Hearing Devices and Services Benefit to Change for Texas Medicaid

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1 Hearing Devices and Services Benefit to Change for Texas Medicaid Information posted August 17, 2012 Effective for dates of service on or after October 1, 2012, benefit criteria will change for hearing devices and services for Texas Medicaid. The benefit for monaural and binaural hearing and related services will change based on the age of the client. In addition, several new services will become a benefit for Texas Medicaid. Monaural and Binaural Hearing Aid Benefit Changes Monaural hearing aids are a benefit for clients of any age when benefit criteria are met. Binaural hearing aids are benefits for clients who are 20 years of age and younger when benefit criteria are met. Hearing aid procedure codes will be limited based on the age of the client. For clients who are 20 years of age and younger, one hearing aid procedure code may be reimbursed per ear per five-rolling-year period as follows: If hearing aids are required for one ear at a time, one monaural hearing aid procedure code may be reimbursed for the left ear with modifier LT, and one monaural hearing aid procedure code may be reimbursed for the right ear with modifier RT during a five-rolling-year period. If hearing aids are required for both ears at the same time, one binaural hearing aid procedure code may be reimbursed during a five-rolling-year period. Note: Monaural and binaural hearing aid procedure codes will not be reimbursed during the same five-rolling-year period. For clients who are 21 years of age and older, one monaural hearing aid may be reimbursed for the left ear, or one monaural hearing aid may be reimbursed for the right ear during a five-rolling-year period. If two monaural hearing aid procedure codes are submitted during the same five-rollingyear period, one of the hearing aids will be denied. Binaural hearing aid procedure codes will no longer be reimbursed for clients who are 21 years of age and older. Monaural Hearing Aid The following monaural hearing aid procedure codes may be reimbursed with established limits for services rendered to clients of any age: V5030 V5040 V5244 V5245 V5246 V5247 V5254 V5255 V5256 V5257 Monaural hearing aid procedure codes V5170 and V5180 will be benefits for services rendered to clients who are 20 years of age and younger only. Procedure codes V5170 and V5180 will no longer be benefits for services rendered to clients who are 21 years of age and older. Monaural hearing aid procedure codes must be billed with modifier LT or RT.

2 Monaural hearing aids may be reimbursed for clients who have no medical contraindication for using a hearing aid and who have documentation of medical necessity. Documentation must be maintained in the client s medical record and must demonstrate that the client meets the following criteria: Hearing loss in the better ear of 35 db or greater for the pure tone average of 500, 1000, 1500, and 2000 Hz; or a spondee threshold in the better ear of 35 db or greater when pure tone thresholds cannot be established. Documentation of communication need and a statement that the patient is alert, oriented, and able to use the device appropriately by themselves or with assistance. Clients who are 21 years of age and older must meet the hearing aid criteria outlined in this article and must have at least a 35-dB hearing loss in both ears to qualify for the purchase of a monaural hearing aid device. Binaural Hearing Aid The following binaural hearing aid procedure codes will be a benefit only for clients who are 20 years of age and younger: V5100 V5210 V5220 V5249 V5250 V5252 V5253 V5258 V5259 V5260 V5261 The binaural hearing aid procedure codes in the above table will no longer be a benefit for clients who are 21 years of age and older. Clients who are 20 years of age and younger must meet the hearing aid criteria outlined in this article and must have at least a 35-dB hearing loss in both ears to qualify for the purchase of binaural hearing aid devices. Hearing Aid-Related The following additional hearing aid-related procedures will be benefits as follows: Procedure Code Description Age Ranges Hearing aid exam All ages Hearing aid exam 20 years of age and younger Hearing aid check All ages Hearing aid check 20 years of age and younger Hearing aid evaluation All ages Hearing aid evaluation 20 years of age and younger V5010 Hearing aid assessment All ages V5011 Hearing aid fitting All ages V5264 Ear mold All ages V5265 Ear mold All ages V5275 Ear impression All ages

3 Ear Molds Claims for ear molds, procedure codes V5264 and V5265, must be submitted using modifier LT or RT. Ear molds for clients who are 20 years of age or younger may be provided to the client as medically necessary. Documentation that supports medical necessity must be maintained in the client s medical record. Ear molds for clients who are 21 years of age or older are limited as follows: Custom ear molds (procedure code V5264) are limited to three ear molds per rolling year when claims are submitted by any provider (regardless of modifier). Disposable ear molds (procedure code V5265) are limited to four ear molds per rolling month when claims are submitted by any provider (regardless of modifier). Hearing Aid Fitting Visit and Dispensing Fee The fitting visit may be reimbursed using procedure code V5011. This procedure code is limited to one visit per hearing aid for a five-rolling-year period. Only one of the following limitations is allowed based on the type of hearing aid purchased (monaural or binaural): One visit per five rolling years for each individual monaural hearing aid purchased (one visit for each ear) One visit per five rolling years for each set of binaural hearing aids purchased (one visit for both ears) The dispensing fee may be reimbursed using one of the following procedure codes: V5090 V5110 V5160 V5200 V5240 V5241 Procedure codes V5110, V5160, V5200, and V5240 may be reimbursed for services that are rendered to clients who are 20 years of age and younger. Procedure codes V5090 and V5241 may be reimbursed for services that are rendered to clients of all ages. Procedure code V5011 may be reimbursed for one fitting visit per hearing aid per procedure code billed. Hearing Aid Revisits Hearing aid revisits will be limited to a total of two per calendar year by any provider. Claims for hearing aid revisits must be submitted as follows: Services for clients of any age who have a monaural device may be reimbursed using procedure code Services for clients who are 20 years of age and younger who have binaural devices may be reimbursed using procedure code Services for clients who are 21 years of age and older who have binaural devices that were reimbursed by Texas Medicaid for dates of service on or before September

