great Nordic (GN Resound) and Sivantos all own clinics, buying groups, and managed care enterprises (EPIC, AHAA, HearUSA, American Hearing Benefits, Audigy, and Hearing Planet). Their goal is to control the delivery streams of amplification.

Your Third-Party Payers (which you voluntarily participate with): HiHealth Innovations Medicaid.

Retail/Franchise Hearing aid dispensers Medical Community: Otolaryngologists. Internists. Optometrists.

Third-Party Administrators: HearPO/Amplifon Hearing. EPIC. TruHearing. HearUSA. AudioNet Arizona Hearing Network. Hearing Care Solutions. American Hearing Benefits. Some offer funded benefits. Many have some degree of manufacturer ownership and involvement.

Discount Programs Hearing Planet Hear.com Ally Nations Hearing Many third–party administrators offer discount plans as well. Technically, every consumer in the US has access to a discount plan.

Big Box Retailers: Walmart/Sam’s Club. CostCo Walgreen’s CVS

The Government: Expansions of VA and Medicaid Benefits and Coverage. Many of these patients would have privately paid for hearing aids 10 years ago.

Applications Available on mobile phones. No FDA regulations. EarMachine: EarSpy: Enhanced Ears: Hearing Aid Pro HearingOS: Jacoti: Petralex: Super Hearing Aid

Personal Sound Amplification Products Currently Available Over the Counter: Able Planet: Amplifiers.html Bean: edocuments/ucm pdf Eargo: Otofonix: 977Hi9Ov8pkBEiQA5B_ipV4Fde6K-q55QQCygObj2rAtr- NVLoB1_hyIpOcyFsIaAmzH8P8HAQ Phantom: PocketTalker: Sound World Solutions: amplifiers-psa/cs50 Thousands of options available through traditional and online retailers. Personal Sound Amplification Products Currently Available from a Provider: Amp: edocuments/ucm pdf Plaid:

Hearing Aids Currently Available Over the Counter: Audicus: Embrace: HiHealth Innovations: IHear: Listen Clear: MD Hearing: Sound World Solutions: Hearing Help Express: Advanced Affordable Hearing: priced-hearing-aids Mail Order Entities EBay

How Will You Differentiate Yourself in the Marketplace and Compete????
Products: Expand the “products” we offer to our patients. Maybe it is time to kick it old-school and have a less product based practice and a more service based practice. THIS is what differentiates us from our competitors and the “disruptions.” Expertise and Services: Raise the level and standard of care.

How Will You Differentiate Yourself in the Marketplace and Compete????
Promotion: Marketing strategies will need to change. Pricing: Unbundling/Itemization.

Products: Assistive Listening Devices FM/DM Systems Accessories
Tinnitus Maskers Affects 20% of patients.

Expertise and Services
Patient education and training programs for non-traditional purchases. Aural rehabilitation. Tinnitus evaluation and management. Vestibular rehabilitation. Auditory processing screening, evaluation, and treatment of adults and children. Primarily cash services. All can influence patient performance and satisfaction with amplification.

Promotion Do we continue to market “price” when consumers can obtain amplification for sometime a fraction of the “price” we are touting? Do we market a “commodity’ when that “commodity” can purchased less expensively elsewhere? Do the strategies of old (direct mail, newspaper, yellow pages) hold up in a digital, social media driven marketplace? Does your marketing tell consumers anything about what makes your practice different?

Pricing Bundling You “bundle” all of your hearing aid product and service costs, as well as our professional fees, under one, singular price (and code). You do not charge separately for the hearing aid evaluation/consultation and, as a result, receive no payment if a patient does not proceed with amplification.

Why Keep Bundling??? Pros: Easy. What everyone else does.

Why Keep Bundling??? Cons: Price often based on nothing tangible.
Not how insurance typically pays for items and services. No patient choice. Prices are not transparent. Increases patient costs for many. Does not reflect your professional time. May be collecting less than you need to receive to cover the “average” patient.

