Patient: A 65-year-old male who is a Medicare Part B beneficiary, whose testing was ordered by his internist

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1 The following examples are to assist you with PQRS reporting. These examples were created in collaboration with the Academy of Doctors of Audiology and the American Speech-Language-Hearing Association to assist audiologists in better understand the practicalities of the PQRS system. Currently, all Medicare Part B fee-for-service patients are eligible patients. When you perform (comprehensive audiology evaluation), (tympanometry) or (acoustic reflex testing), you have 2 measures that are reportable, and maybe 3, depending on the ICD-9 codes. You must report measures based on the CPT and ICD-9 codes, not based on the measure description. Example #1: Patient: A 65-year-old male who is a Medicare Part B beneficiary, whose testing was ordered by his internist Chief Complaint: Gradual hearing loss bilaterally. He does not report any difference in hearing acuity between his ears. He has never had his hearing tested previously and he has never worn amplification No history of head injury or any recent accident or injury No history of noise exposure, ear drainage, cerumen impaction, tinnitus, dizziness or ear pain Patient does not currently take any prescription medication, over the counter medications or multivitamins Otoscopy revealed two large exotoses in both ears. The patient revealed that he swims daily in Lake Michigan, 6-8 months out of the year. Comprehensive hearing test (92557) No depression screen was performed Sensorineural hearing loss, bilateral (389.18) Exotosis of external ear canal (380.81)

2 Referral to otolaryngologist for an otologic evaluation due to canal exotoses prior to hearing aid evaluation and selection Evaluation for binaural amplification pending medical evaluation and clearance Measure #188: Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of the Ear G8556: Referral to a physician for an otologic evaluation performed rapidly progressive hearing loss (this is still the appropriate code to report as a referral for the otologic evaluation was necessary due to the exotoses) G8430: Provider documentation that patient is not eligible for medication assessment appropriate standardized tool (this is the appropriate code as a screening was not performed) Example #2: Patient: A 75-year-old male who is a Medicare Part B beneficiary, testing was ordered by his otologist Chief Complaint: Patient was in a serious car accident four days prior to the appointment, having sustained significant damage/trauma to his right outer ear as a result of the air bag deploying. Patient reports hearing loss, drainage, otalgia, and tinnitus in his right ear. The patient has worn hearing aids bilaterally for the past five years and was wearing his hearing aids at the time of the accident. No prior history of noise exposure, cerumen impaction or dizziness Patient currently takes an oral dose of Synthroid daily for his thyroid condition and Xanex orally, as needed, for anxiety

3 Otoscopy was unremarkable for the left ear and revealed evidence of a hematoma on the right pinna, drainage and swelling/collapse of the right ear canal. The referring physician reported that the right tympanic membrane was perforated. Comprehensive hearing test (92557) Tympanometry (92567) No depression screen was performed Sensorineural hearing loss, unilateral (389.15) Mixed hearing loss, unilateral (389.21) Hematoma of auricle or pinna (380.31) Acquired stenosis of external ear canal, secondary to trauma (380.51) Central perforation of tympanic membrane (384.21) Report including the results forwarded to ordering otologist for review Recommend follow-up testing following medical/surgical intervention by otologist Recommend use of a water resistant ear plug in his right ear when showering or swimming until perforation healed Hearing aid follow-up/check appointment post medical clearance when patient may resume hearing aid use in the right ear. Measure #188: Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of the Ear

4 G8557: Patient is not eligible for the referral for otologic evaluation measure (e.g. for patients for whom an assessment of the congenital or traumatic deformity of the ear has been performed by a physician within the past six months, patients already under the care of a physician for congenital or traumatic deformity of the ear rapidly progressive hearing loss G8428: Current medications (includes prescription, over the counter, herbals, vitamin/mineral [nutritional] supplements) with drug name, dosage, frequency, and route not documented by the provider, reason not specified (this is still the appropriate code, as the audiologist documented the drug name, frequency and route but did not document the dosage) appropriate standardized tool (this is the appropriate code as a screening was not performed) Example #3: Patient: A 67-year-old female who is a Medicare Part B beneficiary, testing was ordered by her primary care physician Chief Complaint: Gradual hearing loss bilaterally, with poorer hearing in the right ear. She has noticed stuff, including a bit of blood, coming out of her right ear for the past two weeks. She has never had her hearing tested previously and has never worn amplification No history of noise exposure, cerumen impaction, dizziness, tinnitus, trauma or deformity of the ear, or ear pain Patient reports allergies for which she takes one 10 mg. Claritin tablet orally each day. Otoscopy unremarkable for the left ear but noted drainage and otorrhea for the right ear. Comprehensive hearing test (92557) Tympanometry (92567) No depression screen was performed

