Billing &
Coding Support

BILLING

Establishing billing and collections policies that are in compliance with federally mandated HIPAA requirements, and are cost effective to implement and maintain, is certainly one of the most challenging aspects of running a successful practice.

Submitting claims correctly the first time is necessary to keep costs to a minimum. According to the AMA, the average resource cost for in-practice claims filings is $11.50 to $18.00 per claim. There are several basic steps practitioners may employ to reduce denials and keep billing costs to a minimum:

STEP 1: MAINTAIN CURRENT REFERENCE TOOLS

Keep a current copy of the CPT, ICD10 (the ICD11 is pending and will be reflected on this page in January of 2017), and HCPCS manuals. These can be purchased from the:

STEP 2: USE A SUPERBILL

Correct use of a Superbill will help reduce denials. Every office needs a Superbill that contains all of the most up to date CPTs, ICD10s, and HCPCS codes; this form must be reviewed and updated annually. Please review our Superbill sample as a guideline, but do modify the Superbill to cover the needs in your office.

Ensure you are only using CPT, ICD10 and HCPCS codes; all local codes have been eliminated under HIPAA. Ensure all necessary modifiers are used and that you note the correct place of service code.

STEP 3: STAY ON TOP OF CONTRACT GUIDELINES

Be aware of the guidelines and contract requirements of the major insurance carriers in your community, including Medicare and Medicaid.

STEP 4: USE ELECTRONIC CLAIM SUBMISSIONS

Electronic claims submissions result in fewer denials, as there is less human error in the claims submission process. Any practice that has 10 or more full-time equivalent employees must file Medicare claims electronically per HIPAA. Medicare provides low or no-cost software to providers for submitting Medicare claims. If you must file paper claims, make sure your staff is knowledgeable on how to correctly complete a HCFA-1500 form. Visit the CMS website for paper forms and instructions.

Tips for Filing Claims and Reducing Denials

[Note: Some carriers prohibit the practitioner from collecting directly from the patient - check your contract with the insurance provider.]

CODING

Coding for audiological services is a complex task. Payment for services requires the use of specific coding systems that indicate patient diagnoses, services, and procedures. It is imperative that practitioners invest the time to learn correct coding procedures, or else payers may not understand the services or products used and will automatically refuse to pay, or pay at a minimal rate.

EarQ offers a number of resources for practitioners to stay current on acceptable coding practices. Within this coding section, you will find tips as well as do's and don'ts for using CPT codes and HCPCS codes. In addition, EarQ has selected the reference tools below to provide additional help on these topics.

Diagnostic Codes

Remember, for effective billing, use the diagnosis code that is provided by a physician in the referral. If not provided, remember that those in the hearing healthcare industry use the diagnosis code based on symptoms.

Code Reference Charts for Audiologists

(Available for download in the "Documents/Tools" section on the left)

Codes Available for Purchase Online

Coding manuals (CPT, ICD10, and HCPCS Level II) are available for purchase through the AMA. Electronic data file versions are also available for purchase and download.

To obtain a copy of the current CPT Manual by mail contact:

American Medical Association 515 North State Street Chicago, IL 60610 800-621-8335

Current Procedural Terminology (CPT) - The Basics of CPTs

CPT is an acronym for Current Procedural Terminology. CPTs are five-digit numeric codes, created and owned by the American Medical Association, to describe medical services and procedures. (Most audiology-related codes begin with the numbers 92-.) These codes are added, deleted, and modified annually. As ancillary medical professionals, it is important for us to consider that CPTs are created by the AMA, and to consult AMA in the presence or absence of particular codes or procedures.

When it comes to CPT codes, one basic premise applies: always select coding which legitimately represents all of the procedures that were completed on each individual patient. Remember, third-party payers, particularly Medicare, cover only the procedures needed to diagnose an otologic or auditory disorder in a patient. Routine services are typically non-covered. For this reason, use of an Advance Beneficiary Notice is essential.

The Advance Beneficiary Notice allows your practice to bill Medicare recipients directly (privately) for non-covered services (i.e. routine audiograms, audiograms for the purpose of obtaining a hearing aid, cerumen removal).

