Chapter 19Hearing Services 19 19.1 Enrollment...................................................... 19-2 19.1.1 Hearing Services for Children.................................... 19-2 19.2 Benefits, Limitations, and Authorization Requirements...................... 19-3 19.2.1 Audiology and Audiometry Evaluation and Diagnostic Services............ 19-3 19.2.2 Hearing Aid Devices and Accessories.............................. 19-5 19.2.2.1 Hearing Aid Devices...................................... 19-5 19.2.2.2 Supplies and Accessories................................. 19-6 19.2.2.3 Hearing Aid Warranty: Repairs and Modifications................. 19-7 19.2.2.4 Fitting and Dispensing Visits and Revisits...................... 19-7 19.2.3 Prior Authorization Requirements................................. 19-8 19.2.4 Bone-Anchored Hearing Aid (BAHA)................................ 19-9 19.2.4.1 Prior Authorization Requirements........................... 19-10 19.2.4.2 Procedure Code Limitations............................... 19-11 19.2.4.3 Reimbursement........................................ 19-11 19.2.5 Cochlear Implants........................................... 19-11 19.2.5.1 Cochlear Implants Authorization Requirements................. 19-13 19.2.5.2 Sound Processor Replacement Guidelines..................... 19-13 19.3 Claims Information............................................... 19-13 19.4 Reimbursement................................................. 19-13 19.5 TMHP-CSHCN Services Program Contact Center.......................... 19-14 CPT only copyright 2009 American Medical Association. All rights reserved.
Chapter 19 19.1 Enrollment Audiologists may enroll with the CSHCN Services Program as individuals or as groups and hearing aid fitters and dispensers may enroll with the CSHCN Services Program as individuals or as facilities. Appropriately-licensed providers may enroll as CSHCN Services Program providers by completing the provider enrollment application available through the TMHP-CSHCN Services Program. Providers must be actively enrolled as Texas Medicaid providers before enrolling in the CSHCN Services Program. A provider of hearing aid fitting and dispensing services must also be licensed by the Texas State Committee of Examiners for Speech, Language, Pathology, and Audiology. Out-of-state providers must meet all of these conditions, and be located in the United States, within 50 miles of the Texas state border. Important: CSHCN Services Program providers are responsible for knowing, understanding, and complying with the laws, administrative rules, and policies of the CSHCN Services Program and Texas Medicaid. By enrolling in the CSHCN Services Program, providers are charged not only with knowledge of the adopted CSHCN Services Program agency rules published in Title 25 Texas Administrative Code (TAC), but also with knowledge of the adopted Medicaid agency rules published in 1 TAC, Part 15, and specifically including the fraud and abuse provisions contained in Chapter 371. CSHCN Services Program providers also are required to comply with all applicable laws, administrative rules, and policies that apply to their professions or to their facilities. Specifically, it is a violation of program rules when a provider fails to provide health-care services or items to recipients in accordance with accepted medical community standards and standards that govern occupations, as explained in 1 TAC 371.1617(6) for Medicaid providers, which also applies to CSHCN Services Program providers as set forth in 25 TAC 38.6(b)(1). Accordingly, CSHCN Services Program providers can be subject to sanctions for failure to deliver, at all times, health-care items and services to recipients in full accordance with all applicable licensure and certification requirements. These include, without limitation, requirements related to documentation and record maintenance, such that a CSHCN Services Program provider can be subject to sanctions for failure to create and maintain all records required by his or her profession, as well as those required by the CSHCN Services Program and Texas Medicaid. Refer to: Section 2.1, Provider Enrollment, on page 2-2 for more detailed information about CSHCN Services Program provider enrollment procedures. 19.1.1 Hearing Services for Children The Program for Amplification for Children of Texas (PACT) has been discontinued, and TMHP has assumed the administration of hearing services for clients who are birth through 20 years of age under the current hearing services benefit, which now includes clients of all ages. To be reimbursed for both audiology services and hearing aid fitting and dispensing services, audiologists must enroll with Texas Medicaid as audiologists and also as hearing aid fitters and dispensers before enrolling with the CSHCN Services Program. Audiology services must be billed using the audiologist provider number and benefit code (for electronic claims only) as indicated on the provider enrollment letter that indicates Audiologist, and hearing aid fitting and dispensing services must be billed with the hearing aid provider number and benefit code (for electronic claims only) as indicated on the provider enrollment letter that indicates Hearing Aid. 19 2 CPT only copyright 2009 American Medical Association. All rights reserved.
