Recently, it has come to the attention of ADA that some confusion exists over numerous coding and reimbursement topics. We are attempting to offer some clarity and documentation supporting the expressed positions.
Audiology services are classified as “other diagnostic services” and we, as a profession, are classified as “suppliers”. As a result, we are subject to the rules outlined in sections 80.3 and 80.6 of Chapter 15 of the Medicare Benefit Policy Manual. Limited audiology services can be provided once per 12 months without an order and the AB modifier can be used. When Medicare patients are seen for services that require an order, the order is required for each incident of care. Standing orders, for example, are not allowed with our class of Medicare provider. There is actually evidence of negative consequences for use of standing orders in audiology: https://oig.hhs.gov/fraud/enforcement/pennsylvania-audiology-practice-agrees-to-voluntary-exclusion/.
Every audiologist in every state does not need a prescription for a hearing aid from a physician. If an audiologist has prescriptive rights for hearing aids in their respective states, a physician prescription is not required. Some health plans may still require a medical clearance.
Every health plan does not allow for upgrades. UHC commercial and most BCBS Association plans (except those with invoice plus and percentage of billed charges contractual relationships) allow for upgrades. BCBS plans require you offer a standard/ basic option within the benefit and, if the patient chooses to upgrade, the patient completes a waiver reflecting their options prior to the provision of care.
S1001, which represents the deluxe item/upgrade, is not allowed or recognized by every health plan. Before utilizing this code, determine how each health plan addresses this code. Some clearinghouses will reject this code and some health plans will deny claims that include this code. This is why it is important to determine its utility for each plan independently.
Providers should bill their usual and customary rates to health plans unless the specific plan, by policy, (out of network Medicare Advantage and common with many Medicaid, workers compensation, vocational rehabilitation, VA Community Care) requires a different billing rate. This requirement for a standard fee schedule is outlined in many managed care agreements. Manufacturer Suggested Retail Pricing (MSRP) should only be billed as specifically allowed by contract.
A health plan should not be billed for hearing aids that have yet to be fit.
Billing for hearing aid before they have been fit can be an example of a false claim. There are no loopholes around this (i.e. fitting a patient with a loaner or demo set of hearing aids). The date of service on the claim should be the date of the hearing aid fitting, as represented on the bill of sale.
Please do not hesitate to reach out to Kim Cavitt at