Audiology Benefit Billing and Policy Manual

Audiology
General Benefit Policies
- Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
Billing Information
Eligible Providers
Covered Audiology Benefits
Specific Non-Covered Benefits
Timely Filing
Audiology Claim Example
Audiology Revisions Log

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Audiology

Providers must be enrolled as a Health First Colorado provider in order to:

Treat a Health First Colorado member
Submit claims for payment to Health First Colorado
Providers should refer to the Code of Colorado Regulations, Program Rules (10 CCR 2505-10 8.2.3.D.2), for specific information when providing audiology care.

General Benefit Policies

All Audiology services must have a written order, referral, or prescription by any of the following:
1. Physician (M.D. or D.O.)
2. Physician's assistant
3. Nurse practitioner
4. An approved Individualized Family Service Plan (IFSP) for Early Intervention Audiology services
Pursuant to the Affordable Care Act's requirements that State Medicaid Agencies ensure correct ordering, prescribing, and referring (OPR) National Provider Identification (NPI) numbers be on the claim form (42 CFR § 455.440):
1. All Audiology claims must contain the valid NPI number of the OPR physician, physician assistant, nurse practitioner, or provider associated with an Individualized Family Service Plan (IFSP), in accordance with Program Rule 8.125.8.A.
  1. Community Centered Boards may have their NPI listed as the referring NPI for IFSP-ordered early intervention services.
2. All physicians, physician assistants, nurse practitioners, or providers associated with an IFSP who order, prescribe, or refer Audiology services for Health First Colorado members must be enrolled in Health First Colorado (42 CFR § 455.410), in accordance with Program Rule 8.125.7.D. OPR Providers can begin enrollment on Health First Colorado's website.
  1. The new enrollment requirement for OPR providers does not include a requirement to see Health First Colorado members or to be listed as a Health First Colorado provider for patient assignments or referrals.
  2. Physicians or other eligible professionals who are already enrolled in Health First Colorado as participating providers and who submit claims to Health First Colorado are not required to enroll separately as OPR providers.
3. Field 17.b on the CMS1500 claim form must be used for the OPR NPI number.
The term "valid OPR NPI number" means the registered NPI number of the provider that legitimately orders, prescribes, or refers the Audiology service being rendered, as indicated by the procedure code on the claim.
1. Claims without a valid OPR NPI number which are paid will then be subject to recovery.
2. Medical documentation must be kept on file to substantiate the order, prescription, or referral for Audiology services. Claims lacking such documentation on file will be subject to recovery.
Health First Colorado recognizes that Audiology services ordered in conjunction with an approved IFSP for Early Intervention may not necessarily have an ordering provider. Under this circumstance alone the rendering provider must use their own NPI number as the OPR NPI number.
1. Early Intervention Audiology claims must have modifier 'TL' attached on the procedure line item for Health First Colorado to identify that the services rendered were associated with an approved IFSP.
  1. Any claim with modifier 'TL' attached must be for a service ordered by an approved IFSP and delivered within the time span noted in the IFSP.
  2. If the OPR NPI on the claim is that of the rendering provider, and the claim does not have modifier 'TL' attached, the claim is subject to recovery.

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)

8.280.4.E Other EPSDT Benefits

Other health care services may include other EPSDT benefits if the need for such services is identified. The services are a benefit when they meet the following requirements:

All goods and services described in Section 1905(a) of the Social Security Act are a covered benefit under EPSDT when medically necessary as defined at 10 C.C.R. 2505-10, Section 8.076.1.8, regardless of whether such goods and services are covered under the Colorado Medicaid State Plan.
For the purposes of EPSDT, medical necessity includes a good or service that will, or is reasonably expected to, assist the client to achieve or maintain maximum functional capacity in performing one or more Activities of Daily Living; and meets the criteria set forth at Section 8.076.1.8.b - g.
The service provides a safe environment or situation for the child.
The service is not for the convenience of the caregiver.
The service is medically necessary.
The service is not experimental or investigational and is generally accepted by the medical community for the purpose stated.
The service is the least costly.

Billing Information

Refer to the General Provider Information manual for general billing information.