Hearing Services 19.2 Benefits, Limitations, and Authorization Requirements The following hearing services are benefits for CSHCN Services Program clients of any age: Services Provider Type Audiology and audiometry evaluation and Audiologists and physicians diagnostic services for suspected and confirmed hearing loss including, but not limited to, the following: Hearing screening Audiological assessment Otological examination Hearing aid evaluation Hearing aid devices and accessories, fitting and Hearing aid fitters and dispensers dispensing visits, and revisits including, but not limited to, the following: Ear mold and second ear mold Hearing aid device Hearing aid fitting Follow-up visits at 30 days (first follow-up) and 60 days (second follow-up) Hearing aid repair Refit and evaluation after repair Hearing aid batteries and supplies Note: CSHCN Services Program clients who are 17 years of age or older who are legal residents of the state of Texas, and who are employable, maybe eligible for assistance from DARS. The CSHCN Services Program may request that clients who meet these requirements apply to DARS, as the CSHCN Services Program is the payor of last resort. 19 All services provided to CSHCN Services Program clients must be medically necessary. Unless otherwise specified, services may be reimbursed without prior authorization within the set limitations. Providers must request prior authorization for medically necessary services that exceed benefit limitations and for those services for which prior authorization is required. 19.2.1 Audiology and Audiometry Evaluation and Diagnostic Services Hearing evaluations must be recommended by a physician based on examination of the client. Medical necessity including hearing evaluation test data must be maintained in the client s medical record. Authorization is not required for hearing services for the evaluation and diagnosis of hearing loss. Documentation of medical necessity must be maintained by the provider in the client s medical record. Retrospective review may be performed to ensure that the documentation supports medical necessity for the service. A basic comprehensive audiometry survey is a benefit of the CSHCN Services Program and includes the following tests: Screening test, pure tone, air only Air only or air and bone pure tone audiometry threshold Speech audiometry threshold (with or without speech recognition) Comprehensive audiometry threshold evaluation and speech recognition The following procedure codes may be reimbursed for audiometry survey services: Audiometry Survey Procedure Codes 92550 92551 92552 92553 92555 92556 92557 Comprehensive procedure code 92557 must be billed when three or more audiometry surveys are performed with the same date of service. CPT only copyright 2009 American Medical Association. All rights reserved. 19 3
Chapter 19 The following procedure codes may be reimbursed for audiometric tests: Audiometric Tests Procedure Codes 92563 92565 92567 92568 92570 92571 92572 92575 92576 92577 92579 92582 92583 92584 92585 92586 92587 92588 Tympanometry (impedance testing) procedure code 92567 may be reimbursed as an objective diagnostic test of middle ear disease and is limited to four services per year by the same provider. Acoustic reflex testing procedure code 92568 is limited to the following diagnosis codes: Diagnosis Codes 2251 3510 3511 3518 3519 38600 38601 38602 38603 38604 38610 38611 38612 38619 3862 38630 38631 38632 38633 38634 38635 38640 38641 38642 38643 38648 38650 38651 38652 38653 38654 38655 38656 38658 3868 3869 3870 3871 3872 3878 3879 3882 38830 38831 38832 38840 38841 38842 38843 38844 38845 3885 38905 38906 38913 38915 38916 38917 38920 38921 38922 7443 7804 The procedure codes in Column A of the following table will be denied if billed with the same date of service as the procedure codes in Column B: Column A (Denied) Column B 92551, 92552, 92553, 92555, 92556 92557 92587 92588 The following procedure codes may be reimbursed for hearing diagnostic services: Hearing Diagnostic Services 92502* 92504* 92540 92620 92621 92625 Examination procedure codes 92502 and 92504 may be reimbursed to physicians. Audiologists will not be reimbursed for these procedure codes. The following procedure codes may be reimbursed for hearing aid examination and assessment: Hearing Aid Examination and Assessment 92591 Hearing screening or other hearing aid examination 92592 First and second revisits for monaural fittings 92593 First and second revisits for binaural fittings Bekesy Audiometry (procedure code 92561) is not a benefit of the CSHCN Services Program. 19 4 CPT only copyright 2009 American Medical Association. All rights reserved.
