Section 23Hearing Aid and Audiological Services 23 23.1 Enrollment...................................................... 23-2 23.2 Reimbursement.................................................. 23-2 23.3 Benefits and Limitations............................................ 23-2 23.3.1 Otology and Audiological Screening............................... 23-2 23.3.1.1 Newborn Hearing Screening................................ 23-2 23.3.1.2 Outpatient Hearing Screening............................... 23-3 23.3.1.3 Referrals for Abnormal Screening Results...................... 23-3 23.3.2 Otology and Audiological Testing................................. 23-3 23.3.3 Hearing Aid Device........................................... 23-4 23.3.3.1 Warranty.............................................. 23-5 23.3.3.2 30-Day Trial Period...................................... 23-5 23.3.3.3 Fitting and Dispensing Visit................................ 23-5 23.3.3.4 First Revisit............................................ 23-5 23.3.3.5 Second Revisit......................................... 23-5 23.4 Limitations and Exclusions.......................................... 23-6 23.5 Documentation Requirements........................................ 23-6 23.6 Claims Information................................................ 23-6 23.6.1 Claim Filing Resources........................................ 23-6 CPT only copyright 2008 American Medical Association. All rights reserved.
Section 23 23.1 Enrollment To enroll in Texas Medicaid, hearing aid professionals (physicians, audiologists, and fitters and dispensers) who provide hearing evaluations or fitting and dispensing services must be licensed by the licensing board of their profession to practice in the state where the service is performed. Hearing aid providers are only eligible to enroll as individuals and facilities. Additionally, audiologists not wanting to enroll as hearing aid providers are allowed to enroll separately as audiologists. Providers cannot be enrolled if their license is due to expire within 30 days. A current license must be submitted. Important: All providers are required to read and comply with Section 1, Provider Enrollment and Responsibilities. In addition to required compliance with all requirements specific to Texas Medicaid, it is a violation of Texas Medicaid rules when a provider fails to provide health-care services or items to Medicaid clients in accordance with accepted medical community standards and standards that govern occupations, as explained in Title 1 Texas Administrative Code (TAC) 371.1617(a)(6)(A). Accordingly, in addition to being subject to sanctions for failure to comply with the requirements that are specific to Texas Medicaid, providers can also be subject to Texas Medicaid sanctions for failure, at all times, to deliver health-care items and services to Medicaid clients in full accordance with all applicable licensure and certification requirements including, without limitation, those related to documentation and record maintenance. Refer to: Provider Enrollment on page 1-3 for more information on enrollment procedures. Managed Care on page 7-1. 23.2 Reimbursement Hearing aids and audiological services are reimbursed in accordance with 1 TAC 355.8141. Fee schedules for services in this chapter are available on the TMHP website at www.tmhp.com. Refer to: Reimbursement Methodology on page 2-2 for more information on reimbursement. Billing Clients on page 1-16 for more information. 23.3 Benefits and Limitations Hearing aid services, including hearing aid devices, are considered for reimbursement when they are medically necessary. Benefits for hearing aid services are determined by statutory and fiscal limitations. For clients 21 years of age or older, hearing aid services are benefits of Texas Medicaid. For Texas Medicaid clients birth through 20 years of age who have suspected or identified permanent hearing loss, hearing aid services are available through the Department of State Health Services (DSHS) Program for Amplification for Children of Texas (PACT). An appropriate hearing screening is a mandatory part of each THSteps medical checkup. When permanent hearing loss is suspected or identified, clients birth through 20 years of age must be referred to an enrolled PACT provider. For a list of PACT providers, providers may visit the PACT website at www.dshs.state.tx.us/audio/program.shtm or write to: DSHS Program for Amplification for Children of Texas (PACT) 1100 West 49th Street Austin, TX 78756-3199 1-512-458-7724 Hearing evaluations and the first and second revisits are reimbursed according to the maximum allowable fee. Reimbursement for the following services are limited to the established maximum fee: Ear molds The fitting and dispensing fee (includes the postfitting check of the hearing aid within five weeks after the dispensing date) The hearing aid device 23.3.1 Otology and Audiological Screening Audiological screening for clients birth through 20 years of age or diagnostic testing for clients of any age are benefits of Texas Medicaid. Otoacoustic emissions (OAE) or auditory brainstem response (ABR) audiometry are benefits of Texas Medicaid for infants, children, and adults and may be used in addition to or in place of conventional audiometry for further diagnosis. 23.3.1.1 Newborn Hearing Screening Initial Screen For Infants Admitted to a Birthing Facility Health Safety Code, Chapter 37, mandates that a birthing facility (hospital or birthing center) offer the parents of a newborn a hearing screening for the newborn for the identification of hearing loss. The screen must be offered during the birth admission (before hospital discharge). The parents must be informed that information may be provided to DSHS upon the parents written consent. A facility where a birth occurs must offer newborn hearing screening through a program mandated by the Texas State Legislature and certified by DSHS. The hospital is responsible for: Purchasing the equipment. Training the personnel. Screening the newborns. 23 2 CPT only copyright 2008 American Medical Association. All rights reserved.
