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Audiology Benefit Billing and Policy Manual

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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.

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General Benefit Policies

  1. 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
  2. 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.
  3. 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.
  4. 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.

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Billing Information

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

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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.

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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.

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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

  1. 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.
  2. 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.

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Cochlear Implants

  1. 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)
  2. 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.

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Hearing Aids

Hearing aids are a covered benefit for members ages 20 and under and for adult members on the Supported Living Services (SLS) Waiver.

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.

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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.

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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.

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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:

  1. Prior to January 1, 2021 the method is invoice cost + 10%. Claims must be submitted with an invoice.
  2. 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.

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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

 

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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.

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Timely Filing

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

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Audiology Claim Example

claim example

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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

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