Compliance, Coding, Reimbursement, and Practice Management for the Audiology Practice - PowerPoint Presentation

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Compliance, Coding, Reimbursement, and Practice Management for the Audiology Practice

Kim Cavitt, AuD

Audiology Resources, Inc.

Live Streamed from Chicago, IL

February 23-24, 2017Slide2

Learning Outcomes

Attendees will be able to:

…

list Federal regulations applicable to audiology. ....identify the FDA warning signs of ear disease.…describe the differences between bundling and unbundling. ...list the CPT and HCPCS codes to be used when fitting a hearing aid. ...define managed care terms.

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A Bit of Housekeeping…

We will be utilizing Poll Everywhere throughout the event.

The only attendees that are eligible for CEUs are those who paid to attend this event.

The only attendees able to ask questions during and after the event are the paid attendees themselves. You will have until March 10 to complete the course evaluation. This is required for CEUs to be processed. This will come as a separate email on Monday. 3Slide4

Things to Know As We Start

I will say things that are unpopular

…

You decide what you do with the information presented over the next two days.I want everyone to make informed decisions.I try to document myself as much as possible though the inclusion of links.

I try to keep politics out of this as much as possible but it is not always possible.

Healthcare reform is a moving target

…

what I tell you today may not apply tomorrow.

I ALWAYS

err on the conservative side of the laws and regulations.Many laws and regulations are too broadly written not to take this stance.I am NOT an attorney and am not providing legal advice.I consulted a healthcare attorney in preparing this boot camp.I strongly suggest every practice retain counsel for legal questions and concerns.

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HIPAA

Health Insurance Accountability and Portability Act of 1996 (HIPAA)

Civil and criminal penalties

https://www.hhs.gov/hipaa/for-professionals/index.html Covers:

Standard Transaction and Code Sets

National Provider Identifier

National Employer Identifier

HIPAA 5010

Security

HITECH (Breach Notification)PrivacyMarketingBusiness Associates6Slide7

HIPAA Audits

HIPAA is now being audited by HHS.

As a result, it is very important that you follow the requirements set forth.

http://www.hhs.gov/hipaa/for-professionals/compliance-enforcement/audit/ Slide8

Standard Transaction and Code Set

This aspect of HIPAA requires that the following code sets be utilized for documenting and billing all medical items and services:

CPT (Current Procedural Terminology)

ICD 10 (International Classification of Diseases-10th Revision)

HCPCS (Healthcare Common Procedure Coding System)

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National Provider Identifier (NPI)

Requires that each individual provider utilize their own distinct, unique individual provider identification number for all payers.

This number stays with the provider as they move from employer to employer.

National Provider Identifier (NPI)National Plan and Provider Enumeration System (NPPES)https://nppes.cms.hhs.gov/NPPES/Welcome.do

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National Employer Identifier (EIN)

Requires that each individual practice or facility utilize their own distinct, unique practice or facility identification number for all payers.

This is required for every practice or facility except a sole proprietorship.

The EIN is issued by the Internal Revenue Service (IRS).Each practice also needs a facility or practice National Provider Identifier (NPI).National Plan and Provider Enumeration System (NPPES)

https://

npiregistry.cms.hhs.gov/

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HIPAA 5010

This was a systems update that went into effect January 1, 2012 (enforcement began ion March 31, 2012) on that required systems updates to allow for transition to ICD-10.

Affected software vendors, payers, and clearinghouses much more than providers.

https://www.cms.gov/Regulations-and-Guidance/HIPAA-Administrative-Simplification/Versions5010andD0/Version_5010.html

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837 Claims Format

837

Claims submission format set forth in HIPAA 5010.

You should ask your office management vendor or EMR about this format.CMS 1500Paper claim formhttp://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/837p-cms-1500.pdf 12Slide13

Protected Health Information (PHI)

Names

Street number and name, city, and last two digits of the zip code

Dates directly related to the individual (birth date)Phone numberFax numberEmail addressSocial security number

Medical record number

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Protected Health Information (PHI)

Health insurance member number

Account numbers

Certificate or license numbersVehicle identifiers and serial numbersDevice identifiers and serial numbersHearing aid serial numbersURLs

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Protected Health Information (PHI)

IP addresses

Biometric indicators

Finger, retinal, and voice printsPhotosAny unique identifying number, characteristic or code

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Security

The Security Rule is an extension of the Privacy Policy.

Went into effect April 20, 2005.

Applies to electronic formats.Providers need to have:Administrative Safeguards.Physical Safeguards.

Technical Safeguards.

You also need policies and procedures related to operations and documentation.

http://www.hhs.gov/hipaa/for-professionals/security/

index.html

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Security Rule

Covered entities must:

“Ensure the confidentiality, integrity, and availability of all e-PHI they create, receive, maintain or transmit.

Identify and protect against reasonably anticipated threats to the security or integrity of the information.Protect against reasonably anticipated, impermissible uses or disclosures.Ensure compliance by their workforce.”

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Security Rule: Risk Assessment

“A risk analysis process includes, but is not limited to, the following activities:

Evaluate the likelihood and impact of potential risks to e-PHI.

Implement appropriate security measures to address the risks identified in the risk analysis.Document the chosen security measures and, where required, the rationale for adopting those measures.Maintain continuous, reasonable, and appropriate security protections.”

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Security Rule: Risk Assessment

What do audiologists need to think about?

Computers

PhonesTabletsFax MachinesAnswering MachinesAudiometersTest Suites

OMS

/EMR

NOAH

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Security Rule:

Administrative Safeguards

Security Measures

To reduce risks of breaching protected health information.Need a Security OfficerInformation Access ManagementRegulate who has access to protected health information.

Minimum necessary access

Training and Accountability

Authorize access to PHI.

Train staff on policies and procedures.

Sanction staff who do not comply.

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Security Rule:

Physical Safeguards

Facility access and control

Limiting and controlling physical access.Workstation and device securityProper use and access to workstations and electronic devices.Policies and procedures related to:

Transfer.

Removal.

Disposal.

Re-use.

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Security Rule:

Technical Safeguards

Control of access

Passwords to protect access.AuditSafeguards to record and examine access.Integrity control

Ensure that PHI is not improperly altered or destroyed.

Transmission security

Protections against “hacking.”

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Security Rule:

Policies, Procedures and Documentation

You must develop policies and procedures to comply with the security rule.

If need guidance, consult an IT consultant who specializes in HIPAA.Must have written policies and procedures.Need to document staff training, actions, activities, and risk assessments.

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Business Associate

“A business associate is a person or organization, other than a member of a covered entity's workforce, that performs certain functions or activities on behalf of, or provides certain services to, a covered entity that involve the use or disclosure of individually identifiable health information. Business associate functions or activities on behalf of a covered entity include claims processing, data analysis, utilization review, and billing.”

“

Business associate services to a covered entity are limited to legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services

.”

Providers are responsible for the actions of their business associates.

http://www.hhs.gov/hipaa/for-professionals/privacy/guidance/business-associates/

index.html

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Common Audiology Business Associates

Hearing aid manufacturers

Earmold manufacturers

AccountantLawyerOMS vendorIT consultantBuying/management group25Slide26

HITECH-Breach Notification

Effective date of February 17, 2010.

Applies to paper and electronic formats.

Breach:An “impermissible” or unauthorized use or disclosure of PHI.Must do a risk assessment.

Breach notification:

Must occur within 60 days.

Providers and business associates have burden of proof that notifications have been made.

Business Associates must notify the covered entity.

Notify the individual.

Oftentimes provide identity theft protections. Notify the Media:If breach is of more than 500 individuals.Notify Secretary of Health and Human Services:If breach is of more than 500 individuals.http://www.hhs.gov/hipaa/for-professionals/breach-notification/

index.html

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Privacy Rule

Protections of patient’s health information and PHI.

Effects both paper and electronic records.

Effective April 14, 2003 and updated in January 2013.Protects “Individually identifiable health information” is information, including demographic data, that relates to:The individual’s past, present or future physical or mental health or condition,

The provision of health care to the individual,

The past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual.

Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number).

http://www.hhs.gov/hipaa/for-professionals/privacy/

index.html

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Privacy: Disclosures That Do Not Require Authorization

Treatment

Ordering/referring physician.

Physician/provider you are referring to.Coordination of care.PaymentInsurance carrier.Health Care Operations“Certain administrative, financial, legal, and quality improvement activities of a covered entity that are necessary to run its business”

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Privacy Rule Specifics:

Keep disclosures to “minimum necessary.”

Need a Privacy Officer.

Need training on privacy and that training must be documented.New hires.AnnuallyMust have a complaint process.

Must have record safeguards:

Storage.

Disposal.

HIPAA: 7 years

Need though to consult state and payer record retention requirements as they can exceed HIPAA.

Access.29Slide30

Privacy Rule Specifics:

Email

Texting

Both can be done with patients through encrypted/secured service providers.http://www.hipaajournal.com/texting-violation-hipaa/ https://www.fusemail.com/resource-center/white-papers/ensure-email-ephi-hipaa-compliant

/

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Use and Disclosure

The HIPAA version of a medical release.

Could also list who can be disclosed to on intake form.

This is a specific, HIPAA form. Allows the patient to list who can be disclosed to and what can be disclosed.Can also restrict disclosures here.31Slide32
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Privacy Rule: Marketing

The Privacy Rule defines “marketing” as making “a communication about a product or service that encourages recipients of the communication to purchase or use the product or service.”

Applies to marketing sent to your database only.

“An arrangement between a covered entity and any other entity whereby the covered entity discloses protected health information to the other entity, in exchange for direct or indirect remuneration, for the other entity or its affiliate to make a communication about its own product or service that encourages recipients of the communication to purchase or use that product or service.”http://www.hhs.gov/hipaa/for-professionals/privacy/guidance/marketing

/

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Marketing versus Education

Marketing

Requires authorization

Is a third-party paying for the communication?Are you trying to get a patient to purchase an item or service?Are you “marketing”:PriceProductPromotion34Slide35

Marketing versus Education

Education

Does not require authorization.

Talks about technology, not productNo mention of specific products or price.No promotions.35Slide36

Privacy Rule:

Marketing Decision Matrix Poll

Do you co-op marketing with a third-party?

Are you an equity member of a buying group whose products you market?Do you have a lease or loan from a third-party vendor?Do you have a business development fund for products you market?

Do you go on vendor-funded trips?

Do you offer discounts, promotions, offers, or discounts?

Do you participate in Medicaid, Medicare, Worker’s Compensation, or TriCare?

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Long Form vs. Short Form Marketing Authorization

Short form

No remuneration, in cash or in kind, exchanges hands in any form for products you market.

You pay for all of your own marketing communications, in full, that are sent to your database.Example:By initialing this section and signing below, I authorize _________________________ to send me educational and/or marketing information on the products and services offered by ____________________________. No remuneration is involved in this communication. I understand that I may revoke this authorization, in writing, at any time.  

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Long Form vs. Short Form Marketing Authorization

Long form

Remuneration, in cash or in kind, occurs regarding a product or service you are marketing.

The vendor is paying in whole or in part for the communication.One page document.38Slide39

Omnibus Rule

Effective September 23, 2013.

Business associates (any entity that creates, receives, maintains, or transmits PHI on behalf of a provider who supplied this information to them) and their contractors and subcontractors, are required to comply to the updated HIPAA Privacy and Security Rules, including breach notification

.Patients have the right to request that a copy of their electronic medical record be supplied to them in an electronic format.http://www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/combined-regulation-text/omnibus-hipaa-rulemaking

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Omnibus Rule

Patients who are paying privately for an item or service have the right to restrict any disclosure about this item or service to their health plan.

“Marketing” has been redefined as any patient communication where the provider receives financial remuneration from a third-party whose products or services are being marketed. When “marketing” is being performed using PHI, a patient authorization must be in place prior to sending this marketing communication.

The sale of PHI is prohibited.

There must be a defined breach notification process where a situation is presumed to be a breach until the provider, business associate, contractor, or subcontractor determines that there is a low probability that the patient’s privacy has been compromised. A risk assessment must be performed anytime there is a breach of PHI

.

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Omnibus Rule

Allows for broader use of PHI for fundraising opportunities.

Allows for a streamlined authorization process for use of PHI for research purposes.

Penalties have increased to up to $1.5 million maximum per calendar (many fines range between $100 and $50,000 per violation and degree of culpability) and up to 10 years in jail.41Slide42

What Every Practice Needs:

2013 or newer revised Notice of Privacy Practices

2013 or newer revised Business Associate Agreement

2013 or newer revised Breach Notification Policy2013 or newer revised Marketing AuthorizationProviders with individual NPIsFacility NPI

Use and Disclosure form

Acknowledgement of Receipt of Notice of Privacy Practices

Can be added to your intake form.

Security Policy and Process

Breach Notification Policy and Process

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What Every Practice Needs:

Risk Assessment Process for breaches.

Independent Contractor Agreement that includes HIPAA Language

Documentation of Staff TrainingEmployee Confidentiality Form43Slide44
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Office of the Inspector General

Also known as OIG.

They are the “policemen” and “auditors” of Medicare and Medicaid.

http://oig.hhs.gov 45Slide46

We Are NOT Immune….

http://oig.hhs.gov/newsroom/media-materials/2016/

takedown.asp

http://oig.hhs.gov/fraud/docs/alertsandbulletins/sfanursingfacilities.pdfhttps://www.justice.gov/sites/default/files/opa/legacy/2014/05/13/lovelace-et-al.pdf Slide47

The Importance of Codes of Ethics

Please be aware of :

The ethical guidelines outlined in your State licensure law.

Failure to comply can result in the loss of your license.Ignorance is not a defense.The Codes of Ethics of organizations which you are a member.Failure to comply can result in you being removed from this organization and/or losing your credentialed status.

Also, some of the aspects of a Code of Ethics can also protect you from violating legal statutes, laws, rules, or regulations.

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Professional Codes of Ethics

AAA

http://www.audiology.org/resources/documentlibrary/Pages/codeofethics.aspx

ASHAhttp://www.asha.org/Code-of-Ethics/

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Ethical Quandary?

Would you feel comfortable telling your patient about your:

Vendor funded trip?

May have OIG implications.Business Development Fund? May have OIG implications.Vendor Payment Arrangement?

Gifts from vendors?

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Ethical Practice Guidelines on Financial Incentives from Hearing Instrument Manufacturers

Created by AAA and ADA in 2003 and updated by AAA in July 2011.

http://audiology-web.s3.amazonaws.com/migrated/20140114_EPC_IndustryGuideline.pdf_5382ed0f4cb195.24348078.

pdfArrangements you must avoid:Prid

P

ro Quo

An exchange of goods or services where one transfer is contingent on another.

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Ethical Practice Guidelines on Financial Incentives from Hearing Instrument Manufacturers

Conflicts of Interest

Ownership interests in company’s whose products you dispense.

Disclosure of any commercial interests to patients.Disclosure of consulting relationship to patients.Acceptance of gifts of any value from manufacturers.

Disclosure of remuneration for research.

Incentive trips (rewarded for conducting business).

Business Development Funds.

Lease arrangements.

Cash rebates.

Sales quotas with manufacturer in order to receive an incentive.52Slide53

When Ethics Violations Can Turn Into Legal Problems

Anti-Kickback legislation:

http://oig.hhs.gov/compliance/physician-education/roadmap_web_version.pdf

Criminal penalties.It is a felony to knowingly and willfully solicit or receive any remuneration, directly, or indirectly, overtly or covertly, in cash or in kind, in return for purchasing, leasing, or(or recommending the purchase, lease, or ordering ) of any item or service reimbursable in whole or in part under a federal health care program.

Medicare

Medicaid

Tricare

They create an incentive to overutilize particular goods and services, impinge upon the patient care process, and create an unfair competitive environment to those who refuse to provide remuneration.

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When Ethics Violations Turn Into Legal Problems

Some examples from Audiology

An audiologist furnishes hearing tests to a physician’s patients at less than fair market value (or free) in exchange for hearing aid referrals where some of these referrals may be for instruments covered under a Federal health program.