5 Sensorineural hearing loss, unilateral (389.15) Mixed hearing loss, unilateral (389.21) Otorrhea, unspecified (388.60) Referral to otolaryngologist for an otologic evaluation due to drainage and otorrhea in the right ear Use of a water resistant ear plug in right ear when showering or swimming until drainage subsides Evaluation for binaural amplification pending medical evaluation, treatment and clearance Measure #189: Referral for Otologic Evaluation for Patients with a History of Active Drainage From the Ear Within the Previous 90 Days G8560: Patient has a history of active drainage from the ear within the previous 90 days G8559: Patient referred to a physician for an otologic evaluation rapidly progressive hearing loss (this is still the appropriate code to report as a referral for the otologic evaluation was necessary due to the drainage, otorrhea, and mixed hearing loss) appropriate standardized tool (this is the appropriate code as a screening was not performed)

6 Example #4: Patient: An 80-year-old female who is a Medicare Part B beneficiary, testing was ordered by her otolaryngologist Chief Complaint: Hearing loss bilaterally. The otolaryngologist has diagnosed the patient with acute serous otitis media bilaterally. She has never had her hearing tested previously and has never worn amplification No history of noise exposure, cerumen impaction, dizziness, tinnitus, trauma or deformity of the ear, or ear pain Patient reports allergies for which she takes one 10 mg. Claritin tablet orally each day during the spring and fall months only. She is currently taking 250mg of Zithromax orally each day for the next 5 days (she is currently on day two) for her ear infection. Otoscopy revealed cloudy tympanic membranes bilaterally Comprehensive hearing test (92557) Tympanometry (92567) No depression screen was performed Mixed hearing loss, bilateral (389.22) Acute serous otitis media (381.01; diagnosis provided by ordering physician) Report including the results forwarded to ordering otolaryngologist for review Recommend follow-up testing following medical/surgical intervention by otolaryngologist Hearing aid follow-up/check appointment post medical clearance when patient medically may resume hearing aid use in the right ear.

7 Measure #189: Referral for Otologic Evaluation for Patients with a History of Active Drainage From the Ear Within the Previous 90 Days G8560: Patient has a history of active drainage from the ear within the previous 90 days G8561: Patient is not eligible for referral for otologic evaluation for patients with a history of active drainage measure (e.g. patients who are already under the care of a physician for active ear drainage) rapidly progressive hearing loss (this is still the appropriate code to report as a referral for the otologic evaluation was necessary due to the drainage, otorrhea, and mixed hearing loss) appropriate standardized tool (this is the appropriate code as a screening was not performed) Example #5: Patient: A 68-year-old male who is a Medicare Part B beneficiary, testing was ordered by his primary care physician Chief Complaint: Gradual hearing loss and tinnitus bilaterally. He does not report any difference in hearing acuity between his ears. He reports that his tinnitus is annoying but not life altering. He has never had his hearing tested previously and he has never worn amplification History of occupational and recreational noise exposure bilaterally No history of ear drainage, cerumen impaction, dizziness, trauma or deformity of the ear, or ear pain

8 Patient reports a history of hypertension and angina. He takes a One a Day vitamin, Lipitor and Ranexa orally daily (did not have dosage information available) Otoscopy unremarkable bilaterally Comprehensive hearing test (92557) Tympanometry and acoustic reflex threshold testing (92550) Assessment of tinnitus (92625) No depression screen was performed Sensorineural hearing loss, bilateral (389.18) Tinnitus, subjective (388.31) Referral to otolaryngologist for an otologic evaluation and medical clearance due to tinnitus and asymmetry between ears Evaluation for binaural amplification pending medical evaluation and clearance rapidly progressive hearing loss (this is still the appropriate code to report as a referral for the otologic evaluation was necessary due to the report of tinnitus and the asymmetry between ears) G8428: Current medications (includes prescription, over the counter, herbals, vitamin/mineral [nutritional] supplements) with drug name, dosage, frequency, and route not documented by the provider, reason not specified (this is still the appropriate code, as the audiologist documented the drug name, frequency and route but the dosage was not documented) appropriate standardized tool (this is the appropriate code because a screening was not performed)