Hearing Services 19.2.2 Hearing Aid Devices and Accessories TMHP does not supply the hearing aid devices, supplies, and accessories. Providers must purchase equipment directly from the manufacturers of their choice and submit claims to TMHP for reimbursement using the appropriate procedure codes. The CSHCN Services Program may reimburse hearing aid fitters and dispensers for the following services: 19 Service Limitation Hearing aid devices 1 per ear every 5 years (monaural codes = bill quantity of 1) (binaural codes = bill quantity of 1) Hearing aid assessment Procedure code V5010 may be reimbursed as medically necessary. Hearing aid accessories Prior authorization is required for procedure code V5267. Hearing aid accessories reimbursed separately for clients who are birth through 20 years of age include, but are not limited to, chin straps, clips, boots, and headbands. Fitting and dispensing visit 1 per hearing aid procedure code Ear mold and ear impression 1 each per hearing aid device may be reimbursed with procedure codes V5264, V5265, and V5275 (monaural codes = bill quantity of 1) (binaural codes = bill quantity of 2) Revisit (as necessary) Batteries (replacement only) Replacement or additional hearing aids within a 5-year period Hearing aid repair or modification 2 per calendar year when billed by any provider. Procedure code 92592 may be reimbursed for the first and second revisits for a monaural fitting. Procedure code 92593 may be reimbursed for the first and second revisits for a binaural fitting. Procedure code V5266 may be reimbursed as medically necessary when a hearing aid device has been previously reimbursed. Note: If a hearing aid has not been reimbursed by the CSHCN Services program in the last 5 years, the replacement batteries may be reimbursed upon appeal with a statement documenting medical necessity. Prior authorization is required for the appropriate hearing aid procedure code. 1 per year after the 1-year warranty period has lapsed may be reimbursed with procedure code V5014. 19.2.2.1 Hearing Aid Devices One hearing aid procedure code per modifier LT or RT as appropriate may be reimbursed once every 5 years from the dispensing date of the initial services without prior authorization (i.e., one monaural procedure code with modifier LT and one monaural procedure code with modifier RT may be reimbursed every 5 years or one binaural procedure code may be reimbursed every 5 years). Prior authorization is not required for services rendered within benefit limitations as outlined in this chapter. Prior authorization is required for additional medically necessary hearing aid devices and replacement devices required within the same 5-year period or for medical necessity outside of the identified criteria. The reimbursement for the monaural and binaural procedure codes will include the required hearing aid package as follows: 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 hearing aid accessories or supplies CPT only copyright 2009 American Medical Association. All rights reserved. 19 5
Chapter 19 Instructions for care and use A 1-month supply of batteries or batteries as appropriate according to the manufacturer s warranty Note: The client, client s family, or caregiver(s) must agree to accept the responsibility for, and be trained in, the proper use of the hearing aid device. The following procedure codes may be reimbursed for monaural hearing aid devices when billed with modifier LT or RT to indicate for which ear the hearing aid was fitted: Monaural Hearing Aid Procedure Codes V5030 V5040 V5170 V5180 V5244 V5245 V5246 V5247 V5254 V5255 V5256 V5257 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. The following medical necessity documentation must be maintained in the client s medical record: Hearing loss in the better ear of 35 dbhl or greater for the pure tone average of 500, 1000, and 2000 Hz A spondee threshold in the better ear of 35 dbhl or greater when pure tone thresholds cannot be established Hearing loss in each ear is less than 35 dbhl at the frequencies below 2000 Hz and thresholds in each ear are greater than 40 dbhl at 2000 Hz and higher Documentation stating medical necessity and a statement that the patient is alert and oriented and able to use the device appropriately by themselves or with assistance The following procedure codes may be reimbursed for binaural hearing