When an audiologist purchases X number of products and gets X free from a manufacturer and bills a federal payer for any of these products once they have been provided to the patient and does not disclose the “buy one, get one” deal54Slide55

What Can I Give Patients?

Anything that is less than $10 in value per item or less than $50 per year.

https://oig.hhs.gov/fraud/docs/

alertsandbulletins/SABGiftsandInducements.pdfhttp://www.hawleytroxell.com/2011/11/gifts-to-patients-and-potential-referral-sources/ http://www.hhhealthlawblog.com/2013/11/gifts-to-referral-sources-and-patients.html

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What Can I Give Physicians?

Gifts of “nominal value” (although they do not define this).

It is better to give nothing!

http://www.hhhealthlawblog.com/2013/11/gifts-to-referral-sources-and-patients.html http://www.hawleytroxell.com/2011/11/gifts-to-patients-and-potential-referral-sources/ 56Slide57

What Gifts Can I Receive from Industry?

Nominal value only.

Education is allowed.

http://journalofethics.ama-assn.org/2014/04/coet2-1404.html http://www.hhhealthlawblog.com/2013/11/gifts-to-referral-sources-and-patients.html 57Slide58

Relationships to Vendors

Sunshine Act: The

Sunshine Act requires manufacturers of

pharmaceuticals, medical devices, biological and medical supplies covered by Medicare, Medicaid or SCHIP to collect, track and report all financial relationships with physicians and teaching hospitals to CMS. http://www.theatlantic.com/health/archive/2013/02/what-the-sunshine-act-means-for-health-care-transparency/272926/ There, as a result, is precedent in health care. Slide59

Relationships to Vendors

Is your relationship with the vendor benefiting:

The patient or consumer?

Your business or practice?You, personally?The vendor?We all need to be more careful and aware of these relationships and have them vetted by our own, personal legal counsel. Slide60

When Ethics Violations Can Turn Into Legal Problems

As a result you want to avoid:

Free hearing tests

Providing free hearing tests when you are a Medicare provider appears to be a clear violation of Medicare rules and regulations. Medicare prohibits offering free services such as hearing testing as an inducement to generate other services such as diagnostic audiologic services. http://www.asha.org/Practice/reimbursement/medicare/audiology-medicare-prohibitions-FAQs

/

You need your own legal counsel to help you work through the ramifications of providing free testing given your specific situation.

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When Ethics Violations Can Turn Into Legal Problems

Use of referral pads.

Write-offs of co-pays and deductibles.

Unless meets established, documented indigent policy.Reminder mailing for annual hearing tests where you are seeking third-party coverage.All could be construed as a solicitation of a Medicare covered service.

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Anti-Kickback

“Section 1128B(b) of the Social Security Act (42 U.S.C. 1320a-7b(b)), previously codified at sections 1877 and 1909 of the Act, provides criminal penalties for individuals or entities that knowingly and willfully offer, pay, solicit or receive remuneration in order to induce business reimbursed under the Medicare or State health care programs. The offense is classified as a felony, and is punishable by fines of up to $25,000 and imprisonment for up to 5 years.”

This provision is extremely broad. The types of remuneration covered specifically include kickbacks, bribes, and rebates made directly or indirectly, overtly or covertly, or in cash or in kind. In addition, prohibited conduct includes not only remuneration intended to induce referrals of patients, but remuneration also intended to induce the purchasing, leasing, ordering, or arranging for any good, facility, service, or item paid for by Medicare or State health care programs

.

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When Ethics Violations Turn Into Legal Problems

False Claims Act

Criminal penalties.

https://downloads.cms.gov/cmsgov/archived-downloads/SMDL/downloads/SMD032207Att2.pdfDo not submit fraudulent claims to any entity.

Claims for services not performed.

Including hearing aids that have not yet been dispensed.

Billing under someone else’s provider number.

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False Claims Act

Upcoding

Billing for a comprehensive test when all you did was air conduction.

Billing for a comprehensive test and not adding a modifier when you only tested one ear.All codes but 92601-92604 imply two ears were tested.52 modifier

Billing for services known to not be covered and not adding the appropriate modifier.

Hearing aids.

Aural rehabilitation.

Evaluation and Management codes.

GY Modifier

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False Claims Act

Submitting claims for services which were not medically necessary and not adding the appropriate modifier.

Annual hearing tests.

Tests solely for the sale of a hearing aid.Presence of a physician order does not guarantee medical necessity.GY Modifier

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FDA Requirements

Requirements:

https

://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfCFR/CFRSearch.cfm?fr=801.420 http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?FR=801.421

Receive a User Brochure

Medical Clearance or Medical Waiver

Needed for each fitting of a child under the age of 18 years of age.

If over 18 years of age, may sign a medical waiver.

The FDA will NOT be policing the lack of use of a medical waiver.

Either needs to be in FDA language.66Slide67

FDA Requirements

“The U.S. Food and Drug Administration today

(December 7, 2016) announced

important steps to better support consumer access to hearing aids. The agency issued a guidance document explaining that it does not intend to enforce the requirement that individuals 18 and up receive a medical evaluation or sign a waiver prior to purchasing most hearing aids. This guidance is effective immediately. Today, the FDA is also announcing its commitment to consider creating a category of over-the-counter (OTC) hearing aids that could deliver new, innovative and lower-cost products to millions of consumers”. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm532005.htm

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FDA Requirements

Many state laws reference the FDA Referral Red Flags:

Active drainage within previous 90 days.

History of sudden or rapidly progressive hearing loss.Unilateral hearing loss.Conductive hearing loss or air-bone gap.Impacted cerumen or foreign body in the ear canal.

Pain or discomfort.

Visibly congenital or traumatic deformity of the ear.

Acute or chronic dizziness.

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FDA and State Dispensing Laws

Just because the FDA has indicated that they will not enforce the medical waiver or medical clearance requirement does NOT mean that your state will immediately remove it from your state dispensing laws.

It is IMPORTANT that, before you discontinue use of the medical clearance and medical waiver for adults, that you contact your state dispensing and/or audiology licensure boards and determine if the requirement remains in your state. Slide70

When in Doubt…

Hire legal counsel which specializes in health care and/or Medicare law.

Do not enter into contractual relationships with others parties, including physicians, healthcare facilities, buying groups, or management services, without legal advice.

Can find an attorney via your state bar association or Google.70Slide71

The Role of State Licensure

It is this that dictates your scope of practice.

National Associations do not dictate this.

Payers do not dictate this.Payers do not have to cover all items and services in your scope of practice.YOU cannot interpret this alone.It is very important that you are aware of the requirements of both the hearing aid and/or audiology licensure boards in your state and the scope of practice limitations.

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The Role of State Licensure

Audiology Assistants, Technicians, and Support Staff.

Cannot perform testing on Medicare beneficiaries and legitimately receive payment.

Be careful of:Scope of practice issues.Lack of licensure.You may be allowing them to practice audiology without a license.

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Managed Care Terms

Accountable Care Organization (ACO): A healthcare payment model that

seeks to tie provider reimbursements to quality metrics and reductions in the total cost of care for an assigned population of

patients; care is typically directed and managed by the PCP, similar to that of an HMO.Allowed Charge (approved charge, allowable): Payment for an item or service under the customary and current system outlined on the payer fee schedule; inclusive of the payment from the primary payer, secondary payer, deductible, co-pay and co-insurance.73Slide74

Managed Care Terms

Alternative Payment Model (APM):

APMs give

Medicare and Medicaid new ways to pay health care providers for the care they give Medicare beneficiaries. The programs are based upon cost savings, patient outcomes, and quality. Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs.Appeal: A request for a health insurer or plan to review a coverage decision or payment again.74Slide75

Managed Care Terms

Assignment of Benefits: A procedure where the member/beneficiary authorizes the payer to make payment of allowable benefits directly to the rendering provider.

Bad Debt: The amount that a practice must write off due to a patient’s failure to meet their financial responsibilities.

Balance Billing: Billing the patient for any amount in excess of the allowed by the payer; billing the difference between what the payer allows and your usual and customary rate to the patient.Beneficiary: A person eligible to receive benefits under a health plan; the insured. 75Slide76

Managed Care Terms

Benefits: The health care items or services covered under a health insurance plan.

Billed Charges: The amount the provider bills to the payer for a specific item or service; same as “submitted charges.”

Bundled Payments: payers compensate providers with a single payment for an episode of care, which is defined as a set of services delivered to a patient over a specific time period. This model aims to incentivize providers to improve care coordination, limit costly and unnecessary services, and reduce variations in care not tied to patient care quality and outcomes. By providing one single payment for various providers, bundled payments seek to promote a team- based approach to care. 76Slide77

Managed Care Terms

Bundling: Billing for multiple, distinct items or services to a payer under a singular code.

Care Coordination: The organization of your treatment across several health care providers. HMOs and ACOs are common ways to coordinate care through a PCP

.Carrier: The insurance company which writes and administers the health insurance policy; the payer.Claim: A demand to the payer, by the patient, for payment of benefits under an insurance policy.Clinical Improvement Activity: An activity associated with care coordination, beneficiary engagement, healthcare system efficiency, beneficiary access and patient safety.Co-insurance: A provision of an insurance plan by which the beneficiary shares in the cost of certain covered expenses with the payer on a percentage basis; cost-sharing.

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Managed Care Terms

Coordination of Benefits: A provision in an insurance plan that, when a patient has coverage by multiple insurance plans, benefits paid by all of the plans will never exceed 100% of the usual and customary fee

.

Co-payment: The provision of an insurance plan by which the beneficiary is required to pay a fixed portion of the cost of their healthcare expenses.Contractual Adjustment: The difference between your usual and customary fee and the amount allowed by the payer; same as “write-off.”Credentialing: The process by which managed care organizations and payers determine that a provider is competent to provide services to their beneficiaries.78Slide79

Managed Care Terms

Customary Charge: The provider’s standard charge for a given item or service.

Date of Service: The date the service is performed or the item is dispensed.

Deductible: A stipulated amount which the beneficiary must pay toward the cost of their healthcare before the benefits and coverage of the plan go into effect; usually a set dollar amount that must be satisfied within a given calendar year.Discount Benefit: This is a benefit that negotiates discounts for their members for non-covered items or services. There is no third-party coverage in this instance. This is the same as an unfunded benefit. 79Slide80

Managed Care Terms

Durable Medical Equipment (DME): Equipment, items, goods, and supplies ordered by a health care provider for everyday or extended use; a cochlear implant and hearing aid are considered to be DME by some payers.

Electronic Claim: A claim form completed, processed, and transmitted from one computer to another.

Electronic Medical Record (EMR): A computerized, digitally stored and transmitted medical record.Eligible Expenses: Same as “allowable” and “negotiated rate.”80Slide81

Managed Care Terms

Explanation of Benefits (EOB): A form included with your payment/denial from the payer which explains the specifics of coverage, denial and/or payment for a specific patient for a given date of service; it also outlines the patient’s financial responsibilities.

Excluded services: Health care items and services that a health insurance plan doesn’t pay for or cover; same as “non-covered service.”

Exclusions: Specific services or conditions which the insurance policy will not cover or which are covered at a limited rate.Fee for Service: Refers to reimbursing healthcare providers for the individual items and services provided.81Slide82

Managed Care Terms

Fee Schedule: The fixed dollar amount which is billed or allowed for a specific item or service.

Funded Benefit: This is a benefit where a third-party payer is paying in whole or in part of a given item or service.

Health Maintenance Organization (HMO): A type of health insurance plan that usually limits coverage to care from doctors who work for or contract with the HMO; care is usually coordinated by a PCP.82Slide83

Managed Care Terms

Incident to: Services defined

as are defined as services or supplies furnished as an integral, although incidental, part of the physician's personal professional services in the course of diagnosis or treatment of an injury or illness

. These services are furnished under the supervision of the attending physician and, as a result, billed under the NPI of this physician as the rendering provider. In-Network (participating): The provider has been credentialed by a specific payer and has agreed to the terms of their payer agreement/contract; the provider must accept the allowable as payment in full.83Slide84

Managed Care Terms

Insured: The individual who represents the family unit in in relation to the insurance benefits and coverage; usually the employee who holds the insurance provided by their employer.

Insurer: Payer.

Medicare Access & CHIP Reauthorization Act of 2015 (MACRA): MACRA makes three important changes to how Medicare pays those who give care to Medicare beneficiaries. These changes:Create Quality Payment Program (QPP)End the Sustainable Growth Rate (SGR) formula for determining Medicare reimbursement for provider services.Create a new system

for rewarding health care providers for giving

better, more affordable care and producing better outcomes and eliminate the incentives for providing more care and services.

Combine the existing

quality reporting programs into one new system.

84Slide85

Managed Care Terms

Medically Reasonable and Necessary: Health care services, items, or supplies needed to prevent, diagnose, or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.

Member: Same as “beneficiary.”

Merit-Based Incentive Payment System (MIPS): MIPS is a new program that combines parts of the Physician Quality Reporting System (PQRS), the Value Based Modifier (VM) and the Electronic Health Record incentive program into a single program in which eligible professionals will be measured on defined metrics. Audiology is ineligible for MIPs in 2017. 85Slide86

Managed Care Terms

Negotiated Rate: Same as “allowable” and “eligible expenses.”

Network: The facilities, providers, and suppliers a health insurer or plan has contracted with to provide health care services and care.

Non-Covered Service: An item or service that is not a covered benefit under a specific insurance plan; same as “excluded services.”Order: A request from one healthcare provider to another healthcare provider requesting that they perform a specific item or service to a given patient; same as “referral” or “prior authorization.”86Slide87

Managed Care Terms

Organization Predetermination: The Medicare Advantage process of advanced beneficiary notification. This process varies payer by payer and must occur prior to the provision of care.

Out of Pocket Expense: Limitation on the amount a beneficiary must contribute to their healthcare costs in a given year; can affect co-insurance.

Out-of-Network: The provider has not been credentialed by a specific payer and has not agreed to accept the terms of the payer agreement/contract; can bill the patient your usual and customary rate; patient’s coverage and benefits often reduced. 87Slide88

Managed Care Terms

Patient Centered Medical Home: The

patient centered medical home (PCMH) model facilitates the coordination of care through a patient’s primary care physician. The PCMH model integrates mental health and specialty services, and involves a team-based approach consisting of physicians, nurses and medical assistants, pharmacists, nutritionists, social workers and care coordinators.

Right now, this model is primarily being applied to chronic care conditions such as diabetes and cardiac care.Patient Responsibility: The amount the patient owes for a given item or service once the payer has processed the claim.88Slide89

Managed Care Terms

Pay for Performance (P4P): This is a

term used to refer to those payment models aimed at improving the quality, efficiency and the overall value of health care. In P4P arrangements, providers are reimbursed based on whether they achieve a pre- determined set of quality

metrics. Payable Amount: The amount paid by the payer for a given item or service; excludes co-insurance, co-payments and deductibles.Predetermination: The process of obtaining a written estimate of what a payer will pay for specific items and services before the item is dispensed or the service is performed; not a guarantee of payment.89Slide90

Managed Care Terms

Primary Insurance: The payer who has the primary responsibility for payment under the coordination of benefits provisions of the patient’s insurance agreement.

Prior Authorization: A requirement by the payer that coverage for a given item or service is dependent on the item or service being approved by the payer or another healthcare entity before the item or service is provided to the beneficiary.

Provider: The individual who provides items and services to beneficiaries.90Slide91

Managed Care Terms

Referral: Same as “order.”

Secondary Insurance: The payer who has the secondary responsibility for payment under the coordination of benefits provisions of the patient’s insurance agreement.

Submitted Charges: Same as “billed charges.”Third-Party Administrator (TPA): A middle-man between the provider and the payer/employer group who negotiates discounts, coverage, and benefits for the payer/group and administers the benefit offerings.Unbundling: The process of coding, billing, and requesting payment for items and services that are typically billed under a single procedure code.91Slide92

Managed Care Terms

Unfunded benefit: The payer has negotiated a discount program for its members but does not pay any payment towards the costs of items or services. This is the same as a discount benefit.

