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Breaking News: 2012 Brings Coding and Reimbursement Changes to Audiology

Abel, Debbie AuD

doi: 10.1097/

Dr. Abel is a Senior Education Specialist of Business Practices with the American Academy of Audiology.



While we were ringing in the new year, several important coding and reimbursement changes for hearing health care took effect. There are new and revised otoacoustic emission (OAE) codes, an additional measure for the Physician Quality Reporting System (PQRS), changes to the Health Insurance Portability and Accountability Act (HIPAA), a new Advanced Beneficiary Notice form, and changes in Medicare enrollment.

Figure. Debbie

Figure. Debbie

Before they adjourned at the end of 2011, Congress approved a two-month extension, which suspended the planned reimbursement cuts that on Jan. 1 would have cut all Medicare-reimbursed procedures by 27.4 percent. This extension will allow 2011 rates to Medicare beneficiaries to continue until the end of February, giving Congress time to agree on a long-term, permanent solution to the Sustainable Growth Rate, a flawed system that threatens to increase the cuts to reimbursement each year. If Congress fails to act by the end of February, the 27.4 percent decrease for all Medicare reimbursed procedures will take effect. This fee schedule is not only essential to Medicare reimbursement rates; many commercial payors also base their fee schedules on the Medicare fee schedule.

Audiologists have suffered several successive years of deep decreases in reimbursement, especially for core procedures such as CPT code 92557 (comprehensive audiometry and the bundled immittance test codes), 92550 (tympanometry, acoustic reflex thresholds), and 92570 (tympanometry, acoustic reflex thresholds, and acoustic reflex decay). The decrease in reimbursement for 92557 and several other audiology procedures is a result of the transition in reimbursement status.

Audiologists moved from the non-physician method of payment to being recognized and paid for work and cognition, one of the three components of the relative value unit formula (the other two are practice expense and professional liability).

CPT codes are created by the American Medical Association Relative Value Scale Committee and then submitted to the Centers for Medicare and Medicaid Services for approval. CMS decreased the OAE reimbursement levels for CPT codes 92587 and 92588 from the recommended values in the 2012 final rule for the Medicare Physician Fee Schedule.

The decrease in reimbursement for the 2010 bundled codes 92540 (basic vestibular evaluation), 92550, and 92570 is a result of a screen conducted by CMS on all procedures performed 90 percent of the time or more on the same date of service. These identified services were then required to be bundled into one code as a Medicare cost-saving measure. Since that time, audiologists have experienced a 50 percent reduction when a claim is filed with 92540. It is anticipated that additional procedure codes will be moved to a bundled format through this process in the future.

CMS also tracks codes that have a substantial increase in utilization over a short period of time. This phenomenon occurred with the limited OAE code, 92587, which caught CMS' attention. An early survey of audiologists illustrated two uses for 92587, screening and limited, and as a result, a new screening OAE CPT code, CPT 92558, results in a pass-fail response via automated analysis. The definitions and requirements for CPT codes 92587 and 92588 have been clarified, and a report explaining the test results must be included in the chart notes.

CPT code 92558 covers evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), and automated analysis. This code is a pass-fail screening at a single intensity level with automation. This is not a covered service under Medicare, but you will need to check with your commercial payors for guidance on this code.

CPT code 92587 is distortion product evoked otoacoustic emissions; limited evaluation to confirm the presence or absence of hearing disorder, three to six frequencies, or transient evoked otoacoustic emissions with interpretation and report. This code is used when you are testing three to six frequencies bilaterally for distortion product OAEs. If you also perform transient OAEs, your payor may recognize the -22 modifier increased procedural services. CPT code 92587 includes the interpretation of the test and a report of the results in the patient's record. You will need to check with your Medicare contractors and commercial payors for guidance on this code and associated modifiers.

CPT code 92587 will have a work value of 0.35 (from the recommended 0.45) for a reimbursement rate of approximately $28 to address the SGR. This amount does not include the Geographic Price Cost Index. You will want to check your Medicare contractor's website for the most current fee schedule.

CPT code 92588 covers comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping) with interpretation and report. It requires a minimum of 12 frequencies in each ear, with the interpretation of the test and a report of the results in the patient's record. If less than 12 frequencies were performed, you will file the claim with 92587. Again, check with your Medicare contractors and commercial payors for guidance on this code and associated modifiers.

CPT code 92588 will have a work value of 0.55 (from the recommended 0.60), for a reimbursement rate of approximately $43. This does not include the Geographic Price Cost Index. You will want to check your Medicare contractor's website for the most current fee schedule.