Bundled Package Includes:
Hearing aid evaluation Batteries Earmold impression, if required Accessories, if provided Manufacturer warranty Electroacoustic evaluation, if done Loss and damage coverage Counseling and/or aural rehabilitation Hearing aid itself Fitting and orientation One year to lifetime of follow- up hearing aid office visits, checks, in-house repairs, and cleanings Dispensing fee Verification, if performed Dome or custom earmold, if required

What is Unbundling? Charging separately for each item or service as it occurs. Breaking the “bundled” cost into each individual piece or aspect of service .

Why Unbundle? Pros: Collecting the amount you need to cover your costs and make a profit (price based on something tangible). Price better reflects actual financial needs. Potential for increased revenues long-term and improved cash flow. Allows for increased reimbursement with most managed care situations. Makes you price competitive. What consumers have been requesting for a decade.

Why Unbundle? Pros: Allows for patient choice on how their hearing aids are delivered. Forces a higher standard of care. Allows for some potential marketing advantages. Allows for pricing for online or e-bay purchases. They pay everything but the cost of the hearing aid itself. You care less about where the aid comes from.

Why Not? Cons: Does not work as well with managed care plans where you have to take a large, provider discount. May have to rebundle hearing aids for certain managed care situations. Will need to change office policies and procedures. Have to collect money from patient and be comfortable with that. Will need to change marketing program.

Hardest Parts of Taking the Leap to Itemization
Analyzing financial needs. - What are the risks versus the rewards? Overcoming fear of change. Valuing yourselves, your skills, and your time. Overcoming fear of the unknown. The “unknown” should be reduced if you have a strong knowledge of your financial needs.

Hardest Parts of Unbundling
Charging for testing and hearing aid evaluations in a world of “free”. - Is it really “free” and what are they really getting? Practicing a “doctor” mentality and “prescribing” solutions rather than “selling” a product.

Hardest Parts of Unbundling
Letting patients make decisions. A letting them live with the consequences of those decisions. Raising the bar on the standard of care you provide. Patients are not willing to pay for the privilege of you selling them something.

Unbundled Pricing Model: HAE/Communication Needs Assessment
On the date of the hearing aid evaluation, you bill the hearing aid evaluation (92590/1 or V5010; whichever pays more for your average third-party hearing aid contract) to the third- party payer or patient, even if they do not proceed with amplification. Most third-party payers who cover hearing aids cover hearing aid evaluations. You would also bill for the earmold impression, each (V5275), if a custom earmold is warranted.

Unbundled Pricing Model: Hearing Aid Fitting
On the date of fit, you would bill the following codes to the patient or the third-party payer: V52--: The code for the hearing aid itself V5---: Dispensing fee 92594/5:Electroacoustic analysis (if performed) with date service is performed V5011: Fitting and orientation V5020: Conformity evaluation (if you perform real-ear and/or functional gain testing) V5264: Earmold (custom) or V5265 Dome (disposable earmold), each V5266: Batteries (per battery) V5267: Accessories 92592/3: Follow-up visits within the Evaluation and Adjustment (global) period

Unbundled Hearing Aid Evaluation and Adjustment Period
Bill 92592/3 or V5011 on the date of each follow-up visit (if billing third party payer). If private pay patient, you may opt to bill these visits on the date of the fitting. Could “bundle” these visits into the fitting visit. Charge a “global” fee for this period.

Unbundling: End of Evaluation and Adjustment Period
On this date, the patient has four choices: Exchange the hearing aid. Return the hearing aid for credit. Keep the hearing aid and “pay as you go” for service. Keep the hearing aid and purchase a service package.

Unbundling: Exchange What was the reason for the exchange?
Can charge a patient a second fitting fee.

Unbundling: Return for Credit
As allowed by State law, you would refund the patient only the cost of the hearing aid itself (you would retain all other monies as the services were provided).

Unbundling: Pay As You Go
Have a fee established for every item or service and charge a patient or their third-party payer (if their benefits have not been exhausted) every time the item is provided or the service is performed. Fees based upon breakeven analysis and/or cost of goods. Nothing is free or no-charge.