aid devices: Binaural Hearing Aid Procedure Codes V5100 V5210 V5220 V5249 V5250 V5252 V5253 V5258 V5259 V5260 V5251 V5261 Binaural procedure codes must be billed with a quantity of 1. The reimbursement for one binaural procedure code will include the set of hearing aid devices (i.e., one set of two devices). To meet the criteria for binaural hearing aids, clients must meet the conditions for a monaural hearing aid and have at least a 35-dB hearing loss in both ears. Providers may request prior authorization using procedure code V5298 for hearing aids that are medically necessary but are not currently benefits of the CSHCN Services Program. Replacement of a hearing aid device will be considered for prior authorization when loss or irreparable damage has occurred. Replacement will not be authorized when the equipment has been abused or neglected by the client, the client s family, or the caregiver. 19.2.2.2 Supplies and Accessories Providers must dispense each hearing aid with all necessary hearing aid accessories and supplies, including the 1-month supply of batteries. Supplies and accessories included in the hearing aid package will be included in the reimbursement of the hearing aid procedure code and are not reimbursed separately. Replacement batteries may be reimbursed as medically necessary without prior authorization using procedure code V5266 for clients with a previously billed hearing aid. Hearing aid batteries for clients who did not receive the hearing aid device through the CSHCN Services Program may be reimbursed on appeal with a statement documenting medical necessity. Replacement hearing aid batteries provided as part of the manufacturer s warranty will not be reimbursed separately. Medically necessary hearing aid accessories that are not part of the hearing aid package including, but not limited to, chin straps, clips, boots, and headbands may be reimbursed with prior authorization. Providers may purchase the accessories from a vendor of their choice. The prior authorization number must be included on the claim. 19 6 CPT only copyright 2009 American Medical Association. All rights reserved.
Hearing Services Documentation for the medical necessity of the item requiring prior authorization must indicate that the requested supply is medically necessary for the appropriate use or functioning of the hearing aid device. 19.2.2.3 Hearing Aid Warranty: Repairs and Modifications A hearing aid dispensed through the CSHCN Services Program must meet the following criteria: Be a new and current model Meet the performance specifications indicated by the manufacturer Include, at minimum, a standard 12-month warranty that begins on the dispensing date of the hearing aid Meet the needs of the individual client receiving the device During the 12-month manufacturer s warranty period, the CSHCN Services Program will not reimburse providers for the following: Replacement hearing aid batteries that are provided as part of the manufacturer s warranty Hearing aid repair or modification Providers must follow the manufacturer s repair process as outlined in the manufacturer s warranty contract. After the warranty period has lapsed, repair or modification of a hearing aid may be considered once a year without prior authorization using procedure code V5014 if repair is a better alternative than a new purchase. Additional repairs or modifications per year may be reimbursed with prior authorization if medical necessity can be demonstrated. Requests for prior authorization must include documentation that supports the need for the requested repair or modification. 19 19.2.2.4 Fitting and Dispensing Visits and Revisits Prior authorization is not required for fitting and dispensing visits and revisits. Hearing aid visits include the fitting and dispensing visit, the first revisit, and the second revisit (as needed): Visit Hearing aid examination Fitting and dispensing visit First and second* revisit Limitations Procedure code 92591 may be reimbursed for a hearing screen or other hearing aid examination. Includes the fitting, dispensing, and post-fitting check of the hearing aid. The post-fitting check of the hearing aid must be performed within 5 weeks of the initial fitting. The post-fitting check is part of the dispensing procedure and will not be reimbursed separately. If additional visits are required after the post fitting check, two additional revisits may be reimbursed as medically necessary. The first revisit must include a hearing aid check. The second revisit must include either a real ear measurement or aided sound field testing 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 readings from the first evaluation. The second revisit is available as needed after the post-fitting check and first revisit. Procedure code 92592 may be reimbursed for the first and second revisit for a monaural fitting. Procedure code 92593 may be reimbursed for the first and second revisit for a binaural fitting. CPT only copyright 2009 American Medical Association. All rights reserved. 