An 82-year-old woman named Mary walked into an audiology clinic in Ohio with her daughter. Mary had failed a hearing screening at her primary care visit and finally agreed to “get her ears checked.” The hearing test confirmed what everyone already suspected: moderate-to-severe sensorineural hearing loss.
The audiologist did everything right. Clear counseling. Realistic expectations. A strong recommendation for hearing aids. Mary nodded along, even smiled when she realized she could hear her daughter clearly again during the demo. Then came the billing conversation.
When Mary’s daughter asked Does Medicare cover this?
The answer was “No and changed the entire appointment.
Medicare covers the diagnostic hearing test. But it doesn’t pay for hearing aids or related audiology services. This gap has been around since Medicare started in 1965.
Stories like Mary’s are not rare; they’re structural. They come from old policies, confusing coding rules, and a system that makes clinicians act as:
- Accountants
- Teachers
- Advocates all at once
In this blog, we will discuss the medicare rules regarding audiology billing and their coverage in the healthcare system.
What Are Medicare Audiology Billing Rules?
Medicare audiology billing rules are federal guidelines that define which audiology services qualify for reimbursement under Medicare Part B, and the documentation requirements providers must meet. These rules apply to:
- Audiologists
- Physicians
- Qualified healthcare providers
Medicare covers diagnostic audiology services when medically necessary. These services help identify hearing loss, balance disorders, and related conditions through standardized testing procedures.
Which Audiology Services Does Medicare Cover?
Medicare Part B covers diagnostic hearing and balance evaluations when a physician orders them for medical necessity. Covered services include
- Comprehensive audiometry (CPT 92557)
- Pure-tone audiometry (CPT 92552)
- Speech audiometry (CPT 92555)
- Tympanometry (CPT 92567)
- Auditory brainstem response testing (CPT 92585)
Medicare reimburses these services at 80% of the approved amount after beneficiaries meet their annual deductible. The remaining 20% becomes the patient’s responsibility unless supplemental insurance covers it.
Diagnostic Services Medicare Covers
Medicare covers 8 primary categories of diagnostic audiology services:
- Pure-tone audiometry for air and bone conduction testing
- Speech recognition and threshold testing
- Tympanometry and acoustic reflex measurements
- Auditory evoked potentials, including ABR and ASSR
- Otoacoustic emissions testing for cochlear function
- Vestibular function tests for balance assessment
- Electrocochleography for Meniere’s disease evaluation
- Central auditory processing evaluations when medically necessary
What Audiology Services Can’t You Bill to Medicare?
Medicare does not cover hearing aid evaluations, hearing aid fitting and dispensing, routine hearing screenings, or any services related to hearing aid selection and maintenance. Medicare also excludes coverage for assistive listening devices, cochlear implant mapping beyond initial programming, and hearing tests performed solely for hearing aid purposes.
Research from the American Speech-Language-Hearing Association indicates that approximately 48 million Americans experience hearing loss. Yet, Medicare’s limited coverage creates significant out-of-pocket expenses for beneficiaries seeking hearing aids.
Non-Covered Services Include
Medicare excludes 5 major service categories from reimbursement:
- Hearing aid evaluations and selection procedures
- Hearing aid fitting, dispensing, and adjustment services
- Routine hearing screenings without medical necessity
- Hearing aid repairs, batteries, and maintenance supplies
- Over-the-counter hearing devices and personal amplification products
How Do You Determine Medical Necessity for Audiology Billing?
Medical necessity exists when a physician orders audiology testing to diagnose or treat a specific medical condition affecting hearing or balance. Documentation must include the referring physician’s order, relevant diagnosis codes from ICD-10-CM Chapter 8 (Diseases of the Ear and Mastoid Process), and clinical notes justifying the need for testing.
Medicare requires that services address symptoms like hearing loss, tinnitus, vertigo, dizziness, or ear pain. Testing performed solely to determine hearing aid candidacy does not meet medical necessity criteria.
What Documentation Must You Provide for Medicare Audiology Claims?
- Medicare audiology claims require a physician’s order, comprehensive test results with interpretation, relevant ICD-10-CM diagnosis codes, and clinical notes demonstrating medical necessity.
- Documentation must include patient history, test protocols used, calibration verification, and the audiologist’s professional interpretation of findings.
- The Centers for Medicare & Medicaid Services mandates that records remain accessible for audit purposes for 7 years from the date of service.
- Incomplete documentation results in claim denials and potential recoupment of payments.
Which Modifiers Apply to Medicare Audiology Billing?
Common modifiers for Medicare audiology claims include:
GY (statutorily excluded service)
- Modifier GY indicates services not covered by the Medicare statute
GA (advance beneficiary notice on file)
- GA confirms the patient received notification of non-coverage and financial responsibility.
Modifier 59 (distinct procedural service)
- Modifier 59 applies when reporting multiple procedures performed during the same session that require separate reimbursement.
Incorrect modifier usage causes claim denials and payment delays.