Hearing Aid and Audiological Services Maintaining certification of the facility s hearing screening program according to DSHS standards. Notifying the provider, parents, and DSHS of the screening results. Procedures for newborn hearing screening provided during the birth admission are considered part of the newborn delivery diagnosis-related group (DRG) payment to the facility and are not reimbursed as separate procedures. Hospitals must use procedure code 09547 to report this newborn hearing screen on the UB-04 CMS-1450 claim form. The provider must do the following: Verify that the parents received the results of the hearing screen at the birthing facility. Check for obvious physical abnormalities. Supply a hearing checklist for parents and instructions on its use (this checklist is discussed at the first inoffice THSteps medical checkup). Provide a referral for further diagnostic audiological testing for an infant with abnormal screening results or who is at high-risk for hearing impairment. This facility-based screening meets the physician s required component for hearing screening in the inpatient newborn Texas Health Steps (THSteps) checkup. The physician must ensure that the hearing screening is completed before discharging the newborn or, when the birthing facility is exempt under the law, that there is an appropriate hearing screening referral to a birthing facility participating in the newborn hearing screening program. The physician must discuss the screening results with the parents, especially if the hearing screening results are abnormal, and order an appropriate referral for further diagnostic testing. If the results are abnormal, the parent s or legal guardian s consent must be obtained to send information to DSHS for tracking and follow-up purposes. Physicians may contact the hospital administrator or the DSHS Audiology Services Program at 1-512-458-7724 with any questions or concerns about the newborn hearing screening process. If the infant is born outside of a birthing facility or not admitted to a birthing facility, the newborn hearing screening is performed during the initial THSteps visit and is considered part of the initial newborn medical checkup. No separate reimbursement is made. Providers who are not THSteps-enrolled must refer the infant to an enrolled THSteps provider for an initial THSteps medical checkup, which includes the newborn hearing screening. An initial newborn hearing screen for infants who are not admitted to a birthing facility consists of the following: Completion of the Hearing Checklist for Parents form Assessment of any physical abnormalities Instructing the parents on the use of the hearing checklist and informing the parents of the results Referral of the high-risk infant to a physician who renders audiology services 23.3.1.2 Outpatient Hearing Screening Hearing screening must be completed during each THSteps medical checkup. Providers may conduct a hearing screen during an acute care visit with the appropriate screening tools or may refer at-risk infants and children to a provider who can provider further testing, diagnosis and treatment. Refer to: Hearing Screening on page 43-19 for information about THSteps medical checkup hearing screenings. 23.3.1.3 Referrals for Abnormal Screening Results All abnormal hearing screenings identified during the newborn hearing screening and the THSteps medical checkup for Texas Medicaid-eligible clients birth through 20 years of age must be referred to an approved Texas Medicaid hearing services provider for diagnostic hearing evaluation and/or other hearing services (e.g., hearing aids, etc.). If the purpose is to determine permanent hearing loss or type of amplification needed, infants and children must be referred to an approved hearing services PACT provider for follow-up. Texas Medicaid fee-for-service providers may be reimbursed for the follow-up care when a local PACT provider is not accessible. Separate procedure codes may be billed for children who require diagnostic hearing testing. The following diagnostic audiometric testing procedure codes may be billed as appropriate: 92567, 92585, 92586, 92587, and 92588. All abnormal hearing screenings for clients 21 years of age or older must be referred to a physician who provides audiological services. 23.3.2 Otology and Audiological Testing Audiometry is the testing of a person s ability to hear various sound frequencies and is performed with the use of electronic equipment. Audiometry is used to identify and diagnose hearing loss. The following audiometry testing are benefits of Texas Medicaid: Air and bone pure tone audiometry threshold testing Pneumatic otoscopy Tympanometry Acoustic reflex testing Evoked response testing Air and Bone Pure Tone Audiometry Threshold Testing Air and bone pure tone audiometry threshold testing assesses air and bone conduction. Speech reception threshold (SRT) and word recognition tests indicate the softest level that a person is able to hear and repeat two-syllable words, and how well a person can repeat words presented at a comfortable listening level. Speech audiometry uses a series of simple recorded words 23 CPT only copyright 2008 American Medical Association. All rights reserved. 23 3