19 7
Chapter 19 Required Documentation Client acknowledgment statement. To confirm that the client was evaluated and offered an appropriate hearing aid that meets the client s hearing need, the client must sign an acknowledgment statement (created by the provider) before the provider dispenses the hearing aid device and supplies. The statement must be maintained in the client s medical record. Retrospective review may be performed to ensure that the documentation supports the medical necessity of the device, service, or supply. 30-day trial period certification statement. After the hearing aid has been dispensed, the client must be allowed a 30-consecutive-day trial period that begins with the dispensing date to determine satisfaction with a purchased hearing aid. The hearing aid fitter/dispenser must provide the client with a written agreement that includes the beginning and ending dates of the 30-day trial period. The contract agreement must include all charges and fees associated with the trial period as well as the name, address, and telephone number of the State Board of Examiners for Speech-Language Pathology and Audiology. The client must receive a copy of this agreement and a copy must also be maintained in the client s medical record. During the trial 30-day trial period, if the client is not satisfied with the purchased hearing aid or if hearing is not improved with the use of the purchased hearing aid, the client may return it to the provider. Providers may dispense additional hearing aids as medically necessary until the client is satisfied with the results of a hearing aid or until 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. The fitter/dispenser must allow 30 days to elapse from the hearing aid dispensing date before completing a 30-day trial period certification statement, which indicates that the client has completed the trial period and has accepted the dispensed hearing aid. The certification statement must be maintained by the provider in the client s medical record. The hearing aid provider must use the appropriate fitting and dispensing procedure code for services rendered during the trial period. No additional fees may be charged to the client or to the CSHCN Services Program during this period. 19.2.3 Prior Authorization Requirements The CSHCN Services Program does not require prior authorization for hearing aid devices and services that are medically necessary and that are provided within the limitations outlined in this article unless otherwise indicated. To submit prior authorization requests for those services that do require prior authorization and for medically necessary services required outside of program benefits, providers may use the CSHCN Services Program Authorization and Prior Authorization Request Form and Instructions form. Requests for prior authorization must be submitted to the TMHP-CSHCN Services Program Authorization Department and must include documentation that supports the medical necessity of the requested device, service, or supply. Prior authorization is required only for the following devices and services: Additional devices and services that exceed benefit limitations as outlined in this article Refer to: The specific sections throughout this chapter for information about submitting the prior authorization requests for devices and services beyond benefit limitations. Hearing aids that are medically necessary but are not currently benefits of the CSHCN Services Program Replacement of hearing aids within 5 years of the initial purchase Hearing aid accessories including, but not limited to, chin straps, clips, boots, and headbands 19 8 CPT only copyright 2009 American Medical Association. All rights reserved.