Eligible Providers

Physicians may provide audiology services, but first must contact the fiscal agent to confirm their enrollment with an otolaryngology specialty.
Certified audiologists are eligible to become Medical Assistance Program providers.
- Audiologists must be registered with the Department of Regulatory Agencies in order to dispense hearing aids.
Colorado Home Intervention Program (CHIP) facilitators must be credentialed by Health Care Programs for Children with Special Needs (HCP) administered by the Colorado Department of Public Health and Environment. CHIP facilitators are eligible to become Medical Assistance Program providers and need to enroll in Health First Colorado.

Covered Audiology Benefits

Hearing benefits are limited to the minimum services required to meet the member's medical needs. As stated in Volume 8.280.06, medically necessary, or medical necessity, shall be defined as a Medical Assistance Program service that will, or is reasonably expected to prevent, diagnose, cure, correct, reduce or ameliorate the pain and suffering, or the physical, mental, cognitive or developmental effects of an illness, injury, or disability, and for which there is no other equally effective or substantially less costly course of treatment suitable for the child's needs. Hearing exams, speech therapy, diagnostic testing, surgeries, and related hospitalizations are regular benefits of the Medical Assistance Program.

Claims must meet all requirements outlined in this manual.

Newborn Hearing Screening

The Colorado legislature passed House Bill 97-1095, which establishes hearing screenings for newborn infants [25-4-1004.7(VI)(b)]. Appropriate testing and identification of newborn infants with hearing loss makes early intervention and treatment possible and promotes the healthy development of children. Hearing Conservation Program (HCP) Audiology Regional Coordinators provide consultation information, technical assistance, and referral services to families of children with special health care needs.

Newborn Hearing Screening Reimbursement Policy

Reimbursement for newborn hearing screening is included in the hospital DRG for inpatient hospital deliveries, and the birth center payment for freestanding birthing center deliveries (see Obstetrical Care billing manual). CPT/HCPCS codes for hearing screening cannot be billed for dates on or during the date span of the delivery stay.
Follow-up testing for newborns who fail their initial hearing screening may be billed using CPT/HCPCS codes. Follow-up testing may be billed only if they occur on dates of service outside of the date span for the delivery.

Newborn hearing screenings are a Preventive Service, but that designation does not supersede the reimbursement policies listed above.

Cochlear Implants

Cochlear implants are covered for members aged 12 months through 20 years under the following criteria:
1. Limited benefit from appropriately fitted binaural hearing aids (with different definitions of "limited benefit" for children four (4) years of age or younger and those older than four (4) years) and a three (3) to six (6) month hearing aid trial.
2. Bilateral hearing loss with unaided pure tone average thresholds of 70 dB or greater.
3. Minimal speech perception measured using recorded standardized stimuli-speech discrimination scores of 50-60% or below with optimal amplification at 1000, 2000 and 4000 Hz.
4. Family support and motivation to participate in a post-cochlear aural, auditory and speech language rehabilitation program.
5. Assessment by an audiologist and otolaryngologist experienced in cochlear implants.
6. Bi lateral and hybrid/Electric Acoustic Stimulation cochlear implantation considered on a case by case basis.
7. No medical contraindications.
8. Up-to-date-immunization status as determined by the Advisory Committee on Immunization Practices (ACIP)
Replacement component(s) of an existing cochlear implant is a benefit for all ages when the currently used component(s) is no longer functional and cannot be repaired.

Hearing Aids

Hearing aids are a covered benefit for members ages 20 and under. Hearing aids for adults are not a covered service.

When billing for a pair of hearing aids, each individual hearing aid must be listed on a separate line on the claim form and must have the appropriate modifier noted to indicate the ear for which it is fitted. The "RT" modifier indicates the hearing aid is for the right ear, and the "LT" modifier indicates it is for the left ear. Billing for two (2) units of a hearing aid, on the same line, without the appropriate modifier will result in a denial.

Hearing Aid Trial Rental Period

The Trial Rental Period is included in the purchase reimbursement for the hearing aid(s). Use the last day of the rental period as the date of service.

