Hearing and balance assessment services are generally covered as “other diagnostic tests” under section 1861(s)(3) of the Social Security Act and payable under the physician fee schedule. Hearing and balance assessment services furnished to an outpatient of a hospital are covered as “diagnostic services” under section 1861(s)(2)(C) and payable under the hospital Outpatient Prospective Payment System (OPPS) or other payment methodology applicable to the provider furnishing the services.
There is no provision in the law for Medicare to pay audiologists for therapeutic services. Audiological diagnostic tests are not covered under the benefit for services incident to a physician's service (described in Pub. 100-02, chapter 15, section 60), because they have their own benefit as “other diagnostic tests”. See Pub. 100-04, chapter 13 for general outpatient diagnostic test policies.
As defined in the Social Security Act, section 1861(ll)(3), the term “audiology services” specifically means such hearing and balance assessment services furnished by a qualified audiologist as the audiologist is legally authorized to perform under State law (or the State regulatory mechanism provided by State law), as would otherwise be covered if furnished by a physician. A list of the codes used for audiology services is linked below.
Audiology services must be personally furnished by an audiologist, or nonphysician practitioner (NPP). Physicians may personally furnish audiology services, and technicians or other qualified staff may furnish those parts of a service that do not require professional skills under the direct supervision of physicians.
Orders are required for audiology services in all settings. 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.
Medicare Part B provides coverage for many types of therapy services. This document serves as a guide to direct professionals to resources regarding audiology services.
The Medicare contractor who pays your claims is the best source of answers to specific Medicare questions. To find local coverage policy and other general instructions, contact your Medicare Contractor using the Provider Call Center Toll-free Numbers Directory which includes phone numbers and website addresses (See Downloads section below).
If you are have difficulty communicating with your contractor, use the CMS Regional Offices' web page (See Related Links Inside CMS below) to identify the CMS Regional Office servicing your area of operations and utilize either the toll-free number or mailing address for assistance.
- Chapter 15 – Covered Medical and Other Health Services [PDF, 1MB]
- Chapter 16 - General Exclusions from Coverage [PDF, 191KB]
- Chapter 5 - Part B Outpatient Rehabilitation and CORF/OPT Services [PDF, 403KB]
- Social Security Act, section 1861(ll)(3) - Opens in a new window
- 42 CFR 410.32 - Opens in a new window
- 42 CFR 484.4 - Opens in a new window
- Page last Modified: 03/27/2012 12:28 PM
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