Hearing Services The following table summarizes the documentation requirements for the items that require prior authorization: Description Hearing aids that are medically necessary but are not currently benefits of the CSHCN Services Program Replacement of hearing aids within a 5-year period Hearing aid accessories include, but are not limited to, chin straps, clips, boots, and headbands. Prior Authorization Requirements The prior authorization request must include: The medical necessity for the requested hearing aid device. The name of the manufacturer. The manufacturer s suggested retail price (MSRP) or average wholesale price (AWP) or the provider s documented invoice cost. The model number, serial number, and the dates that the warranty is in effect for the requested hearing aid. Requests for prior authorization must include documentation that supports medical necessity which may include documentation that loss or irreparable damage has occurred. Requests for prior authorization for hearing aid supplies will be considered when submitted with documentation that shows that the requested supply is medically necessary for the proper use or functioning of the hearing aid device. 19 Authorizations may be submitted online, by fax, or by mail to: Online: www.tmhp.com Fax: 1-512-514-4222 Mail: Texas Medicaid & Healthcare Partnership TMHP-CSHCN Services Program Authorization Department 12357-B Riata Trace Parkway, Suite 150 Austin, TX 78727 Request form: CSHCN Services Program Authorization and Prior Authorization Request Form and Instructions The prior authorization number must be included on the claim form when submitted to TMHP. 19.2.4 Bone-Anchored Hearing Aid (BAHA) A bone-anchored hearing aid (BAHA) may be reimbursed by the CSHCN Services Program for clients who are 5 years of age or older and who meet the medical necessity criteria. The following procedure codes may be reimbursed with prior authorization: Procedure Codes L8690 L8691 L8692 69714 69715 69717 69718 *FM systems are not a benefit of the CSHCN Services Program. Procedure codes L8691 and L8692 will be denied as part of another service when billed by any provider for the same date of service as L8690. Replacement batteries for the BAHA may be reimbursed using procedure code V5266 and do not require authorization. Replacement batteries are limited to clients with a previously-billed hearing device. Replacement batteries for clients who did not receive the hearing device under CSHCN Services Program benefits may be reimbursed on appeal with a physician s statement documenting medical necessity. The BAHA is Food and Drug Administration (FDA)-approved for clients who are 5 years of age or older. Clients who are younger than 5 years of age do not have sufficient bone density for implantation of the device. The following provider types may be reimbursed for the BAHA device and services: Physicians Audiologists Home health DME CPT only copyright 2009 American Medical Association. All rights reserved. 19 9
Chapter 19 Medical and DME supplier Custom DME providers Ambulatory surgical centers (freestanding/independent and hospital-based) Hospitals 19.2.4.1 Prior Authorization Requirements Prior authorization is required for a BAHA. Prior authorization consideration will be given if the client is 5 years of age or older and all of the following documentation is provided: Previous attempts at hearing aids and why these devices are inadequate or have failed. Scores on hearing tests for bone conduction thresholds and on maximum speech discrimination. Audiological testing showing good inner ear function. Assessment that shows the client is motivated, is able to follow given instructions, and is willing to participate in follow-up therapy. Appropriate diagnosis including, but not limited to, the following: Diagnosis Code Description 1601 Malignant neoplasm of auditory tube, middle ear, and mastoid air cells 1710 Malignant neoplasm of connective and other soft tissue of head, face, and neck 1732 Other malignant neoplasm of skin of ear and external auditory canal 20931 Merkel cell carcinoma of the face 20932 Merkel cell carcinoma of the scalp and neck 2120 Benign neoplasm of nasal cavities, middle ear, and accessory sinuses 2150 Other benign neoplasm of connective and other soft tissue of head, face, and neck 2162 Benign neoplasm of ear and external auditory canal 2322 Carcinoma in situ of skin of ear and external auditory canal 38032 Acquired deformities of auricle or pinna 38110 Simple or unspecified chronic serous otitis media 38120 Simple or unspecified chronic mucoid otitis media 3813 Other and unspecified chronic nonsuppurative otitis media 3823 Unspecified chronic suppurative otitis media 3829 Unspecified otitis media 3870 Otosclerosis involving oval window, nonobliterative 3871 Otosclerosis involving oval window, obliterative 3872 Cochlear otosclerosis 3878 Other otosclerosis 3879 Unspecified otosclerosis 38901 Conductive hearing loss, external ear 38902 Conductive hearing loss, tympanic membrane 38906 Conductive hearing loss, bilateral 38908 Conductive hearing loss of combined types 38915 Sensorineural hearing loss, unilateral 74401 Congenital absence of external ear causing impairment of hearing 74402 Other congenital anomaly of external ear causing impairment of hearing 7560 Congenital anomalies of skull and face bones 19 10 CPT only copyright 2009 American Medical Association. All rights reserved.