Section 23 spoken at various volumes into headphones worn by the person being tested. The person repeats each word back as it is heard. The total component for procedure code 92557 is a comprehensive code. If any of the following procedure codes are submitted with the same date of service as procedure code 92557, they are denied as part of another service: Procedure Codes 92551 92552 5-92553 92555 92556 If three or more of the procedure codes listed above are performed on the same date of service, the provider must bill the most inclusive procedure code (92557). Three or more of the above procedure codes billed with the same date of service are denied with instructions to bill the appropriate audiometry procedure code. Otoscopic Examinations and Tympanometry It is recommended that pneumatic otoscopy be the primary method to visualize and assess the mobility of the tympanic membrane when distinguishing between otitis media with effusion and acute otitis media. Tympanometry (procedure code 92567) should never be used as the sole clinical means to establish the presence or absence of acute or chronic middle ear effusion or infection. Direct otoscopic examination by a suitably qualified provider, with or without pneumatic otoscopy, is the key element of the standard method used to establish a diagnosis of middle ear disease. Tympanometry must be limited to selected individual cases where its use demonstrably adds to the provider's ability to establish a diagnosis and provide appropriate treatment. Tympanometry is limited to four services per year by the same provider and is based on medical necessity. Medical necessity must be documented in the patient s medical record. Tympanometry does not meet the requirements for a sensory screening component of the THSteps medical checkup. Acoustic Reflex Testing Acoustic reflex testing (procedure codes 92568 and 92569) provides information about the middle ear, specifically middle ear muscle reflexes in response to sound. The test can help distinguish between sensory (cochlear) hearing loss and neural (retro-cochlear) hearing loss. Acoustic reflex testing is limited to the following diagnosis codes: Diagnosis Codes 2251 3510 3511 3518 3519 38600 38601 38602 38603 38604 38610 38611 38612 38619 3862 38630 38631 38632 38633 38634 38635 38640 38641 38642 38643 38648 38650 38651 38652 38653 38654 38655 38656 38658 3868 3869 3870 3871 3872 3878 3879 3882 38830 38831 38832 38840 38841 38842 38843 38844 38845 3885 38905 38906 38913 38915 38916 38917 38920 38921 38922 7443 7804 Note: Medical necessity for each service must be documented in the client's medical record. The total component for procedure codes 92563, 92567, 92568, and 92569 are diagnostic hearing procedures that may be considered for reimbursement separately. Auditory or Otoacustic Evoked Response Testing Auditory or otoacustic evoked response testing includes the following procedures: Procedure Testing Codes ABR, also called Brainstem Evoked Potential (BSER) 92585 92586 Otoacoustic Emissions (OAE) 92587 92588 Each evoked potential test is considered a bilateral procedure. If separate charges are submitted for left- and right-sided tests of the same type, the tests are combined and considered as a quantity of one. When an electroencephalogram (EEG) is submitted with the same date of service as an evoked response test, both are considered for reimbursement at the full reimbursement rate. Procedure code 95920 is considered for reimbursement in addition to each evoked potential test. Procedure code 95920 is limited to a maximum of two hours each day, regardless of provider, without documentation of medical necessity. 23.3.3 Hearing Aid Device Hearing aid devices are a benefit of Texas Medicaid and are limited to eligible clients 21 years of age or older whose air conduction puretone average in the better ear is 45 db or greater. The client must have medical necessity for a hearing aid device and have no medical 23 4 CPT only copyright 2008 American Medical Association. All rights reserved.