How Do Diagnostic and Hearing Aid Services Differ in Billing?
| Category | Diagnostic Audiology Services | Hearing Aid Services |
| Primary Purpose | Evaluate hearing and balance for medical diagnosis | Select, fit, and adjust hearing devices |
| Medical Necessity | Considered medically necessary | Not considered medically necessary |
| Medicare Coverage | Covered by Medicare | Not covered by Medicare |
| Billing Destination | Medicare Part B | Patient self-pay or private insurance |
| Examples of Services | Hearing tests, balance assessments | Hearing aid evaluation, fitting, and programming |
| Reimbursement Eligibility | Eligible for Medicare reimbursement | No Medicare reimbursement |
| Documentation Requirements | Must support medical evaluation and diagnosis | Must be clearly separate from diagnostic services |
| Billing Rules | Must be billed separately from hearing aid services | Cannot be combined with diagnostic services on the same claim |
| Compliance Risk | Combining with hearing aid services violates Medicare rules | Bundling with diagnostic services is not allowed |
What Are the Place of Service Requirements for Audiology Billing?
Medicare audiology services must be provided in approved healthcare settings, including hospital outpatient departments (POS 22), ambulatory surgical centers (POS 24), or office settings (POS 11). The place of service code on the claim form must accurately reflect where services occurred.
Home-based audiology services (POS 12) require specific documentation of medical necessity explaining why office-based testing was not feasible. Incorrect POS codes trigger claim edits and denials.
Which Diagnosis Codes Support Medicare Audiology Claims?
Appropriate ICD-10-CM diagnosis codes for audiology claims include H90 series (conductive and sensorineural hearing loss), H81 series (disorders of vestibular function), and H93 series (other disorders of the ear, including tinnitus). Diagnosis codes must correspond to the chief complaint and test results documented in the medical record.
Using unspecified codes like H91.90 (unspecified hearing loss) increases audit risk. Specific codes like H90.41 (sensorineural hearing loss, unilateral, right ear) provide stronger medical necessity support.
What Are Common Medicare Audiology Billing Errors?
The 7 most common Medicare audiology billing errors include
- Incorrect Modifier Usage
- Missing Physician Orders
- Inadequate Medical Necessity Documentation
- Billing Non-Covered Services To Medicare
- Incorrect Place Of Service Codes
- Unbundling Component Tests
- Using Unspecified Diagnosis Codes
These errors result in claim denials, payment delays, and potential audit findings.
A study by the Office of Inspector General found that improper billing accounts for approximately $1.2 billion in Medicare payment errors annually across all specialties, emphasizing the importance of accurate coding and documentation.
How Do You Handle Advance Beneficiary Notices for Non-Covered Services?
Providers must issue an Advance Beneficiary Notice of Noncoverage (ABN) before delivering services that Medicare may deny as not medically necessary or statutorily excluded. The ABN form CMS-R-131 informs beneficiaries of potential financial responsibility and allows them to decide whether to proceed with services.
ABNs apply to hearing aid evaluations, routine screenings, and diagnostic tests lacking medical necessity. Properly executed ABNs with modifier GA allow providers to bill patients directly when Medicare denies claims.
What Are the Consequences of Improper Medicare Audiology Billing?
Improper Medicare audiology billing results in claim denials, payment recoupment, financial penalties, exclusion from Medicare programs, and potential fraud investigations. The False Claims Act imposes penalties between $13,946 and $27,894 per false claim, plus treble damages for knowing violations.
Medicare Administrative Contractors conduct prepayment and postpayment audits to identify billing errors. Providers with high error rates face increased scrutiny, educational interventions, and potential referral to the Office of Inspector General.
How Can Audiology Providers Ensure Billing Compliance?
Audiology providers ensure billing compliance by implementing 5 essential practices:
- Maintaining current knowledge of Medicare policies
- Documenting medical necessity thoroughly
- Using accurate cpt and icd-10 codes
- Training staff on billing requirements
- Conducting regular internal audits
Compliance programs reduce claim denials and minimize audit risk.
The American Academy of Audiology recommends reviews of billing practices and annual staff training on Medicare coverage policies. These proactive measures prevent errors before claims submission.
Conclusion
Medicare audiology billing rules require precise knowledge of coverage policies, documentation standards, and coding requirements. Understanding what services Medicare covers and excludes protects your practice from compliance issues while ensuring appropriate reimbursement for diagnostic services.
Consult with Kansas Medical Billing to streamline your audiology billing process. Our certified billing specialists understand Medicare regulations, manage complex claims, reduce denials, and maximize reimbursement for your diagnostic audiology services. Contact Kansas Medical Billing today to ensure accurate, compliant billing that supports your practice’s financial health and allows you to focus on patient care.
FAQs
How Often Does Medicare Cover Repeat Audiology Testing?
Medicare does not impose specific frequency limitations on diagnostic audiology services when medical necessity supports repeat testing.
What is the 60-60 rule in audiology?
The 60/60 rule for hearing health is a guideline for using personal listening devices like headphones or earbuds: listen at no more than 60% of the device’s maximum volume for no longer than 60 minutes at a time, followed by a break, to prevent noise-induced hearing loss.
Can an audiologist bill E&M codes?
Audiologists may use E/M codes (e.g., 99202, 99203) only if allowed by state licensure and scope of practice.
Can an audiologist get a kickback for ordering a hearing aid?
The key federal fraud and abuse laws include the Anti-Kickback Statute, the Civil Monetary Penalties Law, and the Stark Law.
