Billing and Coding FAQs

Q: We are starting a new Baha^® program. Do payers cover Baha?

A: Most payers, including Medicare, have some level of coverage for Baha. Your reimbursement manager can help you look into general details of payer coverage, but it's important to note that different patients with the same payer can have very different coverage for the same services depending on the plan restrictions. Cochlear’s OMS service is available to assist with patient-specific coverage benefit determinations and pre-authorizations for Baha.

Q: Cochlear implants and Bahas are medical devices, how can we make sure we get appropriate reimbursement to cover these costs?

A: There are many factors that play into the financial success of a program, including proper coding, patient population, payer mix, contracts, etc. Contact your Cochlear Americas' regional reimbursement manager for assistance in identifying any areas where the hospital can optimize each of these important aspects of a medical device program and how to minimize billing errors and improper reimbursement.



Q: Ambulatory surgery centers (ASCs) have not traditionally performed many procedures involving implantable medical devices? Can we be reimbursed for those procedures?

A: Both hospitals and ASCs are able to have successful cochlear implant and Baha programs. Although it's true that Medicare discounts ASC reimbursement from the rates they pay hospitals, a diversified payer mix can allow any facility to have a successful program. It is important to ensure that ASC contracts with private payers are written to allow proper reimbursement for implantables if these types of procedures have not been previously performed at that location. By working with the facility and implanting surgeon(s), Cochlear Americas’ reimbursement managers can help them determine how to build a successful implant program in any setting.



Q: How do I know if my patient is eligible for an upgrade replacement of the patient’s Cochlear-provided sound processor for either cochlear implants or the Baha?

A: There may be various ways that a patient could be eligible for an upgrade replacement, depending upon the patient's insurance coverage.

Commercial Health Insurance and Upgrade Coverage

Most private insurance plans specify when and under what circumstances they will pay for a replacement part, including an upgrade. Because each commercial health insurance plan is different and has its own criteria, it is important to check each plan regarding coverage criteria on replacement parts and upgrades. Health insurance carriers, however, may cover replacement sound processors based upon the following two criteria:

1. The pre- /post- audiologic test results for a specific patient or information and data that clearly predict improved performance with use of the new technology (i.e., Medical Necessity).
2. The age or "useful life" of a sound processor. As a general rule, if the current processor has been continuously used for 5 years, replacement with improved technology may be possible.

Medical Necessity

To request coverage and payment for medically necessary services, a letter of medical necessity (LMN) must be written by a currently treating medical professional familiar with the patient's medical condition and situation. Cochlear Americas cannot establish medical necessity. The following topics are usually included in an LMN:

• A description of the condition.
• A description of treatment.
• The relationship of treatment to the condition.
• The lack of alternatives available to meet the treatment needs of the patient.
• The anticipated benefit from the treatment or service.

For Medicare and Medicaid

Medicaid generally, but not always, follows Medicare requirements for replacement of DME parts and accessories (which is usually how cochlear implant and Baha external parts and accessories are categorized). There are three primary ways that Medicare allows replacements:

1. loss or irreparable damage
2. useful life
3. where required because of a change in the patient’s condition

Loss or irreparable damage. Cochlear requires paperwork to be provided to give proof in these situations. Note that Medicare does NOT support coverage for irreparable wear (as opposed to irreparable damage) which refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified.

Useful Life.If the item of equipment has been in continuous use by the patient for the equipment’s useful lifetime, the patient may be eligible for a replacement. Medicare generally applies a 5-year useful life to the primary sound processor for a cochlear implant or Baha user.

Change in the patient’s condition. This is not the same standard as a “medically necessary” standard. To qualify for a replacement under this standard, the patient’s current treating physician must issue an order that justifies the replacement of the product with another product due to an identifiable change in the patient’s condition that would warrant the replacement. This standard generally does not apply in the large majority of situations involving a cochlear implant or Baha device.



Q: Is there a limit to number of sessions or frequency for cochlear implant mapping/programming?