4 30, 2012, may be reimbursed to the client s treating physician or audiologist using procedure code for the first revisit and for the second revisit. Note: Binaural hearing aid revisit procedure code will not be reimbursed for services rendered to clients who are 21 years of age and older. Hearing Aid Exam and Check For procedure code 92591, services that are rendered in the office, skilled nursing facility (SNF), intermediate care facility (ICF), or extended care facility (ECF) setting may be reimbursed to hearing aid fitter and dispenser providers; and services rendered in the office, SNF, ICF, or ECF setting will no longer be reimbursed to nurse practitioner (NP), clinical nurse specialist (CNS), physician assistant (PA), clinical nurse midwife (CNM), portable X-ray supplier, radiological laboratory, and physiological laboratory providers. Services that are rendered in the home, inpatient hospital, outpatient hospital, independent laboratory, or other location setting will no longer be reimbursed. New Benefits Repair or Removal of Electromagnetic Bone Conduction Hearing Device Procedure code will be a benefit for removal or repair of an electromagnetic bone conduction hearing device and may be reimbursed as follows: The surgical component may be reimbursed to physician providers for services rendered in the inpatient hospital or outpatient hospital setting, and to ambulatory surgical center (ASC) providers for services rendered in the outpatient hospital setting. The assistant surgery component may be reimbursed to physician, NP, PA, and CNS providers for services that are rendered in the inpatient hospital or outpatient hospital setting. Two services per lifetime may be reimbursed when billed by any provider. New Hearing Aid Exams and Evaluations The following procedure codes will be a benefit of Texas Medicaid and will be reimbursed as indicated: Procedure Code 92590, 92594, Reimbursement Information Services rendered in the office, SNF, ICF or ECF setting may be reimbursed to physician, audiologist, and hearing aid fitter and dispenser providers. Procedure codes and may be reimbursed to clients of any age. Procedure code may be reimbursed for clients who are 20 years of age and younger. Benefit and Limitation Clarifications

5 30-Day Trial Period Clarifications If a hearing aid is dispensed in a provider's office and the client fails to return by the end date of the trial period, the provider must contact the client. If the client does not return to the provider s office after three attempts to contact the client, the provider must document in the client s file all contact attempts with the client and maintain this documentation in the client's file. Retrospective review may be performed to ensure documentation supports the contact attempts and the client's failure to return to the provider's office. This does not apply to clients receiving hearing aids in other places of service (i.e., nursing homes). Claim Filing Clarifications The hearing aid device and accessories are considered dispensed after the 30-day trial period has been successfully completed. After a 30-day trial period has been successfully completed, the procedure codes for the hearing aid device(s), accessories, fitting visit, and dispensing visit may be reimbursed once regardless of the number of times the hearing aid device(s) were returned during the trial period. The fitting visit may be reimbursed once per five-rolling-year hearing aid benefit period (i.e., one visit per five rolling years for each monaural hearing aid purchased, or one visit per five rolling years for each set of binaural hearing aids purchased). Auditory Rehabilitation Auditory rehabilitation will be a benefit of Texas Medicaid when medically necessary for clients who have received a surgically implanted hearing device or have prelingual or postlingual hearing loss when the treating physician has determined that auditory rehabilitation would be beneficial. The benefit for auditory rehabilitation is one evaluation and 12 visits per 6-rolling-month period. Prior authorization is not required. Auditory rehabilitation services beyond the limit of 12 visits per 6-rolling-month period must be prior authorized and will be considered for clients who are 12 months through 20 years of age, with documentation that supports the medical necessity of continued services. Additional therapy services beyond the benefit outlined above are available through the client s speech therapy benefit. Refer to the 2012 Texas Medicaid Provider Procedures Manual, Nursing and Therapy Services Handbook, subsection 4.2.3, ST and Aural Rehabilitation Services for detailed information on speech therapy benefits. The following procedure codes are benefits for auditory rehabilitation: Procedure code is an add-on procedure and must be billed with the primary procedure code (92626) in order to be considered for reimbursement. For procedure code 92626, services that are rendered in the office setting may be reimbursed to physician, audiologist, and Comprehensive Care Program (CCP)

6 providers; and services that are rendered in the outpatient hospital setting may be reimbursed to hospital providers. One service may be reimbursed every six rolling months when submitted by any provider. For procedure code 92627, services that are rendered in the office setting may be reimbursed to physician, audiologist, and CCP providers; and services that are rendered in the outpatient hospital setting may be reimbursed to hospital providers. Service will be limited to four services per day by the same provider. For procedure code 92630, services that are rendered in the office setting may be reimbursed to physician and CCP providers; services that are rendered in the outpatient hospital setting will no longer be reimbursed to physician and CCP providers. For procedure code 92633, services that are rendered in the office setting may be reimbursed to physician and CCP providers; services that are rendered in the outpatient hospital setting may be reimbursed to hospital providers. Claims for procedure codes and no longer require modifier GN. One procedure code per day and up to 12 services per 6 rolling months of either procedure code or may be reimbursed when submitted by any provider. Additional Changes The following changes will be applied to the procedure codes indicated: Procedure Code L8690, L8691 S2230 Reimbursement Information Procedure codes L8690 and L8691 must be prior authorized and are no longer restricted to certain diagnosis codes. Procedure code S2230 will no longer be reimbursed. For more information, call the TMHP Contact Center at

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