Hearing Services 19.2.4.2 Procedure Code Limitations Procedure code L8691 will be denied as part of another service when billed by any provider with the same date of service as L8690. The following procedure codes will be denied as part of another service when billed for the same date of service by the same provider as procedure codes 69714, 69715, 69717, or 69718: 19 Procedure Codes 36000 36410 37202 51701 51702 51703 62318 62319 64415 64416 64417 64450 69424 69501 69502 69505 69511 69530 69601 69602 69603 69670 69700 92502 96360 96365 96372 96374 96375 Procedure code 69714 will be denied when billed with the same date of service by the same provider as procedure code 69715. Procedure code 69717 will be denied when billed with the same date of service by the same provider as procedure code 69718. Procedure code 69711 is not a benefit of the CSHCN Services Program. 19.2.4.3 Reimbursement Noncustom DME may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid. Expendable medical supplies may be reimbursed the lower of the billed amount or the amount allowed by CMS, when available, or Texas Medicaid. Ambulatory surgical centers (ASCs) may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid based on ASC groupings approved by CMS. Inpatient hospital care may be reimbursed at 80 percent of the rate authorized by the Tax Equity and Fiscal Responsibility Act (TEFRA) of 1982 for a total of 60 days per calendar year. Orthotics and prosthetics may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid. Physicians and audiologists may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid. 19.2.5 Cochlear Implants Cochlear implants and aural rehabilitation are benefits for CSHCN Services Program clients who meet the following criteria: The client is 12 months of age or older. The client has a profound, bilateral, sensorineural hearing loss. The client who requests the cochlear implant has had limited or no benefit from a trial with appropriately fitted hearing aids. A trial of 3 to 6 months is required for clients who do not have previous experience with hearing aids unless there is a documented reason that hearing aids will not work for that particular client. The client has the cognitive ability to use auditory cues. The client or parents are willing and able to comply with aural rehabilitation. The client is assessed by both an audiologist and an otolaryngologist experienced in the implantation of cochlear implants or auditory brainstem implants (ABIs) and who indicate that the client is a good candidate for the procedure. CPT only copyright 2009 American Medical Association. All rights reserved. 19 11
Chapter 19 Cochlear implants are not considered for reimbursement when one or more of the following situations exist: The client has an active ear infection. The client is deaf due to lesions of the acoustic nerve or central auditory pathways. There is radiological documentation of absent cochlear development. The client or the client s parents lack the cognitive ability or willingness to complete aural rehabilitation. Procedure code 69930 (which may be reimbursed to physicians and hospitals) must be used for the cochlear implant device, implantation and components. The device and separate components include the cochlear device itself, headpiece/headset, microphone, transmitting coil, transmitter cable, external speech processor, zinc air batteries, alkaline AA batteries, recharger units, and rechargeable AA batteries. Note: The device must be approved by the FDA and must be age-appropriate for the client. Up to a maximum of 15 zinc air or a maximum of 31 alkaline replacement batteries per month are benefits. ABI is an adaptation of a cochlear implant. It is a benefit of the CSHCN Services Program for clients 12 years of age or older when submitted with the following: Procedure Code Diagnosis Code S2235 23772 A diagnostic analysis of a cochlear implant and its subsequent programming are considered for reimbursement to physicians, APRNs, audiologists, hospitals, and rehabilitation centers using procedure codes 92601, 92602, 92603, and 92604. Replacement equipment for a cochlear implant device is also a benefit of the CSHCN Services Program. Replacement equipment includes batteries, sound processors, cables, coils, headsets, and microphones. Prior authorization is required for replacement of external sound processors and rechargeable AA batteries for a cochlear implant device. Replacement components and nonrechargeable batteries must be submitted for reimbursement using the following procedure codes: Procedure Code L8614 L8615 L8616 L8617 L8618 L8619 L8621 L8622 L8627 L8628 L8629 Provider Types Which May be Reimbursed: Prosthetists, orthotists, medical and DME suppliers, ambulatory surgical centers, medical supply companies, and hospitals Home health DME suppliers, physicians, audiologists, prosthetists, orthotists, medical and DME suppliers, and custom DME suppliers Home health DME suppliers, physicians, audiologists, prosthetists, orthotists, medical and DME suppliers, and custom DME suppliers Home health DME suppliers, physicians, audiologists, prosthetists, orthotists, medical and DME suppliers, and custom DME suppliers Home health DME suppliers, physicians, audiologists, prosthetists, orthotists, medical and DME suppliers, and custom DME suppliers Home health DME suppliers, audiologists, prosthetists, orthotists, medical and DME suppliers, medical supply companies, and hospitals Home health DME suppliers, prosthetists, orthotists, medical supply companies, and custom DME suppliers Home health DME suppliers, prosthetists, orthotists, medical and DME suppliers, medical supply companies, and custom DME suppliers Physicians, audiologists, home health DME providers, DME medical suppliers, and custom DME providers Physicians, audiologists, home health DME providers, DME medical suppliers, and custom DME providers Physicians, audiologists, home health DME providers, DME medical suppliers, and custom DME providers 19 12 CPT only copyright 2009 American Medical Association. All rights reserved.
