ADA Coding and Reimbursement Update

Dr. Cavitt begins by noting that there are no new CPT, HCPCS, or ICD-10 code changes for audiologists that will take effect on January 1, 2025. However, many countries have already transitioned to ICD-11, and the U.S. is expected to do so within the next three years. Providers will receive advance notice before implementation. Medicare is set to reduce allowable reimbursement rates by 2–3%, though legislation could still intervene to offset these cuts. The audiology and speech-language pathology interstate compact may open for licensure applications as early as late 2025, enabling practice across state lines under specific conditions.

The webinar also covers recent updates to HIPAA regulations. Patients must now be allowed to view and photograph their health records at no charge, and providers must publish their record-copying fee structures online. Federal guidelines will supersede state-specific fee laws. Covered entities are expected to respond to medical record requests within 15 days. Dr. Cavitt stresses that HIPAA permits providers to share records with other providers involved in care coordination without additional patient authorization, though erring on the side of caution is still recommended. Additionally, every audiology practice is required to have a HIPAA security policy in place due to heightened requirements stemming from cybersecurity concerns.

Informed consent is emphasized as a growing area of importance. Audiologists must obtain written consent before providing care, including telehealth, and ensure compliance with state-specific laws. Some states may require separate consents for treatment, telehealth, email, and text communications, often grouped under “electronic communications.” Dr. Cavitt suggests that practices consult legal counsel to ensure forms meet local legal standards.

The webinar also addresses the topic of credit card surcharges. While practices may be allowed to pass on credit card processing fees to patients, doing so must comply with varying state laws. Dr. Cavitt outlines three options: raising prices across the board, offering cash discounts, or implementing surcharges carefully, always ensuring compliance with payer contracts and marketing considerations.

Telehealth continues to be a viable care delivery method in audiology but comes with limitations. Coverage is dependent on each health plan, and audiologists must ensure HIPAA-compliant systems are used. Cross-state practice requires licensure in the state where the patient is located at the time of service. Dr. Cavitt discusses billing codes like Q3014 for telehealth site origination fees and notes that many Medicare telehealth codes remain temporary and are not universally covered. She also explains remote therapeutic monitoring codes (98975–98981) and the importance of documenting interactive communication and time thresholds.

On the topic of technicians and audiology assistants, Medicare allows only technical services under direct physician—not audiologist—supervision, and only when a procedure has separate technical and professional components. Audiograms and ABRs, which do not have such splits, cannot be delegated to technicians. State laws and payer contracts must be consulted to ensure compliance, as missteps can result in false claims or the unlicensed practice of audiology.

Binocular microscopy (CPT 92504) is addressed as well. Its use requires an actual binocular microscope—not an otoscope—and is appropriate only when other visualization methods are insufficient. It is rarely appropriate in routine audiology practice.

The billing of impacted cerumen removal (69209, 69210) is clarified. Medicare and Medicaid often consider it bundled with audiometric testing and do not reimburse separately when performed on the same day. Audiologists cannot privately bill patients when coding edits deem the procedures inclusive. Commercial payers may vary depending on scope of practice and contract terms.

Regarding hearing aids and assistive technology, Dr. Cavitt clarifies that most health plans only cover devices for medically necessary treatment of hearing loss. For patients with normal hearing, hearing protection or electronic amplification devices are not typically reimbursed and should be billed as non-covered services using appropriate HCPCS codes like V5274 or V5298.

The webinar also delves into evaluation and management (E/M) coding. Audiologists may use E/M codes (e.g., 99202, 99203) only if allowed by state licensure and scope of practice. Documentation must support the medical necessity, time, and complexity involved in the visit. Dr. Cavitt cautions against misuse, particularly billing incident-to or applying these codes to hearing aid visits. She strongly recommends that practices review payer policies, maintain proper documentation, and apply E/M codes consistently across similar clinical scenarios and payer types.

Lastly, insurance navigation is covered extensively. Dr. Cavitt distinguishes between traditional Medicare (red, white, and blue card), Medicare Advantage plans, and commercial insurers. She discusses deductibles, copays, use of ABN and notice of non-coverage forms, and third-party administrators like True Hearing and United Healthcare Hearing. A major update noted is the United Healthcare policy change effective February 1, 2024, removing the requirement for written hearing aid recommendations. Additionally, practices in specific states were advised of changes to their Anthem contracts that remove hearing aid codes, requiring providers to work with True Hearing to remain in-network.

In sum, this webinar delivers an advanced-level, detailed update for audiologists navigating the evolving regulatory and reimbursement landscape in 2025, reinforcing the need for legal awareness, coding accuracy, payer communication, and patient transparency.

• Kim Cavitt, Au.D.