As of October 2003, HIPAA regulations require that all insurance carriers, including Medicare and Medicaid, use CPTs to report the testing or procedures that were completed. Therefore, it is imperative for all hearing healthcare practices to be current on CPT codes and their application.

CPT TIPS

EXAMPLE: Do not bill 92553 for pure-tone air and bone and 92556 for speech awareness threshold and speech recognition rather than 92557 for a comprehensive audiogram, which includes the two former procedures.

EXAMPLE: If you bill out services under your physician-employer's UPIN number, or if you are billing for intraoperative monitoring, cerumen removal, or canalith repositioning.

EXAMPLE: Patient F is having a post-op hearing evaluation on his operative ear only. If audiologist G billed for 92557, he/she must add a 52 modifier (Reduced services) to reflect that only one ear was tested. 92586 (ABR; limited) and 92587 (OAE; limited) are screening measures, often used in infant screening. 92585 (ABR; comprehensive) and 92588 (OAE; comprehensive) are clinical or diagnostic measures.

Common Procedure Coding System - The Basics of HCPCS

HCPCS is the acronym for HCFA (Health Care Financing Administration), a common procedure coding system. This system is used to bill specific procedures, services, and supplies that are not defined or outlined in the CPT coding system.

HCPCS codes are used by hearing healthcare providers to bill hearing aids and supplies to third party payers. The insurance carrier will specify if they want a bundled or unbundled hearing aid price package.

HCPCS codes consist of a letter followed by four digits. Hearing services are classified as a V followed by the number 5000-5999. Cochlear implants, bone anchored hearing aids, and their supplies are often classified for third party payers by an L code followed by four digits.

HCPCS coding (see "Documents/Tools") changed markedly in 2002; therefore, it is highly recommended for healthcare professionals use the latest HCPCS reference book, available for purchase on the AMA website.

HCPCS TIPS: DO's & DONT'S

In order to use HCPCS codes for hearing aid billing, practices must create an unbundled hearing aid cost package.

Do not forget to bill for the hearing aid itself, the conformity evaluation (V5020), the fitting/orientation/checking of hearing aid (V5011), the assessment for hearing aid (V5010) and batteries (V5266), as well as the aid itself, any ear molds (V5264), the ear mold impression (V5275) and the dispensing fee (V5241 or V5160).

Unless restricted by a contractual obligation which requires an actual manufacturer's invoice cost, bill insurance companies for the single-unit price of the hearing aid rather than any discounted price. The insurance plan should not get the benefit of a provider's volume discount; it will also increase the hearing healthcare professional's profit margin.

Contact the insurance company, prior to seeing the patient to determine coverage and amounts.

99% of the time, insurance carriers do not cover 100% of the cost of binaural, digital hearing aids; if an insurance carrier will not provide you with a benefit amount, assume the maximum benefit is $1000 per ear.
It is essential to perform an insurance verification; create a standard form that can be modified when needed.

Be familiar with the terms of the managed care contracts you have signed so you can determine if you are contractually allowed to balance-bill the patient if they opt for more advanced hearing aids. (Balance-bill refers to billing the patient for the difference between their insurance coverage and your office's usual and customary fee for the hearing aid they have selected.)

If the coverage sounds too good to be true, it probably is!

A predetermination letter (see "Documents/Tools") is never a bad idea when dealing with hearing aids in a managed care environment.

DISCLAIMER: The foregoing information is provided as a resource for our members. It is not intended and should not be construed as an endorsement of any of the vendors or their products or services; as such, The EarQ Group makes no warranty whatsoever, either express or implied, including the warranties of merchantability and fitness for a particular purpose regarding any of the products listed above and makes no recommendation as to the accuracy or suitability of the information for your particular situation. EarQ Group members are encouraged to seek legal counsel to ensure compliance and are responsible for their own knowledge of both federal and state policies as it pertains to HIPAA. Neither The EarQ Group, nor any of its officers, directors, agents, employees, committee members or other representatives shall have any liability for any claim, whether founded or unfounded, of any kind whatsoever, including, but not limited to, any claim for costs and legal fees, arising from the use of these opinions.

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