Page 105 - Medicare Benefit Policy Manual

When the qualified physician or NPP orders diagnostic audiology services furnished by
an audiologist without naming specific tests, the audiologist may select the appropriate
battery of tests.

C. Coverage and Payment for Audiology Services.

Diagnostic services furnished by a qualified audiologist meeting the requirements in
section 80.3.1 of this chapter or physicians and NPPs as described in section 80.6 are
covered and payable under the MPFS as “other diagnostic tests.”

Services furnished in a hospital outpatient department are covered and payable under the
hospital Outpatient Prospective Payment System (OPPS) or other payment methodology
applicable to the provider furnishing the services.

Coverage and, therefore, payment for audiological diagnostic tests is determined by the
reason the tests were performed, rather than by the diagnosis or the patient’s condition.

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.

Payment of audiological diagnostic tests is allowed for other reasons and is not limited,
for example, by:

• Any information resulting from the test, for example:

ο Confirmation of a prior diagnosis;
ο Post-evaluation diagnoses; or
ο Treatment provided after diagnosis, including hearing aids, or

• The type of evaluation or treatment the physician anticipates before the
diagnostic test; or

• Timing of reevaluation. Reevaluation is appropriate at a schedule dictated by
the ordering physician when the information provided by the diagnostic test is
required, for example, to determine changes in hearing, to evaluate the
appropriate medical or surgical treatment or to evaluate the results of
treatment. For example, reevaluation may be appropriate, even when the
evaluation was recent, in cases where the hearing loss, balance, or tinnitus
may be progressive or fluctuating, the patient or caregiver complains of new