Unbundling: Service Package
This is the service you are currently providing at no-charge once the aids are fit and accepted. Think of it as the difference between your current bundled fees and the unbundled package cost. A patient pays you a fixed rate per aid or per fitting (based upon the breakeven analysis) for managing their hearing aids and services for a given period of time. Base this on the data of your “average” patient.

Unbundling: Service Package
Could have a fixed number of visits, accessories (hard to track and maintain) or services OR unlimited number of visits, with defined amounts of accessories or services (built upon the average number of visits you provide per ear per aid fit now in your bundled model).

Disclaimer Prices listed are for illustrative purposes only and should not be construed as a recommendation of any given price. Price must be established individually by each clinic.

Example of Bundled Price
V5261 (Hearing aid, digital, behind-the-ear, binaural): $5100

Example of Unbundled Price
V5261: The code for the hearing aid itself 92633: Aural Rehabilitation, post lingual $2400 (single unit two aids) $100 (30 minutes) V5160: Dispensing fee, binaural V5266: Batteries (per battery) $200 (represents one hour) $1.50 x 8 92595:Electroacoustic analysis, binaural V5264: Earmold (custom) $33 (10 minutes) $40 x 2 V5011: Fitting and orientation $200 (one hour) V5020: Conformity evaluation $66 (20 minutes)

Example of Unbundled Price
Assume example of $200 per hour fee (breakeven plus profit) Hearing aid evaluation of $200 and $33 x 2 earmold impression paid on the date of that service $100 for each 30 minute hearing aid checks can be billed on the date of service (if insurance case) or at fitting (for private pay patient)

Unbundled Package $266 paid on date of hearing aid evaluation
$3091 paid on date of fitting $200 total paid for two, 30 minute follow-up visits within evaluation and adjustment period Collected $3557 by date of acceptance

Unbundled Pricing Model Example: After the Fitting
Pay as You Go: They can purchase a service plan at any point $100 for every 30 minute visit (hearing aid follow-up) $50 for every 15 minute visit (earmold service, hearing aid check, drop off repair) Does not matter if one or two aids; it is all about the time scheduled (as you cannot see anyone else).

One Year Basic Service Plan (based upon an average of five follow-up visits, one in-house repair, and one manufacturer repair per patient fit): $700 Based upon data from your average patient in a bundled model Includes unlimited follow-up visits, in-house repairs, manufacturer repairs, loss and damage fittings, and earmold service visits over 12 calendar months

Three-year Premier Service Plan (based upon an average of 15 follow-up visits, three in-house repair, three manufacturer repairs, 220 batteries, and one Dry and Store per patient fit and ): $2540 Based upon data from your average patient in a bundled model Includes unlimited follow-up visits, in-house repairs, manufacturer repairs, loss and damage fittings, 220 batteries, loaner aids, Dry and Store, earmold impressions and earmold service visits over 36 calendar months

Price Comparison: Bundled versus Unbundled (Private Pay)
Pay as You Go = $3557 With One Service Package (monaural or binaural) = $4257 With Three Year Premier Service Package (monaural or binaural) = $6097

Want to Dispense an Better Aid than a Online HA Retailer at a Better Cost?
Patient pays $1620 ($810 each) at an online, health insurance backed retailer for a hearing aid with no tax, no service, no evaluation, no verification, 30 batteries, package of wax guards, no extra domes or earmolds, no follow-up, no loss and damage coverage, and no manufacturer warranty for repairs due to moisture or wax (one year otherwise). Unbundled: $1757 total - $957 in professional fees plus two hearing aids with a single-unit price of $400 each, with no tax, no service, evaluation, verification, two follow-up appointments, aural rehabilitation, custom earmolds, a three-year manufacturer warranty for any repair issue, loss and damage, and 8 batteries

Want to Compete with an Online PSAP or Hearing Aid?
Patient pays $605 at an online retailer for two devices with $56 in tax (if that is required in your state), no service, no evaluation, no verification, no batteries, no follow-up, no loss and damage coverage, and no manufacturer warranty for repairs due to moisture or wax (one year otherwise). Unbundled: $1083 total - $478 in professional fees with a single-unit price of $349 each, with no tax, no service, evaluation, fitting, verification, and 8 batteries or $749 to purchase over the counter with evaluation and no services.

