Clarifying Medicare Audiology Billing Services: FAQ on Audiology
We have received a number of questions regarding the requirements for billing audiology services. In response, the Academy developed resources to provide clarification and guidance for the billing of audiology services. (See http://www.entnet.org/Practice/Medicareupdates.cfm#AUDHP and the March Bulletin article titled “Clarifying Medicare Audiology Billing Services.”) What is an NPI and does an audiologist need one to bill Medicare? Any audiologist who is seeing Medicare patients must obtain a National Provider Identifier (NPI) and enroll in Medicare as a provider. These two separate processes must be completed before Medicare will consider payment of the claims. (Medicare does not reimburse any provider or practitioner who is not enrolled in the program.) Please note that this is not a new policy from CMS; it has been in effect for several years, but CMS has been strengthening its data collection of provider numbers. The NPI is a unique identification number for covered healthcare providers. All health plans and healthcare clearinghouses use the NPIs in the administrative and financial transactions adopted under HIPAA. Audiologists who “perform services under the supervision of an otolaryngologist and normally bill for services using the otolaryngologist’s NPI” are required to obtain and use their own NPI designating them as the “rendering provider.” The audiologists must also be enrolled in Medicare if they are seeing Medicare beneficiaries; Medicare will not consider the billed charges if the audiologist is not enrolled as a provider. To enroll as a provider, visit https://pecos.cms.hhs.gov. What services can an audiologist perform? According to Medicare, as defined in the Social Security Act, section 1861(ll)(3), the term “audiology services” specifically means such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under state law (or the state regulatory mechanism provided by state law), as would otherwise be covered if furnished by a physician. These hearing and balance assessments are covered as “other diagnostic tests” and therefore private practice audiologists can bill Medicare directly for diagnostic services. Audiological diagnostic testing refers to tests of the auditory and vestibular systems, e.g., hearing, balance, auditory processing, tinnitus, and diagnostic programming of certain prosthetic devices, performed by qualified audiologists. There is currently no provision in the law for Medicare to pay audiologists for therapeutic services, such as vestibular treatment, auditory rehabilitation, and auditory processing treatment. While they are considered within the scope of practice for an audiologist, they are not diagnostic tests and therefore cannot be billed to Medicare by audiologists. CMS produced MedLearn Matters article #MM5717 http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5717.pdf that provides a more detailed assessment of which audiology services are covered by Medicare. It is important to note that Medicare requires a referral from a qualified physician for audiological services rendered by an audiologist. Also, Medicare no longer allows audiologists to use the incident-to billing that had been widely used. Regulatory language from 2003 requires that services with their own benefit category cannot be billed under the incident-to billing methodology. What is “incident-to” billing and what does it mean that audiologist services can’t be billed as “incident-to”? According to Medicare Medlearn Matters article #SE0441, “‘Incident to’ services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home. These services are billed as Part B services to your carrier as if you personally provided them, and are paid under the physician fee schedule. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision. That is, you must be present in the office suite to render assistance, if necessary.” Because audiologists are now required to have their own NPI, services performed by the audiologists must be billed under the name and NPI of the audiologist, not the physician’s name and NPI. Services provided by other non-physician providers (such as audiology/oto-technicians, physician assistants, and nurse practitioners) would be billable as “incident-to” the physician service, but only if the service meets the qualifying criteria for Medicare (reference to Social Security Act, Title XVIII, Chapter 15, Section 1861). It is important to note that if a non-physician provider is performing the technical component of a service, it can only be billed “incident-to” the qualified physician and not to the audiologist. For a more thorough explanation of what services an audiology technician or oto-tech can provide, see the Academy’s March Bulletin article titled “Clarifying Medicare Audiology Billing Services” or the Academy’s newly revised audiology services informational webpage at http://www.entnet.org/Practice/Medicareupdates.cfm#AUDHP. The Academy realizes this is a complex issue and other questions may arise regarding Medicare audiology billing. The Academy has several resources available for members to help them navigate Medicare’s audiology billing requirements, including a newly revised Audiology FAQ available on our website. The Academy also provides a coding hotline to members for specific questions about coding, which can be reached from Monday through Friday, 7:00 am-4:00 pm MST at 1-800-584-7773. Additional questions can be submitted to the Health Policy team at healthpolicy@entnet.org.