Utilization Review: The process of reviewing items and services provided by a specific provider or facility to determine if the items and services provided were reasonable and necessary; a provision included in most third-party contracts.

Verification: The act of predetermining eligibility, coverage, and benefits for a specific patient for specific items and services.Write-Offs: The amount that is not paid by the payer but cannot be billed to the beneficiary; same as “contractual adjustment.”92Slide93
Slide94

Coverage versus Reimbursement

Coverage is when a third-party is paying all or part of the cost of the item or service.

Lack of coverage does NOT mean a lack of reimbursement.

Reimbursement is when you, the provider, receive payment for the cost of the item or service.WE NEED TO CARE MORE ABOUT REIMBURSEMENT AND LESS ABOUT COVERAGE!94Slide95

Facts

Other than Medicare, you are a

VOLUNTARY

participant in managed care.Participation is a business decision. Must be credentialed before you can bill a payer as an in-network provider. Otherwise, you are an out-of-network provider and patient should pay in-full for any item or service they receive on the date the item or service is provided.The patient should be informed of your network status (as it pertains to their insurance) prior to making an appointment and be informed of their financial obligations.95Slide96

Medicare Enrollment

Audiologists CANNOT opt out of Medicare.

Need enrollment as an individual (855-I) and practice (855-B).

Must have an NPI, license, and address before proceeding with enrollment.Can enroll online through: https://pecos.cms.hhs.gov/pecos/login.do

Best way to enroll; avoid paper applications.

Read the tutorials

96Slide97

What Is the Medicare Opt Out?

You enter into private contracts with Medicare beneficiaries for Medicare covered services.

Services will not be covered by Medicare.

Collect payment from patients.You do not file claims to Medicare.Opted out for two yearshttps://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/OptOutAffidavits.html Audiologists cannot opt out!97Slide98

Medicare Enrollment

Determined on 855-R.

Options

Participating:Accept Assignment.Listed in provider directory.Rolls-over to secondary.Medicare pays 5% more.98Slide99

Medicare Enrollment

Non-Participating:

Accept assignment on claim by claim basis or charge patient limiting charge (115% of allowed amount).

Patient pays provider on date of service.Patient receives 95% of Medicare allowed charge from Medicare/secondary payer.Typically does not roll-over to secondary carrier.99Slide100

Medicare Enrollment

Free

Audiologists cannot opt out of Medicare.

If charge $X to one person, you must charge $X to all.100Slide101

Medicare Enrollment Options

101

Par

Non-Par who accepts assignmen

t

Non-Par who do not accept assignment (Limiting Charge)

Billed Amount

$125

$125

$115

Medicare Allowed Amount

$100

$95

$95

80% of Medicare Allowed

$80

$76

$76

Beneficiary Co-Insurance

$20

$19

$19

Total Payment to Provider

$100

$95

$

115

(95 x 1.15 limiting charge); patient

paid $20

differenceSlide102

Medicare Revalidation

This is Medicare’s attempt to update your enrollment.

ONLY do it online via PECOS

at https://pecos.cms.hhs.gov/pecos/login.do#headingLv1 102Slide103

Initial Steps to Contracting: Who?

Need to do a market analysis.

What insurers represent the major employers in your area?

What insurances do your referral sources and local hospitals accept?Some referral sources cannot, by contract, refer to out of network providers.What insurers offer lucrative hearing aid benefits?103Slide104

Request Information

Begin the process with a Google search.

Most payers have excellent websites that contain useful information regarding provider enrollment and guidance.

Take a look at their provider manual or administrative guidance.You can often begin the application request/enrollment process directly from the payer website.Provider/healthcare professional section of the website.104Slide105

Payer Reply

Once your application/enrollment request is completed, you will receive a reply from the payer. This can include:

Rejection:

Closed Network. They can and do say “no.”Provider Agreement and Payer Fee Schedule.105Slide106

Rejection

Periodically, attempt to re-enroll if participation with this payer is lucrative for your business.

Have data to illustrate how many of their members are seeking your services, how underserved your community is (if a patient has to drive more than 5 miles to see an in-network provider), or how your practices offers services or products not provided by other in-network providers (such as auditory processing, vestibular or tinnitus evaluation or management, pediatrics or implants).

106Slide107

Rejection

Reach out to the human resources department of the employer providing these benefits to their employees.

Have data to illustrate how many of their members are seeking your services, how underserved your community is (if a patient has to drive more than 5 miles to see an in-network provider), or how your practices offers services or products not provided by other in-network providers (such as auditory processing, vestibular or tinnitus evaluation or management, pediatrics or implants).

107Slide108

Rejection

Have your patients advocate for your inclusion in the plan.

Encourage them to contact customer service or the human resources department of their employer.

108Slide109

Rejection

Purchase a practice that is in-network with the payer in question.

109Slide110

CAQH

Credentialing clearinghouse.

Free.

http://www.caqh.org/To participate:Must be a contracted provider with a least one of the CAQH participating payers.Must be invited by CAQH once registered.110Slide111

Receive Provider Agreement

Read the

entire

agreement and review the fee schedule.Things to consider:You want these answers IN WRITING ONLY!What products am I participating with: Medicare Advantage? Medicaid? HMOs?If Medicare Part C, what are the organizational pre-determination requirements? Does it allow for balance billing or patient upgrades for hearing aids?Is there a required waiver process?Does it require patients complete notices of non-coverage before non-covered services are provided?Can student externs or technicians see members of this plan?Can hearing aid dispensers see members of this plan?

Can certain services be carved-out of the contract?

What are the termination terms? Renegotiation terms?

For hearing aids, am I required to supply a manufacturer’s invoice?

What are the renewal terms?

“Evergreening” of contract.

111Slide112

Receive Provider Agreement

Things to consider:

You want these answers IN WRITING ONLY.

How is medical necessity defined?What are the requirements for standard processes and procedures for all patients?What are the means of provider notification of substantive changes to the agreement?What are the requirements for standard fee schedule/charge master?What are the timely claims filing requirements?Are there any other claims filing requirements.

Can I file paper claims?

Are there clinic hour requirements?

What are the medical record retention requirements?

How does it address evaluation and management services provided by audiologists?

Do they require hearing aid patients be referred to a third-party administrator for dispensing?

Does the fee schedule address all of the items and services you provide?HCPCS and CPT How are unlisted codes processed? 112Slide113

Fee Schedule

What the payer allows, per contract, for each specific item and service you provide for each specific product you are contracted to provide.

Never accept less than you can afford.

Need to know your breakeven plus profit amount per hour to properly analyze this.Do the benefits outweigh the costs?Be careful of:Inclusive hearing aid coverage benefits.Large hearing aid discounts (percentages of dollars billed). “Fitting fee only” or Invoice plus arrangements.Requirements to provide the manufacturer invoice.Sometimes you do not buy the aid in this equation.Sometimes it is a better business decision to be out-of-network providers as patients pay you in full on the date of service.

113Slide114

Third-Party Administrators

They exist to:

Allow payers a single point of contact and payment for hearing aid related items and services.

Defined risk for the payer.Cost containment for the member.An established standard of care for the member.Audiologists helped create the need for these programs and help maintain their existence through their participation. Slide115

Considering a TPA

TPAs (third-party administrators) are becoming more and more prolific in the audiology space.

Before you agree to join, please consider the following:

Is the plan offering a funded or unfunded (discount) benefit?Is your practice bundle or unbundled?Can you create a competitive product offering?What is my responsibility in informing the patient of their benefits, either funded or unfunded? How many patients do you stand to potentially lose if you do not enroll in the program?What products does the plan offer? What if the member wants a product that is not in the program?Slide116

Considering a TPA

Before you agree to join, please consider the following:

Can I charge the patient or their healthcare insurer for a hearing test?

What items and services are included in the fitting fee?If it is not included in the fitting fee, are their limits to what I can charge?Do I have to notify patients of these costs, in writing, upfront?Do I receive a greater fitting fee if I am a member of a specific buying group or membership organization? How long is the trial period?What do I receive if the patient returns the aids for credit?How long do I have to manage the patient for the fitting fee?Are their limits as to what I can charge for service outside of the fitting fee window?Slide117

Before You Initially Sign…

Make a copy of the entire contract and fee schedule and SAVE IT.

Ask questions when you lack answers.

Don’t sign until you get your answers!Do not be afraid to negotiate.The worse they can do is say “no.”What are the pros versus cons of contracting with each payer?If unsure of some of the contract terms, hire an consultant and/or attorney to review.117Slide118

If You Have Already Signed: Renegotiation

It is NOT the payers responsibility to have a copy of your contract.

If you cannot locate it, request, in writing, a copy of their current agreement and review any

administrative guidance or provider manuals on their websites.Request, in writing, a copy of the current fee schedule.Slide119

Renegotiation

Know what you want and defend why you deserve it.

Have a knowledge of your current agreement and your Medicare fee schedule for your area

.Follow the guidance in the contract on termination but, instead of sending a termination letter, send a request for renegotiation.You must also be willing to walk away in negotiation or you have no power or leverage.Slide120

Renegotiation

Follow the same contract evaluation process you would follow if you were signing up for the first time.Slide121

Non-Participation

Again, other than Medicare, you are a voluntary participant in managed care.

It is an option to not participate in third-party, managed care plans and be an out of network provider.

In this situation, the patient pays in full on the date of service. Your office can submit claims to the payer as a courtesy to the patient.The patient is reimbursed, from the payer, their out of network benefits. You often see this in mental health, dental and optometry offices. Slide122

Two Separate Business Entities

This option is often selected when a practice has a large physician referral base or a large diagnostic practice.

An option that many physician practices choose is to spin their hearing aid or auditory rehabilitative practice off into a separate business, with a separate legal structure and separate tax identification number.

As a result, this second entity would not be encumbered by the managed care obligations of the original business.This new, second business could be strategically enrolled in various managed care enterprises, while avoiding those with poor coverage and benefits for treatment, including haring aids. This is becoming more common in audiology practices as well. In order to do this, you will need to hire an attorney and an accountant to evaluate this option for your situation and effectively and legally create this new business entity. Slide123

Billing 101: The Facts

It is ALL about PROCESS and POLICIES.

Providers complete the testing, write the report, and fill out the superbill.

Data is power!!!Complete a superbill (or OMS encounter) on every patient you see, even no-charge visits.Someone has to collect patient responsibility on the date of service.Billing costs YOU money!!!Office staff takes the superbill information, submits the claim, and monitors payment.123Slide124

Billing 101: The Facts

Claims should be posted within two business days.

Payments should be posted daily.

No one should be able to write-off sums over $100 other than the manager or owner.Stop seeing patients who owe you money.124Slide125

Billing 101: The Facts

You must invest in staff training and materials.

Office management or billing software.

The days of paper claims are almost over!Manuals.You will have to make an investment in ICD-10.Training.You must have consistent, no-exceptions financial policiesSTOP GIVING IT AWAY!!Should be in writing and available.125Slide126

Billing Checks and Balances:

Owners and managers, regardless of your work setting, must monitor accounts receivable (especially that outside of 90 days) and

accounts payable

.Monthly, at a minimum.Collect patient responsibility on date of service.126Slide127

How You End Up in Insurance Hell

YOU put yourself there, not the Insurer!

You do not ask the right questions at scheduling and intake.

You sign ANYTHING without reading or negotiating it.You do not have a working knowledge of the agreement YOU agreed to.You do not verify an individual patient’s coverage and benefits EVERY time.You insist everyone needs top of the line products.127Slide128

How You End Up in Insurance Hell

YOU put yourself there, not the Insurer!

You insist on remaining in a bundled delivery model.

You do not charge patients privately for non-covered services and to notify them in writing of their out of pocket expenses. You do not collect patient responsibility (co-pays, deductibles and co-insurance) at the time of the visit.128Slide129

How Do You Get Out of Insurance Hell

Have a strong scheduling and intake process.

Run your practice like your dentist, optometrist, chiropractor, or podiatrist runs theirs.

All business is not good business. Third-party administrators exist because you sign up. KNOW your contracts!Nothing is free!Collect payment at time of visit.Fit the patient, with something audiologically appropriate, within their benefit. http://www.harlmemphis.org

129Slide130

Third-Party

Coverage

Know the terms of your third-party contracts and fee

schedules.

Good reimbursement begins and ends with

you.

Starts from the minute the patient

calls.

Accountability is

key.

Verification is required EVERYTIME!

Have to ask the right

questions.

Hearing

aids.

BAHA.

Cochlear implants.

130Slide131

Third-Party Coverage

Third-party coverage of diagnostic and hearing aid services is the result of an agreement between the PATIENT and the INSURER.

Sometimes patients have out of pocket expenses and financial responsibility for non-covered or denied coverage for services.

Sometimes the fight for payment is a fight between the patient and the payer and NOT you!131Slide132

Insurance Verification

KNOW YOUR CONTRACTS!!!

Do as much as possible online.

Who did you call? At what number? Do they have a reference number?

132Slide133

Insurance Verification

Who did you call? At what number? Do they have a reference number?

Is the benefit or discount only available through a specific third-party administrator?

Does the patient have a hearing aid benefit? Allowance?

Can the patient have out-of-pocket expense? Can they upgrade?

Is this a funded (the payer is covering all or a portion of the costs of the device) or unfunded (discount) benefit?

Do they have out-of-network benefits? (You ask this if you are an out-of-network provider).

What services are covered?

Literally, provide the codes 92591, 92593, 92595, V5011, V5020, and V5160.

Are they eligible

today

?

Know your deductibles!

They can sometimes be larger than the cost of the hearing aids.

133Slide134

Insurance Verification

What are the coverage/benefit specifics?

Does the HL have to be related to accident., illness or injury?

Is this an inclusive benefit?

Does the benefit include all services related to the evaluation and fitting of the device?

How frequent?

X number of months or years

Dollars?

A fixed defined dollar amount or an “up to” amount

“Up to” generally means your allowable fee for the device itself

134Slide135

So I Verified Benefits? Now What?

You must treat managed care patients as you would treat a private pay patient.

The date you bill is the date you fit!

Date of service is the day the item is dispensed or the service is provided. Can the patient upgrade?If no, you must fit within the benefit.Itemization can help in these situations. If yes, you need to offer them a product within their benefit. If they choose to “upgrade”, then they need to be notified in writing, prior to fitting, of the fact that they could have received a product at no-charge (except for co-pays, co-insurance and deductibles) but, instead, they have opted to upgrade and their financial responsibility is X.Is it an “up to” benefit or a fixed dollar amount?“Up to X” does not mean “X”Fit a entry level product.

You will need to fit within the benefit.

Itemization can help in these situations. Slide136

Insurance Verification

If the patient does NOT have an inclusive hearing aid benefit, consider unbundling the charges, even if you remain bundled to your private pay patients, as it may push about $200-300 to patient responsibility.

You unbundled total needs to equal your bundled total.

Restrict the level of product provided.

If a carrier states that they pay a “maximum of x dollars” or “up to” X dollars but do not specifically define a benefit amount, assume the $500 rule as, on many occasions, they will not actually pay the maximum (the maximum would typically apply to a digital CIC).

“Up to X” does not mean you will receive “X”

It means they cover the allowable rates.

136Slide137

Hearing Aid Verification Scenarios:

Scenario 1: You contact the third-party payer and complete the insurance verification form in full. Per the third-party payer, you are allowed to balance bill the patient for the difference between the insurance coverage/allowable amount and the your usual and customary charge.

This one is easy!

137Slide138

Scenario 2: You contact the third-party payer and complete the insurance verification form in full. Per the third-party payer, you are not allowed to balance bill the patient for the difference between the insurance coverage/allowable amount and your usual and customary charge.

You must restrict product cost to an aid whose invoice cost is less than $250-350 per aid maximum

.

The patient has no

out-of-pocket

expense in this scenario (except for unmet co-pays or deductibles).

You must accept the negotiated rate as payment in full

.

