Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after November 1, 2018, benefit and policy language will change for otology and audiometry services.
Hearing Screening
Hearing screening provided due to client concern, or at the provider’s discretion, is a benefit for clients of any age when the client is referred by a Medicaid-enrolled physician, and the screening is provided by a Medicaid-enrolled provider licensed to perform these services.
Note: A nurse practitioner, clinical nurse specialist, or a physician assistant under physician supervision and delegation may also refer the client for hearing screening.
Abnormal Hearing Screens
Clients who are birth through 35 months of age and who have suspected hearing loss must be referred to Early Childhood Intervention (ECI) as soon as possible but no longer than 7 days after identification, even if referred to an appropriate provider for further testing. The provider should obtain consent from the client’s responsible adult prior to making the referral to ECI. The client’s responsible adult may refuse to permit the referral.
Audiometry (Hearing Testing)
Short increment sensitivity index (SISI) procedure code 92564 will be added to the policy for audiometric testing.
Evaluative and Therapeutic Services
The following procedure codes may be reimbursed for evaluative and therapeutic services:
|
Procedure Codes |
||
|---|---|---|
|
92620 |
92621 |
92625 |
Audiology providers may be reimbursed for services rendered in the office setting for procedure code 92621.
Intraoperative Neurophysiology Monitoring (IONM)
Audiology providers may be reimbursed for performing intraoperative neurophysiology monitoring (IONM) with the following procedure codes:
|
Procedure Codes |
|
|---|---|
|
95940 |
95941 |
Providers may refer to the current Texas Medicaid Provider Procedures Manual Medical and Nursing Specialists, Physicians, and Physician’s Assistant Handbook, subsection 9.2.27.3 “Evoked Potential Testing,” for more information about intraoperative neurophysiology monitoring.
Reimbursement
Texas Medicaid does not reimburse for hearing screening completed in a day care, Head Start location, or a school, unless the screening is performed in a school-based health clinic as a follow-up to an acute care medical visit. Separate procedure codes should not be billed for these services.
Procedure codes 92553 and 92556 are not reimbursed on the same day, same provider, and same client. If both procedure codes are billed for the same date of service, same provider, and same client, they will be denied with instructions to bill with the more appropriate, comprehensive audiometry procedure code 92557.
Procedure codes 92551, 92552, and 92553 for pure tone audiometry are limited to one of any of these procedure codes per day, same provider, same client.
The following type of service procedure codes assume that testing is done on both ears and may be reimbursed once per day, same provider, same client:
|
Procedure Codes |
Type of Service |
|---|---|
|
92558 |
Medical Service |
|
92585, 92587, and 92588 |
Total Component |
|
92586 |
Laboratory |
The procedure codes in the table above must be billed with modifier 52 if the testing is only performed on one ear.
Procedure codes 92620, 92621, and 92625 may be reimbursed to the same provider four times each rolling calendar year. Providers must submit a prior authorization request for additional reimbursement of either procedure code.
Prior Authorization
Prior authorization requests may be submitted to the TMHP Prior Authorization Department via mail, fax, or the electronic portal. Prescribing or ordering providers, dispensing providers, clients’ responsible adults, and clients may sign prior authorization forms and supporting documentation using electronic or wet signatures.
Providers should use the Special Medical Prior Authorization (SMPA) Request Form for all prior authorization requests.
Benefit Changes
Audiology providers may be reimbursed for services rendered with the following procedure codes:
|
Procedure Code |
Type of Service |
Place of Service |
|---|---|---|
|
92520 |
Medical Service |
Office, Outpatient hospital |
|
92540 |
Total and Professional Component |
Office, Outpatient hospital |
|
92540 |
Technical Component |
Office |
|
95940 |
Laboratory |
Inpatient and Outpatient hospital |
|
95941 |
Laboratory |
Inpatient and Outpatient hospital |
Procedure code 92568 will no longer be diagnosis restricted.
For more information, call the TMHP Contact Center at 800-925-9126.