Hearing Services Refer to: Section 17.3.4, Cochlear Implant Device, on page 17-7. Section 19.2.5, Cochlear Implants, on page 19-11. Section 30.2.13, Cochlear Implants, on page 30-24. 19 19.2.5.1 Cochlear Implants Authorization Requirements All implants and associated aural rehabilitation must be prior authorized. The following information must accompany the request for prior authorization: Documentation from the audiologist and otolaryngologist that indicates the client is a good candidate for the procedure and meets the requirements outlined earlier in this chapter. Documentation that a referral to an appropriate aural rehabilitation provider is in place. Documentation from the client s primary physician, neurologist, or school diagnostician that the client has the cognitive ability to use the implant. Replacement of rechargeable AA batteries must be prior authorized. A total of 12 replacement rechargeable AA batteries may be prior authorized per year. 19.2.5.2 Sound Processor Replacement Guidelines Unless ordered by a physician, a processor must be used for 12 months before the replacement of a unit is considered for reimbursement. The replacement of a sound processor requires prior authorization with adjustment to reimbursement based on the manufacturer s trade-in policy. The physician must submit documentation of medical necessity when requesting prior authorization for the replacement of the sound processor. 19.3 Claims Information Hearing services must be submitted to TMHP in an approved electronic format or on the CMS-1500 paper claim form. Providers may purchase CMS-1500 paper claim forms from the vendor of their choice. TMHP does not supply the forms. When completing a CMS-1500 paper claim form, all required information must be included on the claim, as information is not keyed from attachments. Superbills, or itemized statements, are not accepted as claim supplements. To avoid claim denials, providers billing as a group must use the performing provider identifier number on their claims. Refer to: Chapter 37, TMHP Electronic Data Interchange (EDI), on page 37-1 for information about electronic claims submissions. Chapter 5, Claims Filing, Third-Party Resources, and Reimbursement, on page 5-1 for general information about claims filing. Section 5.7.1.3, CMS-1500 Paper Claim Form Instructions, on page 5-22 for instructions on completing paper claims. Blocks that are not referenced are not required for processing by TMHP and may be left blank. 19.4 Reimbursement Hearing aids and related services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid. Additional charges (e.g., rental fees) to the client for covered services constitute a breach of the provider s contract with the CSHCN Services Program. The medically necessary hearing aid devices that are not currently a benefit of the CSHCN Services Program (procedure code V5298) and the hearing aid accessories not included in the hearing aid package (procedure code V5267) are manually priced and may be reimbursed the lower of the billed amount or the manufacturer s suggested retail price (MSRP) less 18 percent when purchased. Cochlear implants or ABIs may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid. For fee information, providers can refer to the Online Fee Lookup (OFL) on the TMHP website at www.tmhp.com. CPT only copyright 2009 American Medical Association. All rights reserved. 19 13
Chapter 19 19.5 TMHP-CSHCN Services Program Contact Center The TMHP-CSHCN Services Program Contact Center at 1-800-568-2413 is available Monday through Friday from 7 a.m. to 7 p.m., Central Time, and is the main point of contact for the CSHCN Services Program provider community. 19 14 CPT only copyright 2009 American Medical Association. All rights reserved.