138Slide139

Scenario 2: Continued

I strongly encourage you to be honest with the patient about the situation (i.e. “the negotiated rate is less than my cost for more advanced products”).

The patient then has four options:

Get a more basic hearing aid paid in full by their third-party payer. This is what most patients prefer.

Refer the patient to a third-party administrator you are contracted with that IS a contracted provider for this plan, is allowed to bill the funded portion of their plan, and is also allowed to balance bill the patient.

Go elsewhere and try to find another provider who will do this for them (in many cases out of network providers would be allowed to balance bill the patient).

Have the patient sign a completed insurance waiver. In this case, they are waiving their insurance coverage and you, as the provider, will not be submitting a claim to their carrier. Please ensure that the patient gets an original copy of their bill or sale and the insurance waiver in the event they attempt to bill their carrier themselves.

If the patient proceeds with the first bullet, the patient should pay any co-insurance amounts (based upon usual and customary rates) and deductible amounts (up to the usual and customary cost of the aids) on the date of the fitting.

139Slide140

Scenario 3: You contact the third-party payer and

complete

the insurance verification form in full. The carrier states that either the dispensing fee and/or hearing aid evaluation can be billed as a separate charge and/or they request that the claim be submitted unbundled.

The patient should also pay any co-insurance amounts (based upon usual and customary rates) and deductible amounts (up to the usual and customary cost of the aids) on the date of the fitting.

You need to unbundle the cost of the hearing aid in this situation

. You can unbundle differently for different payers, based upon what is allowed in each contract, as long as the total package always equals the same amount!

140Slide141

Scenario 3: Continued

Hearing aid (V5…)

Dispensing Fee (V5…, if allowed)

Hearing aid evaluation (92590/1)

Hearing aid check (92592/3)

Electroacoustic analysis of aid (92594/5, if performed)

Fitting and Orientation of aid (V5011)

Conformity Evaluation (V5020, if performed)

Earmold, if applicable (V5264) or dome (V5265)

Earmold Impression, if applicable (V5275)

Batteries (V5266)

Accessories (V5267, if provided)

141Slide142

When Dealing with Hearing Aids in a Third-Party World, Please

Consider

:

The insurance verification form and process is completed prior to the hearing aid evaluation. If possible, the insurance information should be gathered at the time the hearing aid evaluation is scheduled.

Please also make sure that the patient pays all outstanding deductibles, co-pays, and percentages of responsibility on the date of fitting, as well as any patient responsibility they may have. You want to be in a position to refund money and not trying to collect outstanding monies from the patient

.

These are all of the monies you can collect on the date of order or fit if you are an in-network provider.

Do not discount hearing aids billed to third-party carriers.

Have all marketing provide a disclaimer to this effect

.You must get your cost of goods as low as possible.

No manufacturer is irreplaceable.

142Slide143

Billing Hearing Aids via Third-Party Administrators

They each have their own processes.

The general process is this:

TPA refers patient to your practice.Your practice sees the patient and recommends amplification.You fax, email or submit via their portal the required paperwork to order and/or acknowledge fitting of the device. The TPA pays for the device and, often, the earmold, if needed. After the end of the trial period, you are paid a fitting fee. You manage the patient, at no additional cost to the patient or the plan, for a fixed time period or number of visits. Slide144

The

D

own

Low on Waivers/Patient NotificationCANNOT USE IF NOT ALLOWED BY CONTRACT!!!

Otherwise, you will be in violation and, if a patient pushes back, you will have to refund

them.

Do they recognize S1001?

Patient Notification

Use

to notify and bill

patient for non-covered

services.

144Slide145

The

D

own

Low on Waivers/Patient NotificationUpgrade Waiver

BCBS.

Must provide an aid (standard) at

no-charge

to patient

.

Patient can upgrade if they so choose and pay the difference between the allowable and usual and customary.

145Slide146

The

Down-Low

on Waivers/

Patient NotificationInsurance Waiver

Patient waives their insurance

benefit.

They do not bill their insurance and you do not bill their

insurance.

Rarely

happens.

146Slide147

CMS 1500 Resources

http://

www.nucc.org

http://www.practicons.com/2013/another-change-in-health-care-cms-1500-claim-forms-are-changing/http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c26.pdf 147Slide148

CPT Basics

CPT is the acronym for Current Procedural Terminology.

CPT is a listing of codes and their descriptions that outline medical services and procedures.

CPTs are added, deleted, and modified annually (first Monday in November) by their creator, the American Medical Association.As of October 2003, HIPAA requires that all insurance carriers, including Medicare and Medicaid, use CPT codes.CPTs are five digit, numeric codes. Most codes that apply to audiology begin with the numbers 92xxx.

Audiology can be involved in this code creation through ASHA and AAA.

148Slide149

Vestibular Testing: Without Recording

92531: Spontaneous nystagmus, including gaze

92532: Positional nystagmus test

92533: Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes four tests)92534: Optokinetic nystagmus testNon-covered by Medicare

149Slide150

Vestibular Testing: With Recording

9

2540: Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal or peripheral stimulation, with recording, and oscillating tracking test, with recording

92541: Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording

92542: Positional nystagmus test, minimum of 4 positions, with recording

92544: Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording

92545: Oscillating tracking test, with recording

Add the -59 modifier if bill two or three of 92541, 92542, 92543, or 92544 on the same patient on the same date of service.

150Slide151

Vestibular Testing with Recording

Both replace 92543 in 2016.

92543 was eliminated.

92537: Caloric vestibular test with recording, bilateral; bithermal (i.e. one warm and one cool irrigation for each ear for a total of four irrigations)Add -52 modifier if only perform three irrigations and -22 modifier if perform more than four irrigations 92538: Caloric vestibular test with recording, bilateral; monothermal (i.e. one irrigation in each ear for a total of two irrigations)Add –52 modifier if only complete one irrigationSlide152

Vestibular Testing: With Recording

92546: Sinusoidal vertical axis rotational testing

NOT for vHIT or headshake

92547: Use of vertical electrodes (List separately in addition to code for primary procedure)ENG

only

(except Florida MAC)

92548: Computerized dynamic posturography

152Slide153

Audiology Codes

92551: Screening test, pure tone, air only

92552: Pure tone audiometry (threshold); air only

92553: Pure tone audiometry (threshold); air and bone92555: Speech audiometry threshold92556: Speech audiometry threshold; with speech recognition

92557: Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)

Add 59 modifier if bill two of 92552, 92553, 92555, or 92556 on the same patient on the same date of service.

153Slide154

Immittance

Codes

92550

: Tympanometry and reflex threshold measurements92567: Tympanometry (impedance testing)

92568: Acoustic reflex testing, threshold

92570: Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing

Reflex thresholds should be established both ipsilateral and contralateral test conditions at at least two to three frequencies

154Slide155

CAPD

Codes

92620: Evaluation of central auditory function, with report; initial 60 minutes

92621: Evaluation of central auditory function, with report; each additional 15 minutesNeed to have spent 31 minutes or more to bill 92620

155Slide156

CAPD

Codes

92571: Filtered speech test

NOT for QuickSIN or speech in noise testing92572: Staggered spondaic word test92576: Synthetic sentence identification test

Code individually only when performed in isolation.

156Slide157

Pediatric

Codes

92579: Visual reinforcement audiometry (VRA)

“Is a test technique that can be performed using either loudspeakers or earphones, which uses flashing lights, moving toys, or video to reinforce a head-turn response to sound stimuli, and it may be used with either tonal or speech stimuli”Four frequenciesThe procedure is repeated with speech, warble tones, narrow tone noise, and frequency specific noisemakers

92582: Conditioning play audiometry

“Is

a test technique in which the patient is taught a game that requires a response to tonal stimuli. A variety of play responses can be used with CPA, such as dropping a toy in a container or putting pegs in a board. It is typically done using earphones.

”

92583: Select picture audiometry

These are NOT method codes.157Slide158

Evoked Potential

Codes

92516: Facial nerve function studies (e.g. ENoG

)Can be billed “incident to”

92584: Electrocochleography (e.g. ECoG) or for CI NRT

92585: Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive

92586: Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited

158Slide159

OAE Codes

92558: Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis

92587: Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3–6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report

92588: Comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report

159Slide160

Hearing Aid Codes

92590: Hearing aid examination and selection; monaural

92591: Hearing aid examination and selection; binaural

92592: Hearing aid check; monaural92593: Hearing aid check; binaural

92594: Electroacoustic evaluation for hearing aid; monaural

92595: Electroacoustic evaluation for hearing aid; binaural

160Slide161

Cochlear Implant Codes

92601: Diagnostic analysis of cochlear implant, patient under 7 years of age; with programming

92602: Diagnostic analysis of cochlear implant, patient under 7 years of age; subsequent reprogramming

92603: Diagnostic analysis of cochlear implant, age 7 years or older; with programming92604: Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming

Add 59 modifier if performed on the same day at 92626.

161Slide162

Audiology Codes

92575: Sensorineural acuity level test

In some PQRS

measures92596: Ear protector attenuation measurements

92625: Assessment of tinnitus (includes pitch, loudness matching, and masking)

92626: Evaluation of auditory rehabilitation status; first hour

92627: Evaluation of auditory rehabilitation status; each additional 15 minutes (List separately in addition to code for primary procedure)

92630: Auditory rehabilitation; prelingual hearing loss

92633: Auditory rehabilitation; postlingual hearing loss

92640: Diagnostic analysis with programming of auditory brainstem implant, per hour162Slide163

Other Audiology Related Codes

69209:

Removal of

impacted cerumen using irrigation/lavage, unilateral69210: Removal impacted cerumen, with instrumentation, unilateral

Technically, a surgical code

While can be billed with a -50 modifier, it typically only is reimbursed as one unit

95992: Canalith repositioning procedure(s), per day

163Slide164

Other Audiology Related Codes

99366: Medical team conference with interdisciplinary team of health care professionals, face to face with patient and/or family, 30 minutes or more, participation by non-qualified health care professional

99368: Medical team conference with interdisciplinary team of health care professionals, patient and/or family not present, 30 minutes or more, participation by non-qualified health care professional

164Slide165

Other Audiology Related Codes

96110: Developmental screening (e.g. developmental milestone survey, speech and language delay screen), with scoring and documentation, per standardized instrument.

165Slide166

Use of 92700

To classify procedures that do not have CPT codes.

Individually reviewed.

ABN required.If reporting 92700, submit report with:Copy of Patient Report

Description of procedure

Clinical Utility of the Procedure

Time

Skills of Tester

Equipment used

Benefit to patientUsual and Customary Fee166Slide167

Common Uses of 92700

VEMPs

High-frequency audiometry

Audiometric WeberEustachian tube function testingASSRMiddle/late latency responseUse of gogglesSaccade testingSensory organization testHead shake testingSpeech in noise testingTinnitus managementRemoval of incidental cerumenFistula testingVHit

167Slide168

Codes to Use with Caution

You need to ensure that you have actually performed the service.

92504: Binocular microscopy

92560: Bekesy audiometry, screening92561: Bekesy audiometry, diagnostic92562: Loudness balance test, alternate binaural and monaural92564: Short increment sensitivity indexSlide169

CPT Tips

Always have the coding legitimately represent all of the procedures that were completed on each individual patient on a given date of service.

Always ensure you actually performed the specific procedure billed.

COVERAGE and PAYMENT does not mean COMPLIANCE.Make sure you are using the most up to date codes.

Make sure you have a 2016 or newer CPT Manual in your office.

It is legitimate to bill for attempted procedures with the appropriate documentation.

Use modifiers when needed.

169Slide170

Modifiers

-22: Increased procedural service

Some examples to consider are threshold search ABR or functional hearing assessment (extensions of another procedure).

-32: Mandated Service-33: Preventative serviceWhen billing for follow-up newborn hearing screening only.

170Slide171

Modifiers

-50: Bilateral Procedure

-52: Reduced service

Only tested one ear.Did not meet all of the components of a code.-59: Distinct Procedural Service

Used in situations where you are unbundling parts of a bundled code.

92540

92552

Used when performing 92601-92604 and 92626/7 on the same patient on the same date of service.

171Slide172

Modifiers

-RT: Right ear

-LT: Left ear

Only modifiers that can be used with HCPCS codes.172Slide173

Modifiers

-GA: Waiver of liability on file

Used when an ABN was completed for required reasons, such as the use of 92700 or the existence of a local coverage determination.

-GY: Item or service statutorily excluded or does not meet the definition of a Medicare benefit.

You want a Medicare

denial.

Used with –GX modifier

only.

-GZ: Item or service expects to be denied as not reasonable or necessary.

Used when an ABN was required but not obtained. 173Slide174
Slide175

Place of Service Codes

These are two-digit

codes placed on

claims to indicate the setting in which a service was provided.You change your setting, you change your place of service code. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7631.pdf Slide176

Place of Service Code Examples

11: Office

12: Home

13: Assisted Living Facility14: Group Home15: Mobile Unit21: Inpatient Hospital*22: Outpatient Hospital*31: Skilled Nursing Facility*32: Nursing Facility34: Hospice*62: Comprehensive Outpatient Rehabilitation Facility*** The facility must submit the claim. Your practice will need a contract with the facility to provide care. ** Audiologic testing is non-covered by Medicare.

https://www.cms.gov/Medicare/Coding/place-of-service-codes/

Place_of_Service_Code_Set.html

176Slide177

Home Visits

You have to reflect the place of service as HOME (12).

If you provide diagnostic services in the home, certain, specific criteria must be met for Medicare COVERAGE.

The patient needs to be homebound.https://www.medicare.gov/Pubs/pdf/10969.pdf https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf Slide178

Skilled Nursing or Hospice

Medicare Part B coverage is dependent on the status of the patient, on the specific date of service, within the Medicare system.

You also have to be careful if they are living in these facilities and are seen in your office.

If they are covered within the Part A time frame, the facility must bill and receive payment from Medicare and the audiologist will receive payment from the facility. You will need a contract with the facility that outlines the responsible party. Slide179

Skilled Nursing or Hospice

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/

SNFSpellIllnesschrt.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/ConsolidatedBilling.html Slide180

Hospital OPPS Billing

“Bundling” is the name of the game.

This is how many hospital outpatient claims are paid, but does not effect how they are billed.

http://www.audiology.org/practice_management/reimbursement/2017-hospital-outpatient-prospective-payment-system-opps-final http://www.asha.org/Practice/reimbursement/medicare/feeschedule/ http://www.asha.org/uploadedFiles/Audiology-SLP-HOPPS.pdf Certain services are not reimbursed separately if provided on the same date of service as other services.You are reimbursed a “package” price for a given date of service.

The reimbursement can often be higher.

This is also a system that is sometimes mandated by a payer. Slide181

Evaluation and Management Code Basics

These are the codes physicians and non-physician practitioners (such as nurse practitioners and physician assistants) utilize to bill for office visits.

Per the CPT manual, these codes can be used by “qualified health professionals who are authorized to perform such services within the scope of their practice.”

So, can an audiologist in your state “evaluate” and ”manage”? Only your state licensure board can determine that. 181Slide182

Evaluation and Management Code Basics

Common codes to be considered by audiologists are 99201-99203 (new patient) and 99211-99213 (established patient).

Avoid 99204-99205 and 99214-99215 as inappropriate for audiologists as this level of code requires a high risk of morbidity and mortality (which otologic issues do not contain).

182Slide183

Evaluation and Management Codes: New Patient

99201

Requires

these key components: a problem focused history, examination (screenings) and straightforward medical decision making. Usually, the presenting problem(s) are self limited or minor. 99202Requires these key components: an expanded problem focused history, examination (screenings) and straightforward medical decision making. Usually, the presenting problem(s) are of low to moderate severity.

183Slide184

Evaluation and Management Codes:New Patient

99203

A detailed history, examination (screening) and medical decision making of low complexity. Usually, the presenting problem(s) are of moderate severity.

184Slide185

Evaluation and Management Codes:Established Patient

99211

May not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal.