We have received a number of questions regarding the requirements for billing audiology services. In response, the Academy developed resources to provide clarification and guidance for the billing of audiology services. (See http://www.entnet.org/Practice/Medicareupdates.cfm#AUDHP and the March Bulletin article titled “Clarifying Medicare Audiology Billing Services.”)
What is an NPI and does an audiologist need one to bill Medicare?
Any audiologist who is seeing Medicare patients must obtain a National Provider Identifier (NPI) and enroll in Medicare as a provider. These two separate processes must be completed before Medicare will consider payment of the claims. (Medicare does not reimburse any provider or practitioner who is not enrolled in the program.) Please note that this is not a new policy from CMS; it has been in effect for several years, but CMS has been strengthening its data collection of provider numbers.
The NPI is a unique identification number for covered healthcare providers. All health plans and healthcare clearinghouses use the NPIs in the administrative and financial transactions adopted under HIPAA. Audiologists who “perform services under the supervision of an otolaryngologist and normally bill for services using the otolaryngologist’s NPI” are required to obtain and use their own NPI designating them as the “rendering provider.” The audiologists must also be enrolled in Medicare if they are seeing Medicare beneficiaries; Medicare will not consider the billed charges if the audiologist is not enrolled as a provider. To enroll as a provider, visit https://pecos.cms.hhs.gov.
What services can an audiologist perform?
According to Medicare, as defined in the Social Security Act, section 1861(ll)(3), the term “audiology services” specifically means such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under state law (or the state regulatory mechanism provided by state law), as would otherwise be covered if furnished by a physician. These hearing and balance assessments are covered as “other diagnostic tests” and therefore private practice audiologists can bill Medicare directly for diagnostic services.
Audiological diagnostic testing refers to tests of the auditory and vestibular systems, e.g., hearing, balance, auditory processing, tinnitus, and diagnostic programming of certain prosthetic devices, performed by qualified audiologists.
There is currently no provision in the law for Medicare to pay audiologists for therapeutic services, such as vestibular treatment, auditory rehabilitation, and auditory processing treatment. While they are considered within the scope of practice for an audiologist, they are not diagnostic tests and therefore cannot be billed to Medicare by audiologists. CMS produced MedLearn Matters article #MM5717 http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5717.pdf that provides a more detailed assessment of which audiology services are covered by Medicare.
It is important to note that Medicare requires a referral from a qualified physician for audiological services rendered by an audiologist. Also, Medicare no longer allows audiologists to use the incident-to billing that had been widely used. Regulatory language from 2003 requires that services with their own benefit category cannot be billed under the incident-to billing methodology.
What is “incident-to” billing and what does it mean that audiologist services can’t be billed as “incident-to”?
According to Medicare Medlearn Matters article #SE0441, “‘Incident to’ services are defined as those services that are furnished incident to physician professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home. These services are billed as Part B services to your carrier as if you personally provided them, and are paid under the physician fee schedule. You do not have to be physically present in the patient’s treatment room while these services are provided, but you must provide direct supervision. That is, you must be present in the office suite to render assistance, if necessary.”
Because audiologists are now required to have their own NPI, services performed by the audiologists must be billed under the name and NPI of the audiologist, not the physician’s name and NPI. Services provided by other non-physician providers (such as audiology/oto-technicians, physician assistants, and nurse practitioners) would be billable as “incident-to” the physician service, but only if the service meets the qualifying criteria for Medicare (reference to Social Security Act, Title XVIII, Chapter 15, Section 1861). It is important to note that if a non-physician provider is performing the technical component of a service, it can only be billed “incident-to” the qualified physician and not to the audiologist.
For a more thorough explanation of what services an audiology technician or oto-tech can provide, see the Academy’s March Bulletin article titled “Clarifying Medicare Audiology Billing Services” or the Academy’s newly revised audiology services informational webpage at http://www.entnet.org/Practice/Medicareupdates.cfm#AUDHP.
The Academy realizes this is a complex issue and other questions may arise regarding Medicare audiology billing. The Academy has several resources available for members to help them navigate Medicare’s audiology billing requirements, including a newly revised Audiology FAQ available on our website. The Academy also provides a coding hotline to members for specific questions about coding, which can be reached from Monday through Friday, 7:00 am-4:00 pm MST at 1-800-584-7773. Additional questions can be submitted to the Health Policy team at healthpolicy@entnet.org.