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December 2016 Texas Medicaid Provider Procedures Manual

Vision and HearingServices Handbook : 2 Nonimplantable Hearing Aid Devices and Related Services : 2.2 Services, Benefits, Limitations, and Prior Authorization : 2.2.3 Audiology and Audiometry Evaluation and Diagnostic Services : 2.2.3.3 Forms and Documentation

2.2.3.3
Providers of hearing evaluations must have a report in the client’s record. Providers must include in the report hearing evaluation test data. The Hearing Evaluation, Fitting, and Dispensing Report (Form 3503) must be completed by the physician or audiologist who conducts the diagnostic testing. The provider who signs the report must maintain it in the client’s file. The report includes audiometric assessment results of the hearing evaluation and must provide objective documentation that amplification improves communication ability. Retrospective review may be performed to ensure documentation supports the medical necessity of the service.
For physician diagnostic hearing services (procedure codes 92502, 92504, 92540, 95940, and 95941), providers must maintain documentation of medical necessity in the client’s medical record. Retrospective review may be performed to ensure that the documentation supports medical necessity for the service.

Texas Medicaid & Healthcare Partnership
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