99212Requires a problem focused history, examination (screenings) and straightforward medical decision making. Usually, the presenting problem(s) are self limited or minor. 185Slide186

Evaluation and Management Codes:Established Patient

99213

An expanded problem focused history, examination (screenings) and medical decision making of low complexity. Usually, the presenting problem(s) are of low to moderate severity.

186Slide187

The Do’s of E/M

Confirm that your state licensure laws allow for evaluation and management services.

Is it in your state defined scope of practice?

Consult your payer contracts and fee schedules to determine if they allow for the use of E/M codes by audiologists.If they do not AND it is allowed by state licensure, can the patient be held financially responsible for the costs? They do not have to allow their use by audiologists.

187Slide188

The Do’s of E/M

If you bill one payer for E/M codes, you must bill all payers and patients (including patients when non-covered, such as Medicare).

Can have it solely apply to specific test scenarios only as long as it applied to every patient.

Auditory prosthetic device candidacyVestibular assessment

Tinnitus evaluation

CAPD evaluation

You must m

eet the documentation requirements of E/M codes or you shouldn

’

t use them.Read the E/M section of your CPT Manual at: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf before proceeding.188Slide189

The Don’ts of E/M

Do not utilize these codes for hearing aid visits.

These are only for use in diagnostic test situations.

Do not accept payment from traditional Medicare for these codes.Use these codes with caution if you work in an ENT or hospital setting.Risks can be great if billing two E/M codes from the same facility for the same patient on the same date of service.

189Slide190

Evaluation and Management Codes

New patient versus established patient:

They are established if they have seen you or another audiologist in your practice within the last three years.

Outpatient versus inpatient.Examination: Typically paid separately, except for the screenings.

As a result, ignore the time designates on the code and focus on the complexity of the visit.

190Slide191

Evaluation and Management Codes

Type of history: problem focused, expanded problem focused, detailed, comprehensive.

Chief complaint

History of present illness (brief or extended)Review of systems (none, problem pertinent, extended, complete)Past, family, and/or social history (none, pertinent, complete)

191Slide192

Evaluation and Management Codes

Problem focused:

Chief complaint

Brief history of present illness or problem Expanded problem focused:Chief complaint

Brief history of present illness or problem

Problem pertinent system review

192Slide193

Evaluation and Management Codes

Detailed:

Chief complaint

Extended history of present illness or problem Problem pertinent system review expanded to include a limited number of additional, appropriate systemsProblem pertinent past, family, and/or social history

Comprehensive:

Chief complaint

Extended history of present illness or problem

Review of all 14 body systems

Complete past, family, and/or social history

193Slide194

Evaluation and Management Codes

Medical decision making: Straightforward, low complexity, moderate complexity, high

complexity.

Number of diagnoses or management options: minimal, limited, multiple, extensive.

Amount and complexity of data to be reviewed: none, minimal, limited, moderate,

extensive.

Risks of significant complications, morbidity, or mortality: minimal, low, moderate,

high.

194Slide195

Utilizing E and M Codes

For evidence based evaluation and management beyond audiometric assessment.

Consider applying them uniformly, but only to specific clinical situations such as:

Vestibular assessmentAuditory prosthetic device candidacy assessmentCentral auditory processing assessmentTinnitus assessment195Slide196

Pediatric Testing

Can bill for testing that is attempted if documentation of:

What happened?

Why you were unable to complete the testing?Did you spend at least half of the typical test time attempting the procedure?Documentation is key!196Slide197

Examples of Pediatric Test Situations:

Child Less Than Two Years

VRA (92579) in soundfield or headphones, includes tones and/or speech

Tympanometry and reflexes (92550) OAEs (92587)ABR (92585)197Slide198

Examples of Pediatric Test Situations:

Child Two to Five Years

Conditioning play audiometry (92582)

Select picture audiometry (92583)Tympanometry and reflexes (92550)OAEs (92587)198Slide199

CAPD

Very hard to do, if participating with third-party payers.

CAPD evaluation (92620/1).

First 31-60 minutes, please report writingTreatment92633 versus 92700Team meeting with patient (99366) and team meeting without patient (99368).Evaluation and management codes?199Slide200

Vestibular Assessment

Basic vestibular evaluation (92540):

Gaze (92541).

Positionals, minimum of four positions (92542).Hallpike testing is a position.Optokinetic (92544).Oscillating tracking (92545).Caloric testing (92537)Evaluation and Management codes?200Slide201

Vestibular Assessment

Positional testing, without recording (92532)

Could be used for Hallpike in isolation.

Rotational testing (92546)Must have a rotational chair.Use of vertical electrodes (92547)For ENG only (except in Florida).Dynamic posturography (92548)Need a platform.Saccades, VEMPs, SOT, and/or use of goggles (92700)Ends up being private pay in most cases. 201Slide202

Auditory Osseointegrated Device

Need pre-determination in writing, if not clearly listed as a benefit on the patient’s contract.

Never call a BAHA a BAHA

Call it an “auditory prosthetic device”. Candidacy testing, if completed (92626).Evaluation and Management codes?Fitting (L9900).Patient pays this amount on the date of the device fitting.Troubleshooting/service (L9900).Suggest patient be billed and pay privately.

202Slide203

CI Candidacy

Audiogram (92557)

Tymps and reflexes (92550)

ABR (92585)OAEs (92587 or 92588)Caloric testing, per irrigation (Calorics x 2)Evaluation of A/R status (92626/7)Team meeting with patient (99366) versus team meeting without patient (99368)Evaluation and Management codes?203Slide204

CI Surgery

NRT (92584)

204Slide205

CI Initial Tune-up

Programming (92601 if less than 7 years or 92603 if 7 years or older)

Could bill as two line items, with RT/LT modifiers or add -50 modifier for bilateral implants

Testing (92626)Add -59 modifierNRT (92584)205Slide206

CI: Everything Else

Re-programming (92602 or 92604)

NRT (92584)

Testing (92626)Must spend at least 31 minutes.Troubleshooting/service (L9900)Suggest patient be billed and pay privately.Recommend you send patients to manufacturer for supplies.More time to bill and collect than you actually receive.L codes exist.206Slide207

Cerumen Removal

Impacted (69209 or 69210):

Use 69209 if you used lavage or irrigation or use 69210 for use of any other form of instrumentation.

Can bill Medicare patients privately.Voluntary ABN.Consult your contract for guidance with other payers.50 modifier for binaural, although they may only pay for one ear.Non-impacted (92700):Inclusive to audiogram if performed on same date of service for Medicare.Can bill Medicare patients privately if done on a separate date of service.Consult your contract for guidance with other payers.

Voluntary ABN.

207Slide208

Tinnitus Management

What does your typical patient look like in terms of test battery, case history, and counseling???

92625

Evaluation and Management? This will help you determine the codes you use and the prices you set.Will need to screen for depression, as allowed by state licensure, for PQRS.Very hard to do, if participating with third-party payers.Medicare does not cover tinnitus maskers.Medicare patients are financially responsible for costs.Consult payer guidance for private insurers.V5299.Tinnitus rehabilitation (92700 versus 92633).

Consult payer guidance for private insurers.

Medicare patients are financially responsible for costs.

208Slide209

Aural Rehabilitation

92630 or 92633

Medicare beneficiaries are financially responsible for the costs.

Consult payer guidance for private insurers.209Slide210

VA, Workers Compensation and Medicaid Coding

These entities follow their own, defined coding conventions

Following the coding recommendations and requirements outlined by these specific payers

210Slide211

ICD-10-CM

ICD-10-CM

is an acronym for the International Classification of Diseases,

10th Revision.ICD-10s are a listing of codes designed to classify diagnoses and symptoms.Created by the World Health Organization and Centers for Disease Control.These codes typically consist of up to seven characters.Changed on October 1 of each year.

Went into effect October 1, 2015.

211Slide212

Fundamentals of ICD10

Code what the patient, their family and/or their physician report in your case history.

Case histories need to focus on the whole patient, not just the auditory system

Code co-morbidities that support medical necessity.i.e. cancer, vascular disorders, autoimmune diseases, diabetes, MSCode what you, the audiologist, measure.i.e. hearing lossCode what you, the audiologist, personally visualize.i.e. exotoses, cauliflower earDo not code merely for coverage. This could be VERY important with the repeal of ACA. Slide213

Importance of Documentation

Documentation of comprehensive case history, test results, and plan of care is key to successful ICD 10 coding, especially if working with certified coder at your facility and they are coding for youSlide214

Meaning of “Unrestricted”and “Restricted” in ICD 10

Unrestricted means “normal” in ICD 10

Restricted means “abnormal” in ICD 10Slide215

What the Numbers Mean

A “3” as the last number means bilateral.

A “2” as the last number means left ear.

A “1” as the last number means right ear.Slide216

Local Coverage Determinations

A Local Coverage Determination (LCD) is a decision by a Medicare Administrative Contractor (MAC) whether to cover a particular service on a

MAC-wide

, basis.Slide217

Local Coverage Determinations

Vestibular and Auditory Testing

Novitas

Evoked PotentialsNovitasIntraoperative MonitoringNovitasFirst CoastWisconsin Physician ServicesTympanometryFirst CoastVestibular Testing OnlyFirst CoastVestibular Testing Also affects 92557Palmetto

NoridianSlide218

ICD-10 Examples

H93.293 Abnormal auditory perception, bilateral

H93.292 Abnormal auditory perception, left ear

H93.291 Abnormal auditory perception, right earH93.3X3 Acoustic nerve disorder, bilateral H93.3X2 Acoustic nerve disorder, left earH93.3X1 Acoustic nerve disorder, right earH61.303 Acquired stenosis of external ear canal, bilateral H61.302 Acquired stenosis of external ear canal, left ear H61.301 Acquired stenosis of external ear canal, right ear

218Slide219

ICD-10 Examples

Z45.320 Adjustment and management of implanted bone conduction device

Z45.321 Adjustment and management of cochlear implant

H93.213 Auditory recruitment, bilateral H93.212 Auditory recruitment, left ear H93.211 Auditory recruitment, right ear Q16.1 Aural atresia G51.0 Bell's Palsy

219Slide220

ICD-10 Examples

D33.3 Benign neoplasm of cranial nerves

H81.13

Benign paroxysmal vertigo, bilateral H81.12 Benign paroxysmal vertigo, left ear H81.11 Benign paroxysmal vertigo, right ear M95.12 Cauliflower ear, left ear M95.11 Cauliflower ear, right ear H93.25 Central auditory processing disorder 220Slide221

ICD-10 Examples

H90.0

Conductive hearing loss, bilateral

H90.12 Conductive hearing loss, left ear, unrestricted hearing in right earH90.11 Conductive hearing loss, right ear, unrestricted hearing in the left earH90.A11: Conductive hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral sideH90.A12: Conductive hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral side221Slide222

ICD-10 Examples

R62.0

Delayed milestone in childhood

F81.89 Developmental disorder of scholastic skills, otherH93.223 Diplacusis, bilateral H93.222 Diplacusis, left ear H93.221 Diplacusis, right ear R42 Dizziness This is a symptom, not a diagnosis. Z51.11 Encounter for antineoplastic chemotherapy

222Slide223

ICD-10 Examples

H69.81 Eustachian tube disorders, other specified, right ear

H69.82

Eustachian tube disorders, other specified, left earH69.83 Eustachian tube disorders, other specified, bilateralH61.813 Exostosis, bilateral H61.812 Exostosis, left ear H61.811 Exostosis, right ear

223Slide224

ICD-10 Examples

Z82.2

Family history of hearing

lossZ46.1 Fitting and adjustment of hearing aid T16.2XXA Foreign body in left ear, initial encounterT16.2XXD Foreign body in left ear, subsequent encounterT16.1XXA Foreign body in right ear, initial encounterT16.1XXD Foreign body in right ear, subsequent encounter

224Slide225

ICD-10 Examples

Z01.12

Hearing conservation and treatment

Z01.110 Hearing examination following failed hearing screeningZ01.10 Hearing/vestibular examination without abnormal findingsH61.123 Hematoma of pinna, bilateral H61.122 Hematoma of pinna, left ear H61.121 Hematoma of pinna, right earZ91.81 History of falling

225Slide226

ICD-10 Examples

H93.233 Hyperacusis, bilateral

H93.232

Hyperacusis, left ear H93.231 Hyperacusis, right ear H61.23 Impacted cerumen, bilateral H61.22 Impacted cerumen, left ear H61.21 Impacted cerumen, right ear

226Slide227

ICD-10 Examples

F70 Intellectual disabilities, mild

F71 Intellectual disabilities, moderate

F72 Intellectual disabilities, severeF73 Intellectual disabilities, profoundF78 Intellectual disabilities, otherF79 Intellectual disabilities, unspecified227Slide228

ICD-10 Examples

H83.13

Labyrinthine fistula, bilateral

H83.12 Labyrinthine fistula, left ear H83.11 Labyrinthine fistula, right earZ79.2 Long term (current) use of antibioticsZ79.82 Long-term use of aspirinZ76.5 Malingering

H81.03

Meniere's disease, bilateral

H81.02

Meniere's disease, left ear

H81.01

Meniere's disease, right ear 228Slide229

ICD-10 Examples

H90.6 Mixed hearing loss, bilateral

H90.72

Mixed hearing loss, left ear, unrestricted hearing in right ear H90.71 Mixed hearing loss, right ear, unrestricted hearing in left earH90.A31: Mixed conductive and sensorineural hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral sideH90.A32: Mixed conductive and sensorineural hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral sideZ96.22 Myringotomy tube(s) status

H83.3X3

Noise effects on inner ear,

bilateral

H83.3X2

Noise effects on inner ear, left

earH83.3X1 Noise effects on inner ear, right ear229Slide230

ICD-10 Examples

H55.00 Nystagmus

Z0.58 Observation

and evaluation of newborn for other specified suspected condition ruled outH92.03 Otalgia, bilateral H92.02 Otalgia, left ear H92.01 Otalgia, right earCan represent pressure and fullness as well. H92.13 Otorrhea, bilateral H92.12 Otorrhea, left ear H92.11 Otorrhea, right ear

230Slide231

ICD-10 Examples

H91.03 Ototoxic hearing loss, bilateral**

H91.02 Ototoxic hearing loss, left ear*

*H91.01 Ototoxic hearing loss, right ear** ** Code poisoning or adverse effectT36.5X5A Poisoning, adverse effect, aminoglycosides, initial encounter T36.5X5S Poisoning, adverse effect, aminoglycosides, long term follow-up T36.5X5D Poisoning, adverse effect, aminoglycosides, subsequent encounter

231Slide232

ICD-10 Examples

T37.2X5A

Poisoning, adverse effect, antimalarials, initial encounter

T37.2X5S Poisoning, adverse effect, antimalarials, long term follow-up T37.2X5D Poisoning, adverse effect, antimalarials, subsequent encounter T45.1X5A Poisoning, adverse effect, antineoplastic, initial encounter T45.1X5S Poisoning, adverse effect, antineoplastic, long term follow-upT45.1X5D Poisoning, adverse effect, antineoplastic, subsequent encounter

232Slide233

ICD-10 Examples

T39.015A Poisoning, adverse effect, aspirin, initial encounter

T39.015S

Poisoning, adverse effect, aspirin, long term follow-up T39.015D Poisoning, adverse effect, aspirin, subsequent encounter T50.1X5A Poisoning, adverse effect, loop diuretic, initial encounter T50.1X5S Poisoning, adverse effect, loop diuretic, long term follow-up

T50.1X5D

Poisoning, adverse effect, loop

diuretic,

subsequent encounter

233Slide234

ICD-10 Examples

T36.3X5A

Poisoning, adverse effect, macolides, initial

encounterT36.3X5S Poisoning, adverse effect, macolides, long term follow-up T36.3X5D Poisoning, adverse effect, macolides, subsequent encounter T46.7X5A Poisoning, adverse effect, vasodilators, initial encounter T46.7X5S Poisoning, adverse effect, vasodilators, long term follow-upT46.7X5D