How Unbundling Can Help with An Insurance Case (Non-inclusive Coverage)
Bundled: You bill an insurance carrier for $4000 for binaural, digital, behind the ear hearing aids using V5261. Insurance pays $1800 ($900 each). The patient cannot be balance billed. You have manage that aid for the same number of years as you would a private pay patient. Unbundled: $2175 total – You bill an insurance carrier in an unbundled manner and receive $1800 for the hearing aids, $50 for the HAE, $40 for the EMI, $80 for the HAF, $80 for the dispensing fee, $25 for the EAA, $60 for the REM, $40 for the EM. This patient can pay as they go for service or purchase a service plan, just like their private pay counterparts.

Patient Buys Their Aids Elsewhere...
WHO CARES?!! They are still NOW your patient. Can charge them: $450 for electroacoustic analysis, fitting, programming, verification, and one follow-up appointment (no follow-up, no batteries, no accessories). Sell them a service package. Allow them to pay as they go for service.

Integrating Itemization
It would begin with all new Communication Needs Assessments/Hearing Aid Evaluation and Selections. Everyone who previously purchased within the bundled model would still be covered within the bundled model. It would also affect: Anyone who purchased their devices elsewhere. Anyone who’s hearing aids are out of your bundled pricing package or warranty.

You would explain that this program gives them, the purchaser, control over how their aids are delivered. You would explain that there is a fee for the Communication Needs Assessment but that they will receive a copy of their evaluation and plan of care (like an optometrist does). You would explain that, if they choose to get a device from you, the fess will be itemized and separated from the cost of the product itself and that, as a result, they will pay less up front. You would explain that is is their choice to pay as they go for service or purchase a bundled, comprehensive service plan.

You will explain that there are different costs for different services, depending on how much time each service requires. If there is a need for repair, they will pay the invoice cost of the repair plus shipping as well as a fee for any service provided by your office. If there is a need for an earmold, they will pay for the earmold impression as well as the cost of the earmolds. For accessories, they will pay invoice plus a markup for stocking/ordering the items and profit. They may also pay a fee if you must fit or explain the use of the accessory.

All the while, you can educate them with materials from HLAA and the NASEM on the role and goals of unbundling and itemization. Some may offer them the ability to purchase certain items themselves or from Big Box retailers, rather than stocking them in their office or having the patient pay more for the same item from them. Audiology becomes more evaluative and rehabilitative. Some may want to stock many different types of products in their offices, including PSAPs, OTCs, Hearables, and ALDs.

Audiologists will need: Well defined informational websites. Well defined, itemized state required bills of sale. Informational office pieces and forms that explain and list your pricing and process. Social media driven marketing campaign. Physician referral program that outlines the differences of your approach to patient outcomes.

Forms Discussed in Boot Camp
Many of the forms discussed in the Boot Camp can be purchased through the Academy of Doctors of Audiology and their Practice Resource Catalog at -resource-catalog. Forms may also be available to members through AAA and ASHA or through your state audiology association.

Questions: Kim Cavitt, AuD kim.cavitt@audiologyresources.com
(773) (phone) I answer questions at no charge for Boot Camp attendees ONLY until September 1, 2017. Change the date.

Kim Cavitt, AuD Audiology Resources, Inc.

Similar presentations

Presentation on theme: "Kim Cavitt, AuD Audiology Resources, Inc."— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Kim Cavitt, AuD Audiology Resources, Inc.

Similar presentations

Presentation on theme: "Kim Cavitt, AuD Audiology Resources, Inc."— Presentation transcript:

Similar presentations

About project

Feedback