CODING AND REIMBURSEMENT | Ensuring Documentation Supports Reimbursement Potential

By Alison Morrison and M.C. Rincon

This article is a part of the September/October 2022, Volume 34, Number 5, Audiology Today issue. 

Accurate and complete documentation is a critical component of audiological service delivery. Clear, comprehensive documentation is essential for establishing a legal record of care provided to patients and assisting with the coordination of care among multiple providers. Clear, comprehensive documentation is also a requirement for the payment of services from Medicare and third-party payers. Audiologists should consider the five tips below to ensure clinical documentation supports reimbursement for services.

Tip #1. Clearly Indicate Medical Necessity

Under Medicare, the requirements for the reimbursement of diagnostic services include that testing must be ordered by a physician or nonphysician practitioner (NPP) to establish a medical diagnosis or determine medical treatment options for a patient’s condition. The reason the testing is being performed should be clearly documented in the patient’s medical record, which includes the audiometric evaluation report, order, and/or referring provider’s notes. 

Audiologists are encouraged to review the Medicare Benefit Policy Manual (Centers for Medicare and Medicaid Services (CMS), 2022a), Medicare Claims Processing Manual (CMS, 2021a), and the American Academy of Audiology Medicare Frequently Asked Questions page (American Academy of Audiology, 2022). These online resources are listed in the References section at the end of this article.  

In the case of an audit, it is the responsibility of the provider whose payment is at risk (in this case, the audiologist) to ensure the medical necessity of the evaluation is appropriately documented. For Medicare, testing is considered routine and therefore is not covered when there are no new signs or symptoms or when the test was completed solely for the purpose of fitting or programming a hearing aid.  

Audiologists should clearly document in their report when changes to hearing sensitivity or other audiological symptoms are suspected, when new otologic symptoms such as tinnitus or vertigo warrant additional testing, or when re-evaluation to determine the effect of surgery or treatment is needed. 

Other examples of appropriate reasons for repeating a test could include when an established diagnosis is associated with probable risk for change in hearing status (such as cholesteatoma, vestibular schwannoma, or ototoxic medication administration), with or without subjective decrease in hearing reported by the patient or caregiver.