For audiologists who practice in hospital outpatient facilities, there will be a slight increase to the 2012 Outpatient Prospective Payment System (OPPS) rates with the exception of basic comprehensive audiometry, cochlear implantation, and evoked otoacoustic emission testing. The ambulatory payment classifications have been changed for 92570, resulting in an increase, but the end result will be a decrease because of a reclassification of CPT code 92588. While the rates for implantation of osseo-integrated devices will increase slightly, the payment for cochlear implantation and implant follow-up will decrease.

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No ICD-9 or HCPCS codes pertinent to audiologists were added for 2012. The date of compliance for the ICD-10 codes will be Oct. 1, 2013, and practices will need to modify their encounter forms and computer systems and consult with billing and clearinghouse vendors to ensure compliance. (See FastLinks for additional further information on the ICD-10 conversion process.)

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CMS has added an additional measure in 2012 on which enrolled Medicare Part B audiologists may report. The Referral for Otology Evaluation for Patients with Acute or Chronic Dizziness measure brings the total eligible reportable measures for audiologists to four, along with congenital or traumatic deformity of the ear; a history of active drainage from the ear within the previous 90 days (for patients who have disease of the ear and mastoid processes), and sudden or rapidly progressive hearing loss.



Audiologists are encouraged to report on all four measures to increase professional recognition within Medicare as well as secure a 0.5 percent bonus of all allowable charges until 2014 for successful reporting. Beginning in 2015, providers who do not satisfactorily report on eligible measures will face a 1.5 percent penalty on Medicare reimbursement. Participating in Physician Quality Reporting System is easy. Just add a modifier to the CMS-approved CPT and ICD-9 codes. (See FastLinks for more information.)

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Effective Jan. 1, the Health Insurance Portability and Accountability Act required the use of HIPAA version 5010 for facilities that transmit personal health information, but CMS recently announced it will not enforce it until March 31. All billing vendors are required to use HIPAA version 5010 in preparation for the Oct. 1, 2013, compliance of the new ICD-10 disease coding system. The previous HIPAA version, 4010, is compatible with the ICD-9 coding system but not with ICD-10. If your claim vendors are not in compliance, claims will likely be denied.

Any facility that accesses, stores, or transmits personal health information is required to meet HIPAA standards. The Office for Civil Rights and the Department of Health and Human Services will continue to test HIPAA privacy and security compliance. Covered entities, including audiology practices, may receive a letter to test audit protocols.

Data breaches continue to make headlines because those affecting more than 500 patients must be reported to the local media. (See FastLinks for more on this from HHS.) Finally, state attorneys general are now trained to perform HIPAA audits, and may issue fines if breaches are discovered.

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Providers enrolled in Medicare Part B prior to March 25, 2011, including audiologists, will be receiving letters from their Medicare contractor requiring the revalidation of Medicare enrollment this year. Providers must revalidate within 60 days of receiving the letter or risk having their Medicare Provider Transaction Number deactivated and claims denied. The letter will arrive in a colored envelope for simple identification, and contractors have requested that you not act until you receive it. (See FastLinks for a sample revalidation letter and more information.)

Those who enrolled in Medicare prior to 2004 will also need to enroll in the Provider Enrollment Chain, Ownership System (PECOS). (See FastLinks.) PECOS also may be used to update a change in office address or a change in a final adverse action no later than 30 days after these have occurred.

Changes in Social Security numbers, business structure (e.g., a sole proprietorship to a corporation), or reassignment of benefits if the provider is not enrolled in PECOS must be submitted via hard copy no later than 90 days after the change occurred.

CMS also issued a new Advanced Beneficiary Notice form, CMS-R-131, which must be utilized after Jan. 1. The form has the “3/11”release date in the lower left corner. (See FastLinks for instructions on use.)

Effective last March 25, only Medicare institutional providers were required to pay an enrollment fee when initially enrolling in Medicare, revalidating their Medicare enrollment, or adding a new Medicare practice location when filing the CMS 855A. The fee for 2012 is $525, and applies only to institutions such as rehabilitation facilities, not private practice audiology or otolaryngology offices.

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• More information on the ICD-10 conversion process is available at,, and

• Read more about the Physician Quality Reporting System and the modifier to CMS-approved CPT and ICD-9 codes at

• HHS has information about data breaches at

• Read more about Medicare revalidation at

• For more information about the Provider Enrollment Chain, Ownership System (PECOS), visit

• The new Advanced Beneficiary Notice form, CMS-R-131, and instructions for its use are available at

• Comments about this article? Write to HJ at

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