Hearing Aid Replacement

Hearing aids are expected to last 3 - 5 years. Replacement of a hearing aid is covered for members ages 20 and under. Hearing aids may be replaced when they no longer fit, have been lost or stolen, or the current hearing aid is no longer medically appropriate for the child.

Softbands (including Bone Anchored Hearing Aids - BAHAs)

Softband hearing devices (including BAHAs) are a covered benefit for members ages 20 and under. All softband purchases require a PAR and must be accompanied by a signed letter from a physician documenting medical necessity. Health First Colorado reimburses softband devices using the following methodology:

Prior to January 1, 2021 the method is invoice cost + 10%. Claims must be submitted with an invoice.
On or after January 1, 2021 the method is Fee Schedule reimbursement. Claims do not require an attached invoice.

Please see the table below for a list of procedure codes covered for softband devices.

All Audiology PARs and revisions processed by the ColoradoPAR Program must be submitted through the Utilization Management (UM) vendor. Clinical information is required for a PAR review. When submitting PARs, please answer the clinical questions in the UM portal, attach the relevant clinical documentation needed for determinations, and select "Medical" type from the drop-down menu. If "DME" is selected this will result in non-payment of the device.

Procedure Code Table

Audiologists are indicated as a rendering provider for the following procedure codes. Whether the code is a Health First Colorado covered benefit is indicated. Reference the current Fee Schedule for rates. Note: this table serves only as a reference guide for audiologists and not a guarantee of payment or coverage. Definitive coverage of a specific procedure code is found on the Fee Schedule.

Last table update: 01/27/2022

Procedure Code	Covered Benefit	Prior Authorization Needed
92502	Yes	No
92504	Yes	No
92507	Yes	Yes
92508	Yes	Yes
92511	Yes	No
92512	Yes	No
92516	Yes	No
92526	Yes	Yes
92531	No	-
92532	No	-
92533	Yes	No
92534	Yes	No
92540	Yes	No
92541	Yes	No
92542	Yes	No
92543	Yes	No
92544	Yes	No
92545	Yes	No
92546	Yes	No
92547	Yes	No
92548	Yes	No
92550	Yes	No
92552	Yes	No
92553	Yes	No
92555	Yes	No
92556	Yes	No
92557	Yes	No
92560	Yes	No
92561	Yes	No
92562	Yes	No
92563	Yes	No
92564	Yes	No
92565	Yes	No
92567	Yes	No
92568	Yes	No
96570	Yes	No
92571	Yes	No
92572	Yes	No
92575	Yes	No
92576	Yes	No
92577	Yes	No
92579	Yes	No
92582	Yes	No
92583	Yes	No
92584	Yes	No
92587	Yes	No
92588	Yes	No
92590	No - See HCPCS V-codes for coverage	-
92591	No - See HCPCS V-codes for coverage	-
92592	No - See HCPCS V-codes for coverage	-
92593	No - See HCPCS V-codes for coverage	-
92594	No - See HCPCS V-codes for coverage	-
92595	No - See HCPCS V-codes for coverage	-
92601	Yes	No
92602	Yes	No
92603	Yes	No
92604	Yes	No
92605	Yes	No
92606	Yes	No
92609	Yes	Yes
92620	Yes	No
92621	Yes	No
92625	Yes	No
92626	Yes	No
92627	Yes	No
92630	Yes	No
92633	Yes	No
92640	Yes	No
92650	Yes	No
92651	Yes	No
92652	Yes	No
92653	Yes	No
92654	Yes	No
95861	Yes	No
95920	Yes	No
95925	Yes	No
95926	Yes	No
95927	Yes	No
95928	Yes	No
95929	Yes	No
95930	Yes	No
95934	Yes	No
95936	Yes	No
95937	Yes	No
96111	Yes	No
97112	Yes	No
99201	Yes	No
99202	Yes	No
99203	Yes	No
99204	Yes	No
99205	Yes	No
99211	Yes	No
99212	Yes	No
99213	Yes	No
99214	Yes	No
99215	Yes	No
L7510	Yes	No
L8515	Yes	No
L8615	Yes	No
L8616	Yes	No
L8617	Yes	No
L8618	Yes	No
L8619	Yes	No
L8621	Yes	No
L8622	Yes	No
L8623	Yes	No
L8624	Yes	No
L8691	Yes	Yes
L8692	Yes	Yes
S0618	Yes	No
V5010	Yes	No
V5011	Yes	No
V5014	Yes	No
V5060	Yes	No
V5090	Yes	No
V5095	No	-
V5140	Yes	No
V5171	Yes	No
V5172	Yes	No
V5181	Yes	No
V5211	Yes	No
V5213	Yes	No
V5214	Yes	No
V5215	Yes	No
V5221	Yes	No
V5244	Yes	No
V5245	Yes	No
V5246	Yes	No
V5247	Yes	No
V5250	Yes	No
V5251	Yes	No
V5252	Yes	No
V5253	Yes	No
V5254	Yes	No
V5255	Yes	No
V5256	Yes	No
V5257	Yes	No
V5258	Yes	No
V5259	Yes	No
V5260	Yes	No
V5261	Yes	No
V5262	No	-
V5263	No	-
V5264	Yes	-
V5265	No	-
V5266	Yes	No
V5267	Yes	No
V5275	Yes	No
V5299	Yes	No
V5336	No	-
V5362	No	-
V5363	No	-
V5364	No	-