Poisoning, adverse effect, vasodilators, subsequent encounter

234Slide235

ICD-10 Examples

H93.A1 Pulsatile tinnitus, right ear

H93.A2 Pulsatile tinnitus, left ear

H93.A3 Pulsatile tinnitus, bilateralH93.A9 Pulsatile tinnitus, unspecified earZ97.4 Presence of external hearing aidH90.3 Sensorineural hearing loss, bilateral H90.42 Sensorineural hearing loss, left ear, unrestricted hearing in right ear

H90.41 Sensorineural

hearing loss, right ear,

unrestricted hearing in

left

ear

H90.A21: Sensorineural hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral sideH90.A22: Sensorineural hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral side235Slide236

ICD-10 Examples

I69.998 Sequealae following unspecified cardiovascular disease,

other

F80.4 Speech and language delay due to hearing lossF80.1 Speech-language disorder, expressiveF80.2 Speech-language disorder, expressive/receptiveF80.89 Speech-language developmental disorder, otherF80.0 Speech-language disorder, phonological236Slide237

ICD-10 Examples

H91.23 Sudden idiopathic hearing loss, bilateral

H91.22 Sudden idiopathic hearing loss, left ear

H91.21 Sudden idiopathic hearing loss, right earH93.243 Threshold shift, temporary, bilateral H93.242 Threshold shift, temporary, left ear H93.241 Threshold shift, temporary, right ear H93.13 Tinnitus, bilateral H93.12 Tinnitus, left ear

H93.11

Tinnitus, right ear

237Slide238

ICD-10 Examples

H93.013 Transient ischemic deafness, bilateral

H93.012

Transient ischemic deafness, left ear H93.011 Transient ischemic deafness, right ear H82.3 Vertiginous disorder of vestibular function, bilateral* H82.2 Vertiginous disorder of vestibular function, left ear* H82.1 Vertiginous disorder of vestibular function, right ear* *Code first underlying

disease

H81.313

Vertigo, aural, bilateral

H81.312

Vertigo, aural, left ear

H81.311 Vertigo, aural, right ear 238Slide239

ICD-10 Examples

H81.43 Vertigo, central,

bilateral

H81.42 Vertigo, central, left ear H81.41 Vertigo, central, right earH81.393 Vertigo, peripheral, other, bilateralH81.392 Vertigo, peripheral, other, left earH81.391

Vertigo, peripheral,

other, right ear

H81.8X3

Vestibular function disorder,

other, bilateral

H81.8X2 Vestibular function disorder, other, left ear H81.8X1 Vestibular function disorder, other, right ear 239Slide240

Different Hearing Losses in Different Ears

H90.A11: Conductive hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral side

H90.A12:

Conductive hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral sideH90.A21: Sensorineural hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral sideH90.A22: Sensorineural hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral side

H90.

A31:

Mixed conductive and sensorineural

hearing loss, unilateral, right ear, with restricted hearing loss on the contralateral

side

H90.A32: Mixed conductive and sensorineural hearing loss, unilateral, left ear, with restricted hearing loss on the contralateral sideYou would need to select two of the above codes to reflect different hearing losses in different ears.240Slide241

Toxicity from Viagra

H91.02 Ototoxic hearing loss, left

ear

T46.7X5A Poisoning, adverse effect, vasodilators, initial encounter First date you diagnose an ototoxic loss.241Slide242

“Routine” Hearing Test

There is no CPT or HCPCS code for a “routine” hearing test.

The best option is ICD 10 code Z0.110.

Sometimes, again, it is the patient’s responsibility to fight for coverage. Slide243

Normal Hearing with No Other Symptoms or Co-Morbidities

Z01.10 Hearing/vestibular examination without abnormal

findings

OrH93.2 - - Abnormal auditory perceptionIf they report communication difficulties.243Slide244

Normal Vestibular

Z91.81 History of Falling

or

R42 DizzinessorH81.93 Vestibular function disorder, unspecified, bilateralorComorbidities that drove medical necessity.Slide245

Newborn Hearing Screening Follow-up

Code pre and post natal conditions or symptoms.

Code any co-morbidities.

Code anything you see or measure.If they previously failed a hearing screening, code Z01.110.Add the -33 modifier to all of the procedures.Consider Z0.58 (Observation and evaluation of newborn for other specified suspected condition ruled out).Slide246

ICD 10 Tips

We code what we learn and find, not for coverage.

You could be giving someone a pre-existing condition.

Do not use rule out diagnoses once you know they do not exist.http://www.cgsmedicare.com/partb/pubs/news/2013/0113/cope21072.html Can code up to 12 diagnoses per claim.Can link diagnosis to procedure (diagnosis pointer; 24e).Field can accommodate up to four pointers. Use the most specific code possible whenever possible.Can be denied over lack of specificity. We have NO IDEA the impact of use of a Z code on reimbursement as this varies payer to payer.

As a result, use other codes

whenever possible.

Avoid these codes being a primary or only diagnosis.

246Slide247

ICD 10 Resources

Online Look-up (free options):

www.icd10data.com

https://www.aapc.com/icd-10/codes/ https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx Manuals/Softwarehttps://commerce.ama-assn.org/store/catalog/subCategoryDetail.jsp?category_id=cat1150010&navAction=pushhttps://www.optumcoding.com/Category/100091/100276/

https://www.aapc.com/medical-coding-books/icd-10-books.aspxSlide248

HCPCS Basics

HCPCS is the acronym for Healthcare Common Procedure Coding System.

HCPCS is a listing of codes and their descriptions that outline items and supplies and the services that surround them.

HCPCS are added, deleted, and modified annually by the Centers for Medicare and Medicaid Services (CMS).As of October 2003, HIPAA requires that all insurance carriers, including Medicare and Medicaid, use HCPCS.HCPCS are a letter followed by four numbers. Most codes that apply to audiology begin with the letters L (cochlear implants or BAHA) or V (hearing aids).

Anyone can submit an application for HCPCS codes but need some form of vendor support as you need their data.

It is now about products only.

248Slide249

HCPCS “L” Codes

L9900:

Orthotic/prosthetic supply, accessory and/or service component of another HCPCS L code (can be used for an abutment revision)

I do not think audiology practices should be in the auditory prosthetic device replacement part business (due to DME requirements).

Patients should work directly with device manufacturers.

249Slide250

HCPCS “S” Codes

Need to determine how each private payer recognizes and reimburses this code before you use

any of the codes.

Not appropriate for Medicare or Medicaid.Sometimes these codes may be used to represent a service for productivity and not billing. S1001: Deluxe item, patient notifiedIt is listed in addition to the code for the basic item. May help with upgrades.S0618: Audiometry for hearing aid evaluation to determine level and degree of hearing lossSome payers may consider this the code to be used for a routine hearing test.

250Slide251

HCPCS “S” Codes

S5165: Home modifications, per visit

Home falls hazard assessment and modification.

S9445: Patient education, not otherwise classified, non-physician provider, individual, per sessionS9446: Patient education, not otherwise classified, non-physician provider, group, per sessionS9476: Vestibular rehabilitation program, non-physician provider, per diem 251Slide252

HCPCS “S” Codes

S9981: Medical records copying fee, administrative

S9982: Medical records copying fee, per page

State medical records policies dictate what can be charged.S9999: Sales tax252Slide253

HCPCS Codes

V5008: Hearing screening

Same as 92551.

V5010: Assessment for hearing aidSame as 92590/1.V5011: Fitting/orientation/checking of hearing aid“Checking” aspect same as 92592/3. V5014: Repair/modification of hearing aidRepairsReprograming

Recase

Replate

V5020: Conformity evaluation

Verification.

253Slide254

HCPCS Codes

V5050: Hearing aid, monaural, in the ear

V5060: Hearing aid, monaural, behind the ear

V5130: Binaural, in the earV5140: Binaural, behind the earThese are without technology. 254Slide255

HCPCS Codes

V5170: Hearing aid, CROS, in the ear

V5180: Hearing aid, CROS, behind the ear

V5210: Hearing aid, BICROS, in the earReceiver and transmitterV5220: Hearing aid, BICROS, behind the earTransmitter and hearing aid/receiver255Slide256

HCPCS Codes

V5254: Hearing aid, digital, monaural, CIC

V5255: Hearing aid, digital, monaural, ITC

V5256: Hearing aid, digital, monaural, ITEV5257: Hearing aid, digital, monaural, BTE256Slide257

HCPCS Codes

V5258: Hearing aid, digital, binaural, CIC

V5259: Hearing aid, digital, binaural, ITC

V5260: Hearing aid, digital, binaural, ITEV5261: Hearing aid, digital, binaural, BTE257Slide258

HCPCS Codes

V5200: Dispensing fee,

CROS

V5240: Dispensing fee, BICROSV5090: Dispensing fee, unspecified hearing aidV5110: Dispensing fee, bilateralV5160: Dispensing fee, binauralV5241: Dispensing fee, monaural hearing aid, any type What encompasses the ordering, programming, and fitting that is not represented by another code.

258Slide259

HCPCS Codes

V5268: Assistive listening device, telephone amplifier, any type

V5269: Assistive listening device, alerting, any type

V5270: Assistive listening device, television amplifier, any typeV5271: Assistive listening device, television caption decoderV5272: Assistive listening device, TDDV5273: Assistive listening device, for use with cochlear implantV5274: Assistive listening device, not otherwise specified

259Slide260

HCPCS Codes

V5281: Assistive listening device, personal FM/DM system, monaural (1 receiver, transmitter, microphone), any type

V5282: Assistive listening device, personal FM/DM system, binaural (2 receivers, transmitter, microphone), any type

V5283: Assistive listening device, personal FM/DM neck, loop induction receiverV5284: Assistive listening device, personal FM/DM ear level receiver260Slide261

HCPCS Codes

V5285: Assistive listening device, personal FM/DM, direct audio input receiver

V5286: Assistive listening device, personal Bluetooth FM/DM receiver (streamer)

V5287: Assistive listening device, personal FM/DM receiver, not otherwise specifiedV5288: Assistive listening device, personal FM/DM transmitter assistive listening device261Slide262

HCPCS Codes

V5289: Assistive listening device, personal FM/DM adaptor/boot coupling device for receiver, any type

V5290: Assistive listening device, transmitter microphone, any type

262Slide263

HCPCS Codes

V5264: Ear mold/insert/not disposable, any type

V5265: Ear mold/insert/disposable, any type

V5275: Ear impression, each263Slide264

HCPCS Codes

V5267: Hearing aid or assistive listening device/supplies/accessories, not otherwise specified

V5266

: Battery for use in hearing deviceV5298: Hearing aid, not otherwise classifiedV5299: Hearing service, miscellaneous264Slide265

V5299 Examples

Extended warranty

Loss and damage deductible

Tinnitus deviceEarmold serviceService planPSAPNoise ear plug/filter265Slide266

HCPCS Tips

Medicaid and the VA see HCPCS code use differently.

Follow their specific requirements.

Available on their websites. No code for tinnitus devices or maskers.

Use V5299.

266Slide267

HCPCS Tips

There are some “duplicates” across CPT and HCPCS codes.

V5010

vs. 92590/1V5014 vs. 92592/3 and 92594/5Use the code covered in your insurance contract, which has the highest reimbursement in your fee schedule, or which is required by the insurance benefit.Remember, there is one code for each type of aid (digital BTE, monaural) and it does not take into account level of technology.

267Slide268

CMS Audiology Policies

Update to Audiology Policies:

Effective October, 2008.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads//R84BP.pdfRevisions and Re-Issuance of Audiology Policies:Effective September, 2010.

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads//MM6447.pdf

268Slide269

CMS Audiology Policies

Addresses:

“Incident to” billing.

Not allowed except for cerumen removal, canalith repositioning, ENoG and tympanometry.Required physician orders.No order…no coverage.

Treatment Services

Medicare never covers treatment provided and billed by an audiologist.

Computerized audiometry.

Not covered.

Role of technicians and their supervision requirements.

Require training and 100% direct supervision of the treating physician.Audiologists cannot supervise technicians and bill the services they provide under the NPI of an audiologist.269Slide270

CMS Audiology Policies

Addresses:

Role of students, including but not limited to, the final year extern and their supervision requirements.

Students require 100% personal supervision for Medicare coverage.Medical necessity.No medical necessity…no coverage.

Billing of technical and professional components.

Audiologists should bill the global fee for the services they provide.

Documentation.

An audiogram in and of itself does not constitute sufficient documentation if audited.

92700

You use this code to bill for procedures and services that have no CPT code.“Opt Out” (audiologist cannot opt out of Medicare).270Slide271

Documentation and Medicare

“Documentation for Orders (Reasons for Tests):

The reason for the test should be documented either on the order, on the audiological evaluation report, or in the patient’s medical record. (See subsection C of this section concerning reasons for tests.)

Documenting skilled services. When the medical record is subject to medical review, it is necessary that the record contains sufficient information so that the contractor may determine that the service qualifies for payment. For example, documentation should indicate that the test was ordered, that the reason for the test results in coverage, and that the test was furnished to the patient by a qualified individual. Records that support the appropriate provision of an audiological diagnostic test shall be made available to the contractor on request”. 271Slide272

Medicare and Medical Necessity

“Under any Medicare payment system, payment for audiological diagnostic tests is not allowed by virtue of their exclusion from coverage in section 1862(a)(7) of the Social Security Act when:

The type and severity of the current hearing, tinnitus, or balance status needed to determine the appropriate medical or surgical treatment is known to the physician before the test; or

The test was ordered for the specific purpose of fitting or modifying a hearing aid.” http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html (Chapter 15, section 80.3)272Slide273

Medical Necessity

“Examples of appropriate reasons for ordering audiological diagnostic tests that could be covered include, but are not limited to:

Evaluation of suspected change in hearing, tinnitus, or balance;

Evaluation of the cause of disorders of hearing, tinnitus, or balance; Determination of the effect of medication, surgery, or other treatment; Re-evaluation to follow-up changes in hearing, tinnitus, or balance that may be caused by established diagnoses that place the patient at probable risk for a change in status including, but not limited to: otosclerosis, atelectatic tympanic membrane, tympanosclerosis, cholesteatoma, resolving middle ear infection, Meniere's disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, acoustic neuroma, demyelinating diseases, ototoxicity secondary to medications, or genetic vascular and viral conditions; Failure of a screening test (although a screening test is non-covered); Diagnostic analysis of cochlear or brainstem implant and programming; and

Audiology diagnostic tests

b

efore and periodically after implantation of auditory prosthetic devices.”

273Slide274

Physician Order Requirements

Needed for each incident of care.

Needs to be in place before testing is performed.

Does not guarantee medical necessity.Should state “audiologic and/or vestibular evaluation.”Should avoid the term “hearing aid.”

For audiologists, tests do not need to be individually listed.

Delivery methods:

Submitted via EMR.

Hand

delivered, faxed, or mailed.

E-mailed.Telephone.Avoid this option.https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs-Items/CMS012673.html (Chapter 15, section 80.6)274Slide275

Advanced Beneficiary Notices

ABN

http://www.cms.gov/Medicare/Medicare-General-Information/BNI/

ABN.htmlApplicable to traditional Medicare only.Has required and voluntary (notice of non-coverage) uses.Must be completed prior to rendering care.Mandatory claims submission.If they select Option 1.

275Slide276

Advanced Beneficiary Notice (ABN)

Required ABN

Use of 92700 or L9900

Local Coverage Determination in place in your localityFor traditional Medicare ONLY.GA Modifier required.Waiver of liability on file.

276Slide277

ABN

Voluntary ABN

When item is statutorily excluded from coverage or does not meet the definition of a Medicare benefit.

Serves as a Notice of Non-Coverage for when an item or service is never covered.GX Modifier required.Can use with a GY modifier.

277Slide278

Voluntary ABN Uses

Routine or annual audiologic testing where medical necessity was not met.

Hearing aids or testing for the sole purpose of obtaining a hearing aid.

