I am finally writing in reply to your recent e-mail reagrding billing
for cerumen removal. You were right on the money with your comments
regarding this. I know it is not something that people want to hear but
it is the status of healthcare today.
Medicare, by its very nature, is a federal "medical" insurance plan!!
In this insurance plan physicians are the "gate keepers" so to speak.
This is no different than many other third party payers. All services
paid for by Medicare must be referred by a physician in order to obtain
reimbursement. I am not saying that I support this or that it is right;
but it is the state of healthcare today!
Medicare only covers services that are required by a physician to obtain
a diagnosis for a patient. If you get right down to it Medicare does
not have to pay for any procedure (regardless of whether this is done in
a physician's office or a private practice audiologist's office) once
that diagnosis has been obtained. This is why I am an advocate of
having every patient sign a "prior notification" prior to rendering any
services. No procedure is guaranteed to be covered and this
notification covers you. The Medicare guidelines actually state that
they do not cover "routine" procedures no matter where they are
completed or how they are billed. They also state that they only cover
the initial procedure based upon the diagnosis given.
When it comes to cerumen removal things even get a little stickier.
Medicare will not cover cerumen removal if it is completed on the same
date of service as an office visit, hearing evaluation, etc. as they
consider part of those procedures and thus not covered separately. This
rule applies whether this is billed by a physician or an audiologist.
Audiologists can only bill for cerumen removal if it is referred by a
physician and is completed as a separate procedure on a separate date of
service from any other audiologic or otolaryngologic procedure or office
consult. Again, I am not saying that this is right but unfortunately
this is how Medicare works!
I agree with Angela Loavenbruck on the point that you need to be aware
of how different policies and states have different requirements and
rules. I would suggest that you do a little survey and take the time to
call the insurance carriers that you use most frequently and find out
what their rules are when it comes to audiologic coverage for your
setting. Take it from me it is invaluable information and it will be
Again, not to be discouraging, HCFA does not have audiologists on its
board. HCFA is governed by physicians. This is key! In order to make
changes we need to have AAA and ASHA team up with AAO or the AMA and see
if they can be of assistance in getting coding and billing changes
enacted. I am a realist; it is not that I do not want to see and elicit
changes, because I do. But I also think it is important to know how to
make the current system work for you rather than against you! I think
we need to start towards autonomy by building up our profession from
within. We need to stop fighting amongst ourselves and we need to work
together towards common goals. We need to make our profession more
visible and vital to consumers. Then and only then will autonomy start
to take shape!!
I hope I was a little helpful in all of this. I would be happy to
discuss this further if you would like to.