Covered Softband/BAHA Procedure Code Details
Code	Description	PAR	Required PAR and Claim Modifier	Allowed Billing Provider Types	Allowed Rendering Provider Types
L8692	New. Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment.	Always	UB	Physician, Pharmacy, Supply, Clinics, Osteopath, Audiologist.	Physician, Osteopath, Audiologist
L8691	Replacement. Auditory osseointegrated device, external sound processor.	Always	UB		Physician, Osteopath, Audiologist

Specific Non-Covered Benefits

Training or consultation provided by an Audiologist to an agency, facility, or other institution is not covered.
The upgrading of an existing cochlear implant system or component if the existing unit is properly functioning is not covered.
Hearing aids for adults (Hearing exams and evaluations are a benefit for adults only when a concurrent medical condition exists) are not covered.
Hearing aid insurance is not covered.
Any service not documented in the member's plan of care is not covered.
Ear molds for the purpose of noise reduction or swimming are not covered.
Any audiological services rendered by a non-licensed audiologist (except for licensed otolaryngologists and enrolled CHIP providers, are not covered.

Timely Filing

For more information on the timely filing policy, including the resubmission rules for denied claims, please see the General Provider Information manual.

Audiology Claim Example

claim example

Audiology Revisions Log

Revision Date	Additions/Changes	Made by
12/1/2016	Manual revised for interChange implementation. For manual revisions prior to 12/1/2016 Please refer to Archive.	DXC
12/27/2016	Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_2.xlsx	DXC
1/10/2017	Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_3.xlsx	DXC
1/19/2019	Updates based on Colorado iC Stage Provider Billing Manual Comment Log v0_4.xlsx	DXC
1/26/2017	Updates based on Department 1/20/2017 approval email	DXC
5/22/2017	Updates based on Fiscal Agent name change from HPE to DXC	DXC
6/22/2018	Removed PAR and other info that can be found in general manual (link under billing), updated timely filing with reference back to general billing	HCPF
10/1/2018	Corrected ear mold policy to separate them from the dispensing fee reimbursement. Updated proc code table to reflect coverage of V5264.	HCPF
1/9/2019	Updated proc code table for new 2019 HCPCS	HCPF
5/2/2019	Updated newborn hearing screening reimbursement explanation	HCPF
6/17/2019	Updated PAR status on certain CPTs in the coding table	HCPF
12/12/2019	Converted to web page	HCPF
2/12/2020	Clarified Softband claim submission type (not paper)	HCPF
5/8/2020	Added OPR policy to General Policy Section	HCPF
12/15/2020	Updated payment language in Softband Hearing Devices section	HCPF
4/30/2021	Updated eQSuite to Utilization Management	HCPF
1/27/2022	Updated Coding Tables	HCPF
3/9/2023	Added EPSDT Benefit Information	HCPF
5/11/2023	Removed incorrect information regarding adult coverage of hearing aids in the SLS Waiver.	HCPF