Section. 23Hearing Aid and Audiometric. Evaluations

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1 Section 23Hearing Aid and Audiometric Evaluations Enrollment Medicaid Managed Care Enrollment Reimbursement Benefits Medicaid Clients Younger Than 21 Years of Age Hearing Screenings Newborn Hearing Screening Initial Test at Birth Outpatient Hearing Screening and Diagnostic Testing for Children Birth Through Three Years of Age Three Through 20 Years of Age Adults Hearing Screening 21 Years of Age and Older Hearing Referrals Hearing Aid Instrument Warranty Day Trial Period Fitting and Dispensing Visit First Revisit Second Revisit Limitations and Exclusions Documentation Requirements Client Eligibility Claims Information Claim Filing Resources CPT only copyright 2005 American Medical Association. All rights reserved.

2 Section Enrollment To enroll in the Texas Medicaid Program, 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 a hearing aid provider 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. Refer to: Provider Enrollment on page 1-2 for more information on enrollment procedures Medicaid Managed Care Enrollment Hearing aid providers must enroll with Medicaid Managed Care to be reimbursed for services provided to Medicaid Managed Care clients Reimbursement Hearing aids and audiometric services are reimbursed in accordance with 1 Texas Administrative Code (TAC) Hearing evaluations and the first and second revisits are reimbursed according to the maximum allowable fee. Procedure codes and should be billed for the first and second revisits, respectively. Reimbursement for ear molds and the fitting and dispensing fee is limited to the established maximum fee. Hearing aid procedures indicated with "" (Manually Review) must be submitted with the Manufacturer's Suggested Retail Price (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. The maximum allowable fee for the hearing aid instrument includes: Acquisition cost of the hearing aid (the actual cost or net cost of the hearing aid 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 Charges for hearing aid components must be verified by the manufacturer s invoice and price lists. The fitting and dispensing fee includes the postfitting check of the hearing aid within five weeks after the dispensing date. Note: Charges to the client for covered services constitute a breach of the Medicaid contract. Refer to: Reimbursement Methodology on page 2-2 for more information on reimbursement. Billing Clients on page 1-9 for more information Benefits Hearing aid services are payable by the Texas Medicaid Program for clients 21 years of age and older. Services for clients younger than 21 are reimbursed through the Program for Amplification for Children of Texas (PACT). Hearing aid services, including hearing aid instruments are reimbursed when medically necessary. The benefits that are reimbursable for hearing aid services are determined by statutory and fiscal limitations Medicaid Clients Younger Than 21 Years of Age Payment for these services for clients who are Medicaideligible and younger than 21 years of age are made through the Department of State Health Services (DSHS) PACT. An appropriate hearing screening is a mandatory part of each medical checkup. When suspicion or indication of a hearing problem occurs, refer Medicaid clients younger than 21 years of age to an enrolled PACT provider. For a list of PACT providers, visit the PACT website at program.shtm, or write to: DSHS Program for Amplification for Children of Texas (PACT) 1100 West 49th Street Austin, TX Hearing Screenings Newborn Hearing Screening Health Safety Code, Chapter 47, Vernon s Texas Codes Annotated mandates that a newborn hearing screening occur at the birthing facility before hospital discharge. The hospital is responsible for the purchase of equipment, training of personnel, screening of the newborns, certification of the program according to DSHS standards, and notification to the provider, parents, and DSHS of screening results. There is no additional Medicaid reimbursement for the newborn hearing screening because the procedure is part of the newborn hospital diagnosis related group (DRG) payment. Hospitals must use procedure code to report this newborn hearing screen on the HCFA-1450 (UB-92) claim form CPT only copyright 2005 American Medical Association. All rights reserved.

3 Hearing Aid and Audiometric Evaluations This facility-based screening also 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 referral for a hearing screening 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. If a physician has any concerns about this process, the physician should contact the hospital administrator or the DSHS Audiology Services Program at Initial Test at Birth 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 Outpatient Hearing Screening and Diagnostic Testing for Children As part of the THSteps medical checkup, physicians are required to complete the hearing screening component. Separate procedure codes must not be billed when hearing screenings are part of medical checkups or day care/school requirements. Medicaid does not reimburse separately. For children who are seen in the office setting, THSteps requires a puretone audiometer for visits where objective screening is required. In other childcare settings (e.g., day care; preschool; Head Start; and elementary, middle, and high school), the DSHS Vision and Hearing Screening Program requires that a puretone audiometer be used for hearing screening. Impedance testing is usually used in the physician s office to monitor children who have a documented history of repeated bouts of otitis media and may be billed separately as a diagnostic hearing test with a THSteps checkup. Impedance testing does not meet the requirements for the sensory screening component of the THSteps checkup Birth Through Three Years of Age A hearing screening must be completed during each THSteps medical checkup. A THSteps hearing screening consists of the following: An observation and history recording obtained from a responsible adult familiar with the child Completion of the Hearing Checklist for Parents form Referral of a high-risk child to a physician who renders audiology services Three Through 20 Years of Age The provider should do the following: Assess children with a puretone audiometric hearing screen (1000, 2000, 4000 Hz) at 4 through 10 years of age. Perform a subjective hearing evaluation, to include client history and observation of the child for the ability to answer questions and follow directions at all other medical checkups where an audiometric screen is not required. Document the results of any school screening audiometric testing program in the 12 months preceding the medical check-up. Refer any child or adolescent in preschool through twelfth grade who does not respond to a 25 db tone at any frequency Adults Hearing Screening 21 Years of Age and Older Auditory brainstem response (ABR) and otoacoustic emissions (OAE) audiometry are a benefit of the Texas Medicaid Program for infants, children, and adults and may be used in addition to conventional audiometry for further diagnosis Hearing Referrals For all age groups, refer Medicaid-eligible children identified during the THSteps medical checkup as needing a diagnostic hearing evaluation or other hearing services, including hearing aids, to an approved hearing services provider. DSHS provides payment to providers for hearing services provided to low-income children who are not eligible for Medicaid. Services for children whose family income is under 150 percent of the federal poverty income limit (whether or not the child is eligible for Medicaid) are administered through the PACT. Separate procedure codes may be billed for children who require diagnostic hearing testing. The following diagnostic audiometric testing codes may be billed as appropriate 5/I-92567, 5/I/T-92585, , 5/I/T-92587, and 5/I/T CPT only copyright 2005 American Medical Association. All rights reserved. 23 3