Hearing Aid and Audiological Services contraindications for using a hearing aid. Each client must be offered an appropriate new hearing aid device within the Medicaid allowable fee schedule. Hearing aids are considered for reimbursement once every six years. The hearing aid device may include the following: Acquisition cost of the hearing aid device (the actual cost or net cost of the hearing aid device after any discounts have been deducted) Manufacturer s postage and handling charges All necessary tubing, cords, and connectors Bone conduction headbands Telephone coils Compression circuits Contralateral Routing of Offside Signal (CROS)/Bilateral Contralateral Routing of Offside Signal (BICROS) features Instructions for care and use One-month supply of batteries Important: TMHP may refer people to the Texas Rehabilitation Commission whose jobs are contingent on possession of a hearing aid as well as people appearing to have vocational potential and who need a hearing aid. 23.3.3.1 Warranty Each hearing aid device dispensed through Texas Medicaid must be a new and current model that meets the performance specifications indicated by the manufacturer and the client s individual hearing needs. A new hearing aid device is one that has never been used and carries a full 12-month manufacturer s warranty. The manufacturer s warranty must be effective for 12 months after the dispensing date. 23.3.3.2 30-Day Trial Period Providers must allow each Medicaid client a 30-day trial period that gives the client time to determine satisfaction with a purchased hearing aid device. The trial period consists of 30 consecutive days beginning with the dispensing date during which the client may return and/or exchange the device if not completely satisfied with the purchase. Providers may dispense additional hearing aid devices as medically necessary until the client is satisfied with the results of the device, or the provider determines that the client cannot benefit from the dispensing of an additional hearing aid device. A new trial period begins with the dispensing date of each hearing aid device. The provider must accept each hearing aid device that is returned by a Texas Medicaid client. If the provider obtained a statement of acknowledgement signed by the client prior to the dispensing of each hearing aid device, the provider may charge the client a rental fee for each returned device. The signed acknowledgement must state that the client understands that he/she is responsible for paying the hearing aid device rental fees if the hearing aid device is returned within the 30-day trial period. The acknowledgement must be retained in the client s medical record. Providers must allow 30 days to elapse from the hearing aid device dispensing date before completing a 30-day trial period certification statement stating that the client has received and is satisfied with the hearing aid device. The 30-day trial period certification statement must be signed by the client after the 30-day trial period has elapsed. 23.3.3.3 Fitting and Dispensing Visit The fitting and dispensing visit also includes the postfitting check. 23.3.3.4 First Revisit Additional counseling is available as needed within a period of six months after the post-fitting check. The first revisit, procedure code 99211, includes a hearing aid check. 23.3.3.5 Second Revisit The second revisit, procedure code 99212, includes aided sound field testing performed by a contracted evaluator according to the guidelines specified for the hearing evaluation. If the aided sound field test scores suggest a decrease in hearing acuity, the provider must include puretone and speech audiometry on Form 3503, Hearing Aid Evaluation Report. The second revisit is available as needed after the post-fitting check and the first revisit. The following table lists the hearing aid device, assessment, and revisit procedure codes. Procedure Codes 99211 99212 V5010 V5011 V5030 V5040 V5050 V5060 V5070 V5080 V5090 V5100 V5110 V5120 V5130 V5140 V5150 V5160 V5170 V5180 V5190 V5200 V5210 V5220 V5230 V5240 V5241 V5242 V5243 V5244 V5245 V5246 V5247 V5248 V5249 V5250 V5251 V5252 V5253 V5254 V5255 V5256 V5257 V5258 V5259 V5260 V5261 V5262 V5263 V5264 V5265 V5275 V5298 V5299 Refer to the Hearing Aid/Audiologist Fee Schedule on the TMHP website at www.tmhp.com for the current fees. Hearing aid instrument procedures that must be manually reviewed according to the fee schedule must be submitted with the MSRP in the Comments field of the claim. If the MSRP is not included in the comments field on the original submission, the claim will be denied. Providers will be required to submit their request as an appeal, and must include an invoice validating the cost of the instrument. 23 CPT only copyright 2008 American Medical Association. All rights reserved. 23 5