9 Example #6: Patient: A 72-year-old male who is a Medicare Part B beneficiary, testing was ordered by his primary care physician Chief Complaint: Sudden (occurred within the last 24 hours) hearing loss and tinnitus in the right ear. He has never had his hearing tested previously and he has never worn amplification No history of noise exposure, ear drainage, cerumen impaction, dizziness, trauma or deformity of the ear, or ear pain Patient reports a history of hypertension. He takes a One a Day vitamin, Lipitor and Ranexa orally daily (did not have dosage information available); he also takes Viagra orally as needed Otoscopy unremarkable bilaterally Comprehensive hearing test (92557) Tympanometry and acoustic reflex threshold testing (92550) No depression screen was performed Sensorineural hearing loss, asymmetrical (389.16) Tinnitus, subjective (388.31) Immediate referral for an otologic evaluation due to tinnitus and asymmetric hearing loss Follow-up testing as part of or post medical intervention

10 G8565: Verification and documentation of sudden or rapidly progressive hearing loss G8564: Patient was referred to a physician for an otologic evaluation G8428: Current medications (includes prescription, over the counter, herbals, vitamin/mineral [nutritional] supplements) with drug name, dosage, frequency, and route not documented by the provider, reason not specified (this is still the appropriate code, as the audiologist documented the drug name, frequency and route but the dosage was not documented) appropriate standardized tool (this is the appropriate code as a screening was not performed) Example #7: Patient: A 68-year-old female who is a Medicare Part B beneficiary, testing was ordered by her primary care physician Chief Complaint: Gradual hearing loss bilaterally and dizziness. She does not report any difference in hearing acuity between her ears. Dizziness is described as a spinning sensation when she gets up in the morning or moves her head quickly. She has never had her hearing tested previously and has never worn amplification No history of head injury or any recent accident or injury No history of ear drainage, cerumen impaction, tinnitus, trauma or deformity of the ear, or ear pain Patient reports osteoporosis for which she takes a daily One a Day vitamin orally and Boniva monthly (did not have dosage information available) Otoscopy unremarkable bilaterally Comprehensive hearing test (92557) Basic vestibular evaluation (92540) Caloric vestibular test, per irrigation (92543 x 4) No depression screen was performed Sensorineural hearing loss, bilateral (389.18)

11 Benign paroxysmal positional vertigo (386.11) Referral to otolaryngologist for an otologic evaluation, treatment and medical clearance due to BPPV diagnosis Evaluation for binaural amplification pending medical evaluation and clearance Measure #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness G8856: Referral to a physician for otologic evaluation performed rapidly progressive hearing loss (this is still the appropriate code to report as a referral for the otologic evaluation was necessary due to the BPPV) G8428: Current medications (includes prescription, over the counter, herbals, vitamin/mineral [nutritional] supplements) with drug name, dosage, frequency, and route not documented by the provider, reason not specified (this is still the appropriate code, even though the audiologist documented the drug name, frequency and route but the dosage was not documented) appropriate standardized tool (this is the appropriate code because a screening was not performed) Example #8: Patient: An 80-year-old female who is a Medicare Part B beneficiary, testing was ordered by her otolaryngologist Chief Complaint: Patient reports her dizziness as an unsteady feeling. She does not report any hearing loss.

12 She has never had her hearing tested previously and she has never worn amplification No history of head injury or any recent accident or injury No history of noise exposure, ear drainage, cerumen impaction, tinnitus, trauma or deformity of the ear, or ear pain The patient is a Type II diabetic and has vascular issues for which she injects insulin at least three times per day and takes Pletal orally two times per day Otoscopy unremarkable bilaterally Comprehensive hearing test (92557) Basic vestibular evaluation (92540) Caloric vestibular test, per irrigation (92543 x 4) No depression screen was performed Sensorineural hearing loss, bilateral (389.18) Dizziness (780.4) Follow-up with otolaryngologist given test findings Evaluation for binaural amplification pending medical evaluation and clearance Measure #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness G8857: Patient is not eligible for the referral for otologic evaluation measure (e.g. patients who are already under the care of a physician for acute or chronic dizziness) rapidly progressive hearing loss (this is still the appropriate code to report as a referral for the otologic evaluation was necessary due to the dizziness)

