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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 : 2.2.4 Hearing Aid Devices and Accessories (Nonimplantable)

2.2.4
Texas Medicaid may reimburse hearing aid fitters and dispensers for the following devices and accessories:
 
For clients who are 20 years of age and younger, 1 hearing aid device per ear may be reimbursed every 5 years from the month it is dispensed.
For clients who are 21 years of age and older, if the client has at least a 35 dB hearing loss in both ears, 1 hearing aid device may be reimbursed every 5 years from the month it is dispensed. Either the left or the right may be reimbursed, but not both in the same 5 year period.
Refer to:
Subsection 2.2.4.1, “Forms and Documentation” in this handbook for additional medical necessity criteria.
Repairs or modifications may be reimbursed without prior authorization once per year after the 1-year warranty period has lapsed if the requested repair or modification is a better alternative than a new purchase.
Procedure codes: See below for monaural and binaural procedure codes.
Date of service: The date of service for the initial hearing aid device is the date the client successfully completes the 30-day trial period and accepts the hearing aid device.
Note: During the warranty period, Texas Medicaid may reimburse providers for a replacement hearing aid and replacement hearing aid batteries. Texas Medicaid will not reimburse hearing aid repairs or modifications that are rendered during the 12-month manufacturer’s warranty period. Providers must follow the manufacturer’s repair process as outlined in their warranty contract.
Limitation: As often as is medically necessary for clients who are 20 years of age and younger with prior authorization.
Date of service: The date of service is the date the client successfully completes the 30-day trial period and accepts the hearing aid device or the date the client receives the replacement accessory item.
Limitation: 1 each per hearing aid device as follows:
Date of service: The date of service for the ear impression is the date the ear impression is taken.
Limitation: As medically necessary for clients who are 20 years of age and younger.
Ear molds must be billed using the appropriate LT or RT modifier. Replacement ear molds may be reimbursed as often as is medically necessary without prior authorization. Documentation of medical necessity must be maintained in the client’s medical record.
Procedure codes: V5264 and V5265
Date of service: The date of service for the ear mold is the date the ear mold is taken.
Limitation: Replacement batteries may be reimbursed as often as is medically necessary when a hearing aid device has been previously reimbursed by Texas Medicaid.
Note: If a hearing aid has not been reimbursed by Texas Medicaid in the last 5 years, the replacement batteries may be reimbursed on appeal with a statement that documents medical necessity.
Date of service: The date of service is the date the client receives the replacement batteries.
The following monaural procedure codes may be reimbursed for medically necessary hearing aid devices and replacements that are rendered to clients of any age when they are billed with the appropriate modifier LT or RT to indicate for which ear the hearing aid device was purchased and fitted:
 
Procedure codes V5170 and V5180 may be reimbursed for monaural hearing aids that are rendered to clients who are 20 years of age and younger only.
The following binaural procedure codes may be reimbursed for medically necessary hearing aid devices and replacements that are rendered to clients who are 20 years of age and younger:
 
Binaural hearing aid procedure codes must be submitted with a quantity of 1 per procedure code. Providers can refer to the Online Fee Lookup (OFL) or the applicable fee schedule on the TMHP website at www.tmhp.com for reimbursement rates.
Refer to:
Section 2.4.2, “Reimbursement” in this handbook for more information about manual pricing.

Texas Medicaid & Healthcare Partnership
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