A: Different payers may set different frequency limitations on this and other audiology services. The only way to know is to call each payer and ask provider services if a particular code has any frequency limitations.



Q: What codes am I allowed to bill together? It seems I get frequent denials for certain combinations of codes.

A: Most payers’ billing systems do include restrictions for which codes are considered separately payable when billed together for the same date of service. For instance, Medicare developed the National Correct Coding Initiative (CCI) which establishes bundling rules for all procedure codes. Some audiology codes are included in this program and are not both payable when billed together. Payers other than Medicare often adopt the CCI rules entirely or use a system based closely on it. Your Cochlear Americas’ reimbursement manager can help you determine which of the codes you frequently bill may be subject to these bundling rules.



Q: Are there any codes for neural response telemetry (NRT)?

A: Although no codes specifically include NRT in their descriptions, there are a few existing codes that most providers use to report this service. The most common codes providers report using for this procedure include:
92584 - Electrocochleography
92585 - Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive
92586 - Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited
95920 - Intraoperative neurophysiology testing, per hour (List separately in addition to code for primary procedure)
69949 - Unlisted procedure, inner ear

The above information offers examples and alternatives that may work for some payers in some situations. Providers should consult with their payers to determine if any of these codes are acceptable.

Q: How do we code for a Baha abutment change? Can we do this service in the office setting?

A: Although the decision of where to perform abutment change should be made on clinical criteria, the reimbursement methodology does not provide for payment in the office setting. Most clinics do not have contracts that include payment options for expensive medical devices, which are typically bundled into physician’s payment for services. Hospitals and surgery centers, on the other hand, are often able to obtain reimbursement for components such as the Baha abutment.

The abutment itself does not have a specific HCPCS code. One option for reporting the abutment is L9900, orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code. This code typically requires submission of documentation about the item and its price (e.g. manufacturer invoice) so the payer can determine coverage and payment rates.

Also, there is not a CPT code that specifically describes the abutment change service. Some providers may choose to simply report the soft tissue work involved in the abutment change. Otherwise, the service can be reported with an unlisted code such as 69399, Unlisted procedure, external ear. The following codes represent some of the soft tissue codes that may be appropriate, along with more detailed descriptions by Ingenix of what these codes entail provided.

11040 - Debridement; skin, partial thickness
11041 - Debridement; skin, full thickness
11042 - Debridement; skin, and subcutaneous tissue
(The physician surgically removes necrotic or dead skin. The physician uses a scalpel or dermatome to remove a superficial layer of affected skin. The epidermal layer is removed with the underlying dermis remaining intact. The partial thickness of skin is excised until viable, bleeding tissue is encountered. A topical antibiotic is placed on the wound. A gauze dressing or an occlusive dressing may be placed over the surgical site. Report 11040 for partial thickness debridement; 11041 for full thickness and 11042 if debridement includes subcutaneous tissue.)

11043 - Debridement; skin, subcutaneous tissue, and muscle
11044 - Debridement; skin, subcutaneous tissue, muscle, and bone
(The physician surgically removes necrotic skin, underlying tissue, and muscle. The physician uses a scalpel to excise the affected tissue into the muscle layer. The dissection is continued until viable, bleeding tissue is encountered. Depending on wound size, closure may be immediate or delayed. The wound may be packed open with gauze and require immediate or delayed reconstruction. Report 11044 if bone is also debrided.)

14060 - Adjacent tissue transfer or rearrangement, eyelids, nose, ears and/or lips; defect 10 sq cm or less.
(The physician transfers or rearranges adjacent tissue to repair traumatic or surgical wounds of the eyelids, nose, ears, and/or lips. This includes, but is not limited to, such rearrangement procedures as Z-plasty, W-plasty, ZY-plasty, or tissue transfers such as rotational flaps or advancement flaps.)

15839 - Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area.
(The physician removes excessive skin and subcutaneous tissue [including lipectomy].)

The above information offers examples and alternatives that may work for some payers in some situations. Providers should consult with their payers to determine if any of these codes are acceptable.

Last update: 10/06/10