4 Section Hearing Aid Instrument Medicaid reimbursement for hearing aid instruments is limited to eligible clients, 21 years of age and 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 instrument and have no medical contraindications for using a hearing aid. Each client must be offered an appropriate new hearing aid instrument within the Medicaid allowable fee schedule. A hearing aid instrument is reimbursable once every six years. 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 Warranty Each hearing aid instrument dispensed through the Texas Medicaid Program 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 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 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 instrument. The trial period consists of 30 consecutive days beginning with the dispensing date. During the trial period, providers may dispense additional hearing aids as medically necessary until the client is satisfied with the results of the aid, or the provider determines that the client cannot benefit from the dispensing of an additional hearing aid. A new trial period begins with the dispensing date of each hearing aid. Under the Texas Medicaid Program, if the client is not satisfied with the purchased hearing aid instrument, the client may return it to the provider, who must accept it. If the aid is returned within 30 days, the provider may charge the client a rental fee. Obtain a clientsigned acknowledgment statement stating the client is responsible for paying the hearing aid rental fees and keep it in the client s file. Providers must allow 30 days to elapse from the hearing aid dispensing date before completing a 30-Day Trial Period Certification Statement Fitting and Dispensing Visit This visit includes the hearing aid instrument s fitting, dispensing, and post-fitting check First Revisit Additional counseling is available as needed within a period of six months after the post-fitting check. The first revisit, 99211, includes a hearing aid check 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 hearing aid instrument, assessment, and revisit procedure codes. Note: Hearing aid procedures indicated with "" 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. Procedure Code Medicaid Fee $ $22.37 V5010 $44.35 V5011 $50.00 V5030 V5040 V5050 V5060 V5070 V5080 V5090 $ V5100 V5110 $ V5120 V5130 V5140 V5150 V5160 $ V5170 V5180 V5190 V5200 $ V5210 V5220 V5230 V5240 $ V5241 $ V5242 V CPT only copyright 2005 American Medical Association. All rights reserved.

5 Hearing Aid and Audiometric Evaluations Procedure Code Medicaid Fee V5244 V5245 V5246 V5247 V5248 V5249 V5250 V5251 V5252 V5253 V5254 V5255 V5256 V5257 V5258 V5259 V5260 V5261 V5262 V5263 V5264 $18.90 V5265 $18.90 V5275 $18.90 V5298 V5299 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 file 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. Not included are auditory training, speech, reading, or other rehabilitative services. Refer to: CMS-1500 Claim Filing Instructions on page 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 must be recommended by a physician (with written medical clearance) for the fitting of a hearing aid by completing the Physician s Examination Report. The Hearing Aid Evaluation Report 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-69. Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) on page B Limitations and Exclusions The following limitations and exclusions apply: Reimbursement for a hearing aid instrument is limited to eligible clients, 21 years of age and older, whose air conduction puretone average in the better ear is 45 db or greater. Hearing aid purchases are limited to one every six years with the exception of clients younger than age 21 through PACT. Clients younger than age 21 must be referred to PACT. 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 physician. The order must be on the client s chart and state the condition necessitating hearing aid services and must be signed by the attending physician. No payment is made for replacement of batteries or cords Client Eligibility The provider determines a client s eligibility for hearing aid services by: Asking to see the client s current Medicaid eligibility form (possession of a current Medicaid eligibility form with a check mark in the hearing aid box indicates the client s eligibility for the month) Using the Automated Inquiry System (AIS) to determine eligibility for Medicaid and for a hearing aid Verifying client eligibility on the TMHP website at Important: AIS provides claim status, client eligibility, benefit limitations, and current check amount. Refer to: Eligibility Verification on page 4-4. Automated Inquiry System (AIS) on page -xiii for instructions or contact TMHP Customer Service at CPT only copyright 2005 American Medical Association. All rights reserved. 23 5

6 Section Claims Information Submit claims for hearing aid services to TMHP on a CMS-1500 claim form or in an approved electronic claims format. Providers must purchase CMS-1500 claim forms from the vendor of their choice; TMHP does not supply them. Providers supplying hearing aids for STAR+PLUS Medicaid Qualified Medicare beneficiary (MQMB) clients should bill TMHP, not the STAR+PLUS HMO for the hearing aid 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-1500 Claim Filing Instructions 5-24 Communication Guide A-1 Hearing Evaluation, Fitting, and B-41 Dispensing Report (Form 3503) Physician s Examination Report B-69 Hearing Aid Assessments Claim Example D-15 Acronym Dictionary F CPT only copyright 2005 American Medical Association. All rights reserved.

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