Treatment services such as cerumen removal, canalith repositioning, tinnitus management, and aural rehabilitation.Tinnitus maskers and devices.Evaluation and Management codes.Audiologic and/or vestibular testing where a physician order was not obtained prior to testing.Audiologic evaluations that were the result of solicitation (e.g. reminder cards, marketing events).Audiologic and/or vestibular testing that was completed by a student in the absence of 100% personal supervision by an audiologist or physician.Audiologic testing that requires the skills of an audiologist or physician but was completed by a technician.

Screenings.

278Slide279

Medicare Advantage

Advanced Beneficiary Notices are not applicable.

May need pre-service organization determination from the payer prior to perform the service or dispensing the item.

You need to consult each payer for their guidance on pre-service organization determination process.92700L9900V5298V5299Some require this process for all non-covered services as well.Slide280

Who Can Order Testing?

As allowed by their state licensure.

Certified Nurse-Midwives

Clinical Nurse SpecialistsClinical PsychologistsClinical Social WorkersInterns, Residents and FellowsNurse PractitionersPhysician AssistantsDoctors of Medicine or OsteopathyDoctors of Dental Medicine or SurgeryDoctors of Podiatric MedicineDoctors of Optometryhttp://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/

MedicareOrderingandReferring.html

280Slide281

Ordering Physicians

Medicare requires a physician order for coverage of audiologic and vestibular services.

The ordering physician MUST be enrolled in Medicare as either a participating, non-participating or opt out provider.

You need to ensure this prior to submitting the claim or your claim will be denied.If the claim is denied, the patient cannot be financially responsible for the costs.https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html Slide282

Medicare Advantage (Part C)

Most (except HMOs) do not require a physician order.

Need to consult each plan to determine requirements.

Many Medicare Advantage plans are reimbursing audiology and vestibular services consistently with Local Coverage Determinations where they exist.Slide283

Medicare Data on YOU

Google yourself and many of you will find that your Medicare claims data is available online to consumers

https://www.cms.gov/research-statistics-data-and-systems/statistics-trends-and-reports/medicare-provider-charge-data/physician-and-other-

supplier.html http://graphics.wsj.com/medicare-billing/ Slide284

Physician Compare

Allows patients to find, choose, and compare physicians and other health care providers who are enrolled in Medicare.

A provision of the Affordable Care Act.

Audiologists are currently listed.Your PQRS participation will be noted as well.http://www.medicare.gov/physiciancompare/search.html 284Slide285

Medicaid

Varies greatly state by state.

Managed programs may be GREATLY affected by repeals in ACA so make sure to check eligibility at every visit.

Know the guidelines and follow them!Medical necessity always applies here.Managed Medicaid can differ greatly from state Medicaid programs. Ask yourself: Why are you participating????Medicaid is generally NOT a revenue generating business unless doing volume!You would need volume to make money.Know how to handle non-covered services and do not provide them for free!There may be notification requirements prior to providing care.

285Slide286

Audiology Physicians Quality Reporting System (PQRS)

PQRS was retired on December 31, 2016

.

Your practice can still be penalized in both 2017 and 2018 for failure to appropriately report in 2015 and 2016. The penalty is 2%. The replacement program, the Merit-Based Incentive Payment System (MIPS) went into effect on January 1, 2017.Audiologists are ineligible for the MIPS program in 2017.As a result, we have no required reporting responsibilities in 2017.Slide287
Slide288

Audiology Physicians Quality Reporting System (PQRS)

The

audiology community is strongly encouraging folks to keep doing the actions, although not necessarily reporting on claims because the data will not be maintained or reported by CMS, because:

It differentiates us in the marketplace,It is evidence based care, andThis system and these measures will return and be required again, with even greater consequences.Slide289

Merit Based Incentive Payment System (MIPS)

The Merit-based Incentive Payment System (MIPS) consolidates three existing quality reporting programs: the Physician Quality Reporting System (PQRS), the Value-based Payment Modifier (VBPM), and meaningful use (MU). The system also adds a new performance category, called improvement activities (IA).

https://qpp.cms.gov/Slide290

Merit Based Incentive Payment System (MIPS) and AudiologySlide291

Merit Based Incentive Payment System (MIPS): What We Do Know

PQRS like measure reporting will be back.

There will be clinical improvement reporting requirements.

Registry reporting only?Likely…ASHA is developing an audiology registry as we speak.Slated for September 2018.Details are yet to be released.Electronic medical record requirements?Maybe….we need to start to prepare for this.Slide292

Clinical Improvement Activities

Expanding practice access

Population management

Care coordinationBeneficiary engagementPatient safety and practice assessmentAchieving health equityIntegrating behavioral and mental healthEmergency Response and PreparednessSlide293

Clinical Improvement Activity Examples

Expanded hours

Telehealth

Patient satisfaction surveysData registry participationReports to physiciansTimely communication to physiciansElectronic health recordsPeer led support groupsEnhanced websitesFalls risk screening and assessment Humanitarian workDepression screeningTobacco screeningSlide294

Facts About Documentation

Think beyond the ear…

If it is not documented, it did not happen.

An audiogram in and of itself does not constitute sufficient documentation, specifically as it relates to medical necessity.Does the testing result in payment?Was the testing ordered?Needs to be complete and legible.It needs to be dated.Must document name and professional identity.https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf

294Slide295

Case History

This is the first step to strong documentation of patient history and medical necessity.

Components

History of chief complaint(s)Right ear, left ear, or binaural.Acute, chronic, progressive, fluctuating, or sudden.Detailed description of chief complaint(s).Congenital versus acquired.

295Slide296

Case History

Components

Family history:

Health status or cause of death of parents, siblings, and children.Specific disease history of parents, siblings, and children.Hereditary medical conditions. 296Slide297

Case History

Components

Past history:

Prior major diseases, illnesses, injuries, or accidents.Surgical history.Current medications or treatments.Allergies (specifically latex).

297Slide298

Case History

Components

Social history:

Marital status, including domestic partners.Employment history.Recreational history.History of drug, alcohol, and tobacco use.

298Slide299

Case History

Components

Review of systems:

Constitutional symptoms.Weight loss, fever, chills, fatigueNon-specificEyes.Ears, nose, mouth, and throat.Cardiovascular.Respiratory.Gastrointestinal.Genitourinary (urinary/genital).Musculoskeletal.

Integumentary (skin and breast).

Neurological.

Psychiatric.

Endocrine.

Hematologic/lymphatic.

Allergic/immunologic. 299Slide300

Results

Need to outline results and explain why you did what you did.

Otoscopic inspection.

Comprehensive hearing test (air, bone, speech and discrimination).Immittance testing.OAEs.Other tests.300Slide301

Recommendations

Make sure to take into account test results and case history findings.

Don’t forget:

Medication management.Tinnitus.Amplification.Maybe not just hearing aids.Assistive devices.Aural rehabilitation.Ear protection.

Referral information.

301Slide302

SOAP Notes

S= Subjective

O=Objective

A=AssessmentP=PlanAll documentation should contain these components.These components can be flipped to focus on assessment and plan at the outset. Useful link: http:// www.physiciansoapnotes.com/ 302Slide303

Notes versus Report

Documentation, in the medical record, is what is needed to document patients’ history, results, plan of care and medical necessity.

A report to the ordering and/or attending physician can replace the notes (in the medical record you would indicate to see reported dated X) IF the report is comprehensive. Slide304

Example

Dan

Brown was seen at the Northwestern University Hearing Clinic on May 21, 2014 for a comprehensive audiologic evaluation. His primary care physician, Ed Jones, MD,

ordered the testing. 304Slide305

Example

Mr. Brown reported hearing loss in his left ear, dizziness that is accompanied by nausea, and tinnitus in his left ear.

The patient does not report any ear deformities, ear drainage, ear pain, sudden or rapidly progressive hearing loss or foreign bodies in the ear. The

patient does report a history of cardiac issues, high blood pressure, smoking and occupational noise exposure. Currently, Mr. Brown is taking Lasix, Lipitor and aspirin daily.305Slide306

Example

Otoscopic inspection revealed evidence of non-occluding cerumen in both ears. This cerumen was removed, using a headlight and curette, prior to testing.

Following cerumen removal, otoscopy was unremarkable.

306Slide307

Example

A comprehensive hearing test was completed to determine the patient’s hearing sensitivity and speech recognition abilities. Pure-tone audiometry revealed

a mild-to-moderate, sensorineural hearing loss in the right ear and a mild-to-severe, sensorineural hearing loss in the left ear. Speech reception thresholds were in good agreement with the pure-tone findings. Speech recognition scores were excellent for the right ear and fair for the left ear at elevated presentation levels. Significant asymmetries were noted between ears throughout the testing, with the left ear being significantly poorer.

307Slide308

Example

Immittance

testing, which accesses the integrity and function of the outer and middles ear systems, revealed normal, Type A tympanograms bilaterally. Acoustic reflex thresholds were established due to the asymmetries between ears and to assist in the differential diagnosis.

Acoustic reflex thresholds were within normal limits for the right ear but were elevated or absent for the left ear. 308Slide309

Example

Mr

. Brown’s test results revealed a binaural sensorineural hearing loss, with the left ear being significantly poorer. The tests results are consistent with possible retrocochlear pathology in the left ear.

309Slide310

Example

Recommendations

:

Comprehensive otologic evaluation with Michael Shinner, MD. I have already contacted Dr. Shinner’s office and I have scheduled Mr. Brown to see him on May 24.Hearing aid evaluation and selection once the cause of the patient’s hearing loss has been determined, a medical plan of care has been developed and implemented and the patient has been medically cleared for amplification.Consistent use of ear protection in noisy settings. I have provided Mr. Brown with a set of disposable earplugs and have instructed him on their use and purchase. I have cautioned Mr. Brown about the risks of driving or operating heavy machinery while experiencing dizziness. Gave Mr. Brown literature regarding smoking cessation.

310Slide311

The Importance of Data

The purpose of coding is not just reimbursement; it is data collection.

Every patient needs to generate an encounter.

You need to collect, via your OMS or EMR.311Slide312

Data You Need (at a minimum)

Number of patients seen

Dollars billed

Dollars collectedNumber of hearing aid evaluations completedNumber of aids fitNumber of no charge visitsNumber of hearing aid repairsIn-houseManufacturer312Slide313

Pricing Strategies

Most pricing strategies I see in this industry are based on

NOTHING.

You CANNOT be afraid to charge for your time and

services.

313Slide314

Pricing Strategies

All prices should reflect:

An understanding of your personal breakeven

analysis.

An understanding of your third-party payer fee

schedules.

An understanding of the prevailing rates in the

area.

314Slide315
Slide316

Breakeven Analysis

Breakeven analysis is what does your practice

needs

to bring in,

per

hour,

per full-time equivalent provider to cover your expenses (salary, overhead, calibration, fixed costs, benefits, annual fees, etc

.).

Hearing aid procurement costs are not here as they are

variable.http://www.audiology.org/sites/default/files/20141001_AAA_Guide2ItemizingUrProfeServices.pdf

You want to add a “profit” amount to

this.

This is the minimum you can

charge.

You base your fees for items and services where no fee schedule

exists.

Based upon the time required to complete the

procedure

.

316Slide317

Breakeven Analysis and QuickBooks

Print a Quickbooks Expense Report for a 12 month period of time.

Take a Black Sharpie and mark through any line item that accounts for goods that are sold (i.e. hearing aids, earmolds, ALDs).

Add up the remaining expenses (including salaries) from the Report.These are your expenses for the year. 317Slide318

Breakeven Analysis and QuickBooks

Divide this amount by 12.

This is the amount you need to breakeven per month.

Divide this amount by the number of full-time equivalent, revenue generating providers.Divide this amount by the number of available hours your providers are available to see patients in an average month.No one should see patients 40 hours a week.318Slide319

Third-Party Fee Schedules

Be aware of the third-party fee schedule

amounts.

You do not want to charge less than you could have

collected.

Must have a standard fee schedule for all patients

.

If you charge

one,

you must charge all.

319Slide320

Prevailing Rates

Least important

aspect,

as you must charge what you need to cover your overhead and you do not want to charge less than you could have collected.

Just because your competitors are idiots does not mean you have to be one too!

320Slide321

Pricing Diagnostic/Treatment Services

Compare break-even rate plus profit to

that of your highest third-party payer for

each code.

Consider how much time you schedule each procedure

for.

NEVER

charge what you expect to

receive unless instructed to do so by the payer!

!

321Slide322

Pricing Hearing Aid Services

What is your breakeven plus profit amount?

How much time do you schedule for each hearing aid procedure?

What is the prevailing third-party reimbursement rate?

322Slide323
Slide324

What is Bundling?

Billing all items and services associated with the evaluation, fitting, and management of a hearing aid, as well as its related goods, under one code on the date of fitting.

324Slide325

Why do the Majority of Practices Bundle Their Hearing Aid Pricing?

Honestly, because that is how hearing aid pricing has always been; long before audiologists began dispensing hearing aids in 1978Slide326

Why Bundle???

Despite changes in medical and retail sales, the influx of audiologists into the delivery paradigm, and changes in technology, hearing aids are delivered in essentially the same manner as they were 50 years agoSlide327

Do You Buy “Commodities” the Same Way Today as You Did in 1970?Slide328
Slide329

The Answer….

Has to be “No” for Most of Us…but we are forcing our patients into the same delivery and pricing model we have always had. Slide330

What is this Bundled Pricing Strategy Actually Based On?

Typically, nothing tangible.

Rather it is typically a rudimentary calculation of invoice times X

330Slide331

Why we Need to Move Past 1970: The New Norm and Why We Need to

Re-Evaluate our Pricing Models

The “status quo” may no longer suffice.

We have to differentiate ourselves and our services from these disruptive forces that now exist in the marketplace.How do we price the product and value the service?How do we provide care and services not offered or available through these disruptive entities?How do we embrace these patients who have procured their devices by “disruptive” means?Do we turn them away?Do we engage the “price shoppers”?

How do we expand our focus from just selling a “widget

” or a “commodity”?

331Slide332
Slide333

Your “Real” Competition

Your Manufacturers You Work With:

Sonova (Phonak), William Demant, (Oticon), Widex, Starkey, Great Nordic (GN Resound) and Sivantos all own clinics, buying groups, and managed care enterprises (EPIC, AHAA, HearUSA, American Hearing Benefits, Audigy, and Hearing Planet).

Their goal is to control the delivery streams of amplification.333Slide334

Your “Real” Competition

Your Third-Party Payers (which you voluntarily participate with):

HiHealth Innovations

Medicaid.334Slide335

Your “Real” Competition

Retail/Franchise

Hearing aid dispensers

Medical Community:Otolaryngologists.Internists.Optometrists.335Slide336

Your “Real” Competition

Third-Party Administrators:

HearPO/Amplifon Hearing.

EPIC.TruHearing.HearUSA.AudioNetArizona Hearing Network.Hearing Care Solutions.American Hearing Benefits.Some offer funded benefits. Many have some degree of manufacturer ownership and involvement.

336Slide337

Your “Real” Competition

Discount Programs

Hearing Planet

Hear.comAllyNations HearingMany third–party administrators offer discount plans as well.Technically, every consumer in the US has access to a discount plan. Slide338

Your “Real” Competition

Big Box Retailers:

Walmart/Sam’s Club.

CostCo Walgreen’sCVS338Slide339

Your “Real” Competition

The Government:

Expansions of VA and Medicaid Benefits and Coverage.