Section 23 23.4 Limitations and Exclusions Clients birth through 20 years of age with suspected or confirmed hearing loss must be referred to a PACT provider. The following limitations and exclusions apply to eligible clients 21 years of age or older: Reimbursement for a hearing aid device is limited to eligible clients whose air conduction puretone average in the better ear is 45 db or greater. Hearing aid device purchases are limited to one every 6 years. Services for residents in nursing facilities (skilled nursing facility [SNF], intermediate care facility [ICF], or extended care facility [ECF]) must be ordered by the attending provider. The order must be included in the client s medical record, must state the condition necessitating the hearing aid device and/or services, and must be signed by the attending provider. No payment is made for replacement of batteries or cords. No payment is made for repairs or replacements of lost, destroyed, or inappropriate hearing aids. No binaural fittings are available except in certain documented cases of legally blind, hearing-impaired clients who have no other available resources. This information must be documented in the client s medical record as well as on the claim submitted for payment for hearing aid services. U.S.-manufactured hearing aids must be considered when the purchase price and quality are comparable to those of foreign manufacturers. Home visit hearing evaluations and fittings are permitted only with the physician s written recommendation. Auditory training, speech, reading, or other rehabilitative services are not included. Refer to: CMS-1500 Claim Filing Instructions on page 5-26. Eligibility Verification on page 4-4 for methods of determining a client's eligibility for hearing aid services. Automated Inquiry System (AIS) on page xiii for instructions or contact the TMHP Contact Center at 1-800-925-9126. 23.5 Documentation Requirements TMHP does not require prior authorization for hearing aids and related procedures. Retain reported audiological and medical information in the client s file until requested. The Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) must include an audiometric assessment. This form must provide objective documentation to support improved communication ability with amplification. Refer to: Physician s Examination Report on page B-77. Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) on page B-47. 23.6 Claims Information Hearing services must be submitted to TMHP in an approved electronic format or on the CMS-1500 claim form. Providers may purchase CMS-1500 claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. Providers supplying hearing aid devices for STAR+PLUS Medicaid Qualified Medicare beneficiary (MQMB) clients must submit claims to TMHP, not the STAR+PLUS Health Maintenance Organization (HMO), for the hearing aid devices. PACT services must be submitted to PACT. Providers may refer to the PACT website at www.dshs.state.tx.us/audio /program.shtm for more information. Refer to: TMHP Electronic Data Interchange (EDI) on page 3-1 for information on electronic claims submissions. Claims Filing on page 5-1 for general information about claims filing. CMS-1500 Claim Filing Instructions on page 5-26. Blocks that are not referenced are not required for processing by TMHP and may be left blank. 23.6.1 Claim Filing Resources Refer to the following sections and/or forms when filing claims: Resource Page Number Automated Inquiry System (AIS) xiii TMHP Electronic Data Interchange 3-1 (EDI) CMS-Claims Filing Instructions 5-26 Communication Guide A-1 Hearing Evaluation, Fitting, and B-47 Dispensing Report (Form 3503) Physician s Examination Report B-77 Hearing Aid Assessments Claim D-15 Example Acronym Dictionary F-1 23 6 CPT only copyright 2008 American Medical Association. All rights reserved.