13 G8428: Current medications (includes prescription, over the counter, herbals, vitamin/mineral [nutritional] supplements) with drug name, dosage, frequency, and route not documented by the provider, reason not specified (this is still the appropriate code, even though the audiologist documented the drug name, frequency and route but the dosage was not documented) appropriate standardized tool (this is the appropriate code because a screening was not performed) Example #9: Patient: An 80-year-old female who is a Medicare Part B beneficiary, testing was ordered by her otolaryngologist Chief Complaint: Patient reports hearing loss bilaterally. There is no report of any asymmetry in hearing acuity between her ears. She had her hearing tested five years ago and currently wears bilateral hearing aids She recently noted a significant change in her hearing bilaterally No history of head injury or any recent accident or injury No history of noise exposure, ear drainage, cerumen impaction, tinnitus, trauma or deformity of the ear, or ear pain The patient take one 150mg Boniva tablet orally each month for osteoporosis Otoscopy unremarkable bilaterally Comprehensive hearing test (92557) No depression screen was performed Sensorineural hearing loss, bilateral (389.18; no significant change in hearing noted) Hearing aid check/evaluation to assess the function and appropriateness of her current amplification

14 rapidly progressive hearing loss G8427: List of current medications (includes prescription, over the counter, herbals, vitamin/mineral [nutritional] supplements) documented by the provider, including drug name, dosage, frequency, and route appropriate standardized tool (this is the appropriate code because a screening was not performed) Example #10: Patient: An 80-year-old male who is a Medicare Part B beneficiary, testing was ordered by a nurse practitioner Chief Complaint: Patient reports hearing loss and tinnitus He has never had his hearing tested before and has never worn amplification No history of head injury or any recent accident or injury No history of ear drainage, cerumen impaction, trauma or deformity of the ear, or ear pain The patient is an arthritic Type II diabetic for which he injects insulin at least three times per day and receives a bimontly Humira injection Otoscopy unremarkable bilaterally Comprehensive hearing test (92557) Assessment for tinnitus (92625) Negative depression screen using Geriatric Depression Scale

15 Sensorineural hearing loss, bilateral (389.18) Tinnitus, subjective (388.31) Evaluation for binaural amplification pending medical evaluation and clearance rapidly progressive hearing loss G8428: Current medications (includes prescription, over the counter, herbals, vitamin/mineral [nutritional] supplements) with drug name, dosage, frequency, and route not documented by the provider, reason not specified (this is still the appropriate code, as the audiologist documented the drug name, frequency and route but the dosage was not documented for all medications) G8510: Negative screen for clinical depression using an age appropriate standardized tool, follow-up not required Example #11: Patient: A 67-year-old female who is a Medicare Part B beneficiary, testing was ordered by her otolaryngologist Chief Complaint: Patient reports a significant, progressive hearing loss bilaterally. The patient is being evaluated for a cochlear implant. She has worn hearing aids consistently since she was 40 years of age No history of head injury or any recent accident or injury No history of noise exposure, ear drainage, cerumen impaction, tinnitus, trauma or deformity of the ear, or ear pain Patient takes no medications Otoscopy unremarkable bilaterally

16 Comprehensive hearing test (92557) Evaluation of aural rehabilitation status, first hour (92626) No depression screen was performed due to poor speech understanding abilities Sensorineural hearing loss, bilateral (389.18) Follow-up with otolaryngologist given test findings Comprehensive evaluation for cochlear implant pending medical review rapidly progressive hearing loss G8430: Provider documentation that patient is not eligible for medication assessment G8433: Screening for clinical depression using an age appropriate tool not, documented, patient not eligible/appropriate Example #12: Patient: A 65-year-old female who is a Medicare Part B beneficiary, testing was ordered by her primary care physician Chief Complaint: Patient reports difficulty understanding people, especially in noise

17 She has never had her hearing tested before and she has never worn amplification No history of head injury or any recent accident or injury No history of noise exposure, ear drainage, cerumen impaction, tinnitus, trauma or deformity of the ear, or ear pain The patient takes 25mg of Xanax orally, as needed for anxiety, 10mg of Ambien as needed for sleep and a 500mg Motrin as needed for pain Otoscopy unremarkable bilaterally Comprehensive hearing test (92557) Positive depression screen using Beck Depression Screen Hyperacusis (388.42) Recruitment (388.43) Immediate follow-up with primary care physician due to positive depression screening Follow-up with audiology to assess and provide treatment for hyperacusis G8427: List of current medications (includes prescription, over the counter, herbals, vitamin/mineral [nutritional] supplements) documented by the provider, including drug name, dosage, frequency, and route G8431: Positive screen for clinical depression using an age appropriate standardized tool and a follow-up plan documented