Many of these patients would have privately paid for hearing aids 10 years ago.339Slide340

Your “Real” Competition

Applications

Available

on mobile phones.No FDA regulations. EarMachine: http://www.earmachine.com/ EarSpy: http://www.earspyapp.com/ Enhanced Ears: http://www.bxtel.com/enhanced.html Hearing Aid ProHearingOS: http://www.hearingos.com/

Jacoti:

https://www.jacoti.com/

Petralex:

http://petralex.pro/

Super Hearing AidSlide341

Your “Real” Competition

Personal Sound Amplification Products Currently Available Over the Counter:

Able Planet:

http://ableplanet.factoryoutletstore.com/cat/52440/Personal-Sound-Amplifiers.html Bean: http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm373747.pdf Eargo: http://eargo.com/ Otofonix: https://otofonix.com/?gclid=Cj0KEQiApqTCBRC-977Hi9Ov8pkBEiQA5B_ipV4Fde6K-q55QQCygObj2rAtr-NVLoB1_hyIpOcyFsIaAmzH8P8HAQ Phantom:

https://phantomhearing.com/

PocketTalker:

https://www.williamssound.com/pocketalker

Sound World Solutions: http://www.soundworldsolutions.com/store/personal-sound-amplifiers-psa/cs50 Thousands of options available through traditional and online retailers.Personal Sound Amplification Products Currently Available from a Provider: Amp: http://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm373747.pdf Plaid: http://www.plaidhearing.com/provider-info.html Slide342

Your “Real” Competition

Hearing Aids Currently Available Over the Counter:

Audicus:

https://www.audicus.com/why-audicus/ Embrace: https://www.embracehearing.com/ HiHealth Innovations: https://www.hihealthinnovations.com/ IHear: http://ihearmedical.com/ihear-hd/ Listen Clear: https://www.listenclear.com/ MD Hearing:

https://www.mdhearingaid.com/

Sound World Solutions:

http://www.soundworldsolutions.com/store/hearing-aids/companion

Hearing

Help Express: https://www.hearinghelpexpress.com/default.aspx Advanced Affordable Hearing: http://advancedhearing.com/quality-low-priced-hearing-aids Mail Order EntitiesEBaySlide343

How Will You Differentiate Yourself in the Marketplace and Compete????

Products

:

Expand the “products” we offer to our patients.Maybe it is time to kick it old-school and have a less product based practice and a more service based practice.THIS is what differentiates us from our competitors and the “disruptions.”Expertise and Services:Raise the level and standard of care.

343Slide344

How Will You Differentiate Yourself in the Marketplace and Compete????

Promotion:

Marketing strategies will need to change.

Pricing:Unbundling/Itemization.344Slide345

Products:

Assistive Listening Devices

FM/DM Systems

AccessoriesTinnitus MaskersAffects 20% of patients.345Slide346

Expertise and Services

Patient education and training programs for non-traditional purchases.

Aural rehabilitation.

Tinnitus evaluation and management.Vestibular rehabilitation.Auditory processing screening, evaluation, and treatment of adults and children.Primarily cash services.All can influence patient performance and satisfaction with amplification.346Slide347

Promotion

Do we continue to market “price” when consumers can obtain amplification for sometime a fraction of the “price” we are touting?

Do we market a “commodity’ when that “commodity” can purchased less expensively elsewhere?

Do the strategies of old (direct mail, newspaper, yellow pages) hold up in a digital, social media driven marketplace?Does your marketing tell consumers anything about what makes your practice different?347Slide348

Pricing

Bundling

You “bundle” all of your hearing aid product and service costs, as well as our professional fees, under one, singular price (and code).

You do not charge separately for the hearing aid evaluation/consultation and, as a result, receive no payment if a patient does not proceed with amplification.Slide349

Why Keep Bundling???

Pros:

Easy.

What everyone else

does.

349Slide350

Why Keep Bundling???

Cons:

Price often based on nothing tangible.

Not how insurance typically pays for items and services.

No patient choice.

Prices are not

transparent.

Increases patient costs for

many.

Does not reflect your professional

time.

May be collecting less than you need to receive to cover the “average” patient.

350Slide351

Bundled Package Includes:

Hearing aid evaluation

Earmold impression, if required

Electroacoustic evaluation, if doneHearing aid itselfFitting and orientationDispensing feeVerification, if performedDome or custom earmold, if requiredBatteriesAccessories, if providedManufacturer warrantyLoss and damage coverageCounseling and/or aural rehabilitationOne year to lifetime of follow-up hearing aid office visits, checks, in-house repairs, and cleanings

351Slide352

What is Unbundling?

Charging separately for each item or service as it

occurs.

Breaking the “bundled” cost into each individual piece or aspect of service

.

352Slide353

Why Unbundle?

Pros:

Collecting

the amount you need to cover your costs and make a profit (price based on something tangible

).

Price better reflects actual financial needs.

Potential

for increased revenues

long-term and improved cash flow.

Allows for increased reimbursement with most

managed

care

situations.

Makes you price competitive.

What consumers have been requesting for a decade.

353Slide354

Why Unbundle?

Pros:

Allows for patient choice on how their hearing aids are delivered.

Forces a higher standard of care.

Allows for some potential marketing advantages.

Allows

for pricing for

online

or

e-bay purchases.

They

pay everything but the cost of the hearing aid

itself.

You

care less about where the aid comes

from.

354Slide355

Why Not?

Cons:

Does

not work as well with managed care plans where you have to take a large, provider

discount.

May have to rebundle hearing aids for certain managed care situations.

Will

need to change office policies and

procedures.

Have

to collect money from patient

and be

comfortable with

that.

Will

need to change marketing

program.

355Slide356

Hardest Parts of Taking the Leap to Itemization

Analyzing financial needs.

- What are the risks versus the rewards?

Overcoming fear of change.Valuing yourselves, your skills, and your time.Overcoming fear of the unknown.The “unknown” should be reduced if you have a strong knowledge of your financial needs.Slide357

Hardest Parts of Unbundling

Charging for testing and hearing aid evaluations in a world of “free”.

- Is it really “free” and what are they really getting?

Practicing a “doctor” mentality and “prescribing” solutions rather than “selling” a product.Slide358

Hardest Parts of Unbundling

Letting patients make decisions.

A letting them live with the consequences of those decisions.

Raising the bar on the standard of care you provide.Patients are not willing to pay for the privilege of you selling them something.Slide359

Unbundled Pricing Model:

HAE/Communication Needs Assessment

On the date of the hearing aid evaluation, you bill the hearing aid evaluation (92590/1 or V5010; whichever pays more for your average third-party hearing aid contract) to the third-party payer or patient, even if they do not proceed with amplification.

Most third-party payers who cover hearing aids cover hearing aid

evaluations

.

You would also bill for the earmold impression, each (V5275), if a custom earmold is warranted.

359Slide360

Unbundled Pricing Model:

Hearing Aid Fitting

On the date of fit, you would bill the following codes to the patient or the third-party payer:

V52--: The code for the hearing aid

itself

V5---: Dispensing fee

92594/

5

:

Electroacoustic analysis (if performed

) with date service is performed

V5011: Fitting and orientation

V5020: Conformity evaluation (if you perform real-ear and/or functional gain testing)

V5264

: Earmold (custom) or V5265 Dome (disposable earmold

), each

V5266: Batteries (per battery)

V5267:

Accessories

92592/3: Follow-up visits within the Evaluation and Adjustment (global) period

360Slide361

Unbundled Hearing Aid Evaluation and Adjustment Period

Bill 92592/3 or V5011 on the date of each follow-up visit (if billing third party payer).

If private pay patient, you may opt to bill these visits on the date of the fitting.

Could “bundle” these visits into the fitting visit.Charge a “global” fee for this period. 361Slide362

Unbundling

: End

of

Evaluation and Adjustment PeriodOn

this date, the patient has

four choices

:

Exchange the hearing

aid.

Return the hearing aid for credit.

Keep the hearing aid and “pay as you go” for

service.

Keep the hearing aid and purchase a service

package.

362Slide363

Unbundling: Exchange

What was the reason for the exchange?

Can charge a patient a second fitting

fee.

363Slide364

Unbundling: Return for Credit

As allowed by State law, you would refund the patient only the cost of the hearing aid itself (you would retain all other monies as the services were provided

).

364Slide365

Unbundling: Pay

As You Go

Have a fee established for every item or service and charge a patient or their third-party

payer

(if their benefits have not been exhausted) every time the item is provided or the service is

performed.

Fees based upon breakeven analysis and/or cost of

goods.

Nothing is free or

no-charge.

365Slide366

Unbundling: Service Package

This is the service you are currently providing at

no-charge

once the aids are fit and

accepted.

Think of it as the difference between your current bundled fees and the unbundled package

cost.

A patient pays you a fixed rate per aid

or per fitting (based

upon the breakeven analysis) for managing their hearing aids and services for a given period of

time.

Base this on the data of your “average” patient.

366Slide367

Unbundling: Service Package

Could have a fixed number of visits, accessories

(hard to track and maintain) or services OR unlimited number of visits, with defined amounts of accessories or services (built upon the average number of visits you provide per ear per aid fit now in your bundled model).367Slide368

Disclaimer

Prices listed are for illustrative purposes only and should not be construed as a recommendation of any given price. Price must be established individually by each clinic.

368Slide369

Example of Bundled Price

V5261 (Hearing aid, digital, behind-the-ear, binaural): $

5100

369Slide370

Example of Unbundled Price

V5261: The code for the hearing aid itself

$

2400

(single unit two

aids)

V5160: Dispensing fee, binaural

$200 (represents one hour)

92595:

Electroacoustic analysis, binaural

$

33 (10 minutes)

V5011: Fitting and orientation

$

200

(one hour)

V5020

: Conformity evaluation

$66 (20 minutes

)

92633: Aural Rehabilitation, post lingual

$100 (30 minutes)

V5266

: Batteries (per battery)

$1.50

x 8

V5264

: Earmold (custom)

$40 x 2

370Slide371

Example of Unbundled Price

Assume example of $200 per hour fee (breakeven plus profit)

Hearing aid evaluation of $200 and $33 x 2 earmold impression paid on the date of that service

$100 for each 30 minute hearing aid checks can be billed on the date of service (if insurance case) or at fitting (for private pay patient)

371Slide372

Unbundled Package

$266 paid on date of hearing aid evaluation

$3091 paid on date of fitting

$200 total paid for two, 30 minute follow-up visits within evaluation and adjustment period Collected $3557 by date of acceptance372Slide373

Unbundled Pricing Model Example: After the Fitting

Pay as You

Go:

They can purchase a service plan at any point

$

100 for every 30 minute

visit (hearing aid follow-up)

$50 for every 15 minute

visit (earmold service, hearing aid check, drop off repair)

Does not matter if one or two aids; it is all about the time scheduled (as you cannot see anyone else

).

373Slide374

Unbundled Pricing Model Example: After the Fitting

One Year Basic Service Plan (based upon an average of five follow-up visits, one in-house repair, and one manufacturer repair per patient fit): $700

Based upon data from your average patient in a bundled model

Includes unlimited follow-up visits, in-house repairs, manufacturer repairs, loss and damage fittings, and earmold service visits over 12 calendar months

374Slide375

Unbundled Pricing Model Example: After the Fitting

Three-year Premier Service Plan

(based upon an average

of 15

follow-up visits,

three

in-house

repair, three

manufacturer

repairs, 220 batteries, and one Dry and Store per patient fit and ): $2540

Based upon data from your average patient in a bundled model

Includes unlimited follow-up visits, in-house repairs, manufacturer repairs, loss and

damage

fittings,

220 batteries, loaner aids, Dry and Store, earmold impressions and earmold

service visits over

36

calendar months

375Slide376

Price Comparison:

Bundled versus Unbundled (Private Pay)

Bundled = $5100

Unbundled

Pay as You Go =

$3557

With

One Service

Package

(monaural or binaural

) =

$4257

With Three Year Premier Service Package (monaural or binaural) = $6097

376Slide377

Want to

Dispense an Better Aid than

a Online HA

Retailer at a Better Cost?

Patient pays

$

1620

(

$

810 each) at an online, health insurance backed retailer for a hearing aid

with

no tax

, no service, no evaluation, no verification,

30

batteries,

package of wax guards, no extra domes or earmolds, no

follow-up, no loss and damage

coverage,

and no manufacturer warranty

for repairs due to moisture or wax (one year otherwise).

Unbundled

:

$

1757

total

-

$957

in professional fees plus two

hearing aids

with a single-unit price of

$400

each, with no tax, no service, evaluation, verification,

two follow

-up

appointments, aural rehabilitation, custom earmolds,

a three-year manufacturer

warranty for any repair issue,

loss and

damage,

and

8 batteries

377Slide378

Want to Compete with an Online PSAP or Hearing Aid?

Patient pays

$605

at an online retailer

for

two devices with $56 in tax (if that is required in your state),

no service, no evaluation, no verification,

no

batteries,

no follow-up, no loss and damage coverage, and no manufacturer warranty for repairs due to moisture or wax (one year otherwise).

Unbundled

:

$1083 total

- $478 in professional fees with a single-unit price of $349 each, with no tax, no service, evaluation, fitting, verification, and 8 batteries or

$749

to purchase over the counter with evaluation and no services.

378Slide379

How Unbundling Can Help with An Insurance Case (Non-inclusive Coverage)

Bundled: You bill an insurance carrier for $4000 for binaural, digital, behind the ear hearing aids using V5261. Insurance

pays

$1800 (

$900

each

). The patient cannot be balance billed. You have manage that aid for the same number of years as you would a private pay patient.

Unbundled

:

$2175 total – You bill an insurance carrier in an unbundled manner and receive $1800 for the hearing aids, $50 for the HAE, $40 for the EMI, $80 for the HAF, $80 for the dispensing fee, $25 for the EAA, $60 for the REM, $40 for the EM. This patient can pay as they go for service or purchase a service plan, just like their private pay counterparts.Slide380

Patient Buys Their Aids Elsewhere...

WHO

CARES?!!

They are still NOW your

patient.

Can charge them:

$

450

for

electroacoustic analysis, fitting, programming,

verification,

and one follow-up appointment (no follow-up, no batteries, no accessories

).

Sell them a service

package.

Allow them to pay as they go for

service.

380Slide381

Integrating Itemization

It would begin with all new Communication Needs Assessments/Hearing Aid Evaluation and Selections.

Everyone who previously purchased within the bundled model would still be covered within the bundled model.

It would also affect:Anyone who purchased their devices elsewhere.Anyone who’s hearing aids are out of your bundled pricing package or warranty. Slide382

Integrating Itemization

You would explain that this program gives them, the purchaser, control over how their aids are delivered.

You would explain that there is a fee for the Communication Needs Assessment but that they will receive a copy of their evaluation and plan of care (like an optometrist does).

You would explain that, if they choose to get a device from you, the fess will be itemized and separated from the cost of the product itself and that, as a result, they will pay less up front.You would explain that is is their choice to pay as they go for service or purchase a bundled, comprehensive service plan.Slide383

Integrating Itemization

You will explain that there are different costs for different services, depending on how much time each service requires.

If there is a need for repair, they will pay the invoice cost of the repair plus shipping as well as a fee for any service provided by your office.

If there is a need for an earmold, they will pay for the earmold impression as well as the cost of the earmolds. For accessories, they will pay invoice plus a markup for stocking/ordering the items and profit. They may also pay a fee if you must fit or explain the use of the accessory. Slide384

Integrating Itemization

All the while, you can educate them with materials from HLAA and the NASEM on the role and goals of unbundling and itemization.

Some may offer them the ability to purchase certain items themselves or from Big Box retailers, rather than stocking them in their office or having the patient pay more for the same item from them.

Audiology becomes more evaluative and rehabilitative.Some may want to stock many different types of products in their offices, including PSAPs, OTCs, Hearables, and ALDs. Slide385

Integrating Itemization

Audiologists will need:

Well defined informational websites.

Well defined, itemized state required bills of sale.Informational office pieces and forms that explain and list your pricing and process.Social media driven marketing campaign.Physician referral program that outlines the differences of your approach to patient outcomes. Slide386

Forms Discussed in Boot Camp

Many of the forms discussed in the Boot Camp can be purchased through the Academy of Doctors of Audiology and their Practice

Resource Catalog at

http://www.audiologist.org/resources/audiologists/practice-resource-catalog.Forms may also be available to members through AAA and ASHA or through your state audiology association. Slide387

Questions:

Kim Cavitt, AuD

kim.cavitt@audiologyresources.com

(773) 960-6625 (phone)I answer questions at no charge for Boot Camp attendees ONLY until September 1, 2017. 387