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Hearing Services Benefits to Change Effective November 1, 2018 for CSHCN Services Program

Last updated on 10/12/2018

Effective for dates of service on or after November 1, 2018, benefit and policy language will change for hearing services for the Children with Special Health Care Needs Services Program.

Abnormal Hearing Screening

Clients who are birth through 35 months of age with suspected or confirmed hearing loss must be referred to Early Childhood Intervention (ECI) as soon as possible, but no longer than seven 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.

Vestibular Evaluations

Hearing pathway tests such as audiometry, automated auditory brainstem response (A-ABR), and Electrocochleography (ECoG) can be used to identify an inner ear disorder.

Hearing Aid Trial Period

A trial period of up to 30 days is authorized by Texas Operations Code §402.401. The 30-day trial period, and any charged rental fee, must meet the Texas Department of Licensing and Regulation (TDLR) rule requirements in 16 TAC §112.140.

Hearing Evaluations

Hearing evaluations must be recommended by a physician based on examination of the client. An advanced practice registered nurse (APRN) or a physician assistant under physician supervision and delegation may also perform the client examination.

Ear Molds

The date of service for ear molds is the date the ear molds are dispensed to the client.

Disposable ear molds, procedure code V5265, are limited to four ear molds per ear, per 30 days, any provider.

Reimbursement

Comprehensive audiometry procedure codes 92553 and 92556 will not be reimbursed on the same day, by the same provider, for the same client. If both procedure codes are billed on the same date of service, by the same provider, for the same client, they will be denied with instructions to bill with the more comprehensive audiometry procedure code 92557.

Pure tone audiometry procedure codes 92551, 92552, and 92553 will be limited to one per day, same provider, same client.

The following audiometric testing procedure codes may be reimbursed for testing performed in both ears:

Procedure Codes

Type of Service

92558

Medical Services

92585

92587

92588

Total Component

92586

Laboratory

For testing that is only performed in one ear, providers must use modifier 52 with the above procedure codes.

The following procedure codes may be reimbursed for evaluative and therapeutic services and are limited to four services per rolling year:

Procedure Codes

92620

92621

92625

Providers must submit a prior authorization request with documentation of medical necessity for additional reimbursement of the procedure codes listed above.

The procedure codes in the following table show added and discontinued provider types:

Procedure Codes

Type of Service

Place of Service

Added Provider Types

Discontinued Provider Types

92540

Total Component

Office, Outpatient Hospital

Audiologist

N/A

92576

Laboratory

Office

Audiologist

N/A

92620

Medical Service

Office

Audiologist

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Independent Lab, Nephrology providers

Inpatient Hospital, Outpatient Hospital providers

Physician, Audiologist providers

Hospital Providers

Laboratory

N/A

All Providers

92621

Medical Service

Office

Audiologist

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Independent Lab, Nephrology providers

Inpatient Hospital, Outpatient Hospital providers

Physician, Audiologist providers

Hospital Providers

Laboratory

N/A

All Providers

92625

Medical Service

Office

Audiologist

Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Independent Lab, Nephrology providers

Inpatient Hospital

Physician, Audiologist providers

Hospital providers

Outpatient Hospital

Physician, Audiologist providers

N/A

Laboratory

N/A

All Providers

Procedure code 92568 will no longer be diagnosis restricted.

For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.