Billing & Payment Policies: Audiology and Hearing Services
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Professional Services -
Audiology and Hearing Services
The following policies and requirements apply to all hearing aid services and devices except for CPT® codes.
SELF-INSURERS
Self-insurers who have entered into contracts for purchasing hearing aid related services and devices may continue to use them. (See WAC 296-23-165 section 1(b).) Self-insurers who do not have hearing aid purchasing contracts must follow L&I‘s maximum fee schedule and purchasing policies for all hearing aid services and devices listed in this section.
AUTHORIZATION REQUIREMENTS
Initial and Subsequent Hearing Related Services
Prior authorization must be obtained from the insurer for all initial and subsequent hearing related services, devices, supplies and accessories in accordance with WAC 296-20-03001 and WAC 296-20-1101. The insurer will not pay for hearing devices provided prior to authorization.
NOTE: In cases of special need, such as when the worker is working and a safety issue exists, the provider may be able to obtain the insurer‘s authorization to dispense hearing aid(s) after the doctor‘s examination and before the claim is accepted. The insurer will notify the worker in writing when the claim is accepted or denied.
The authorization process for State Fund claims may be initiated by calling the claim manager or the State Fund‘s Provider Hotline at 800-848-0811 (in Olympia call 902-6500).
For self-insured claims the provider should obtain prior authorization from the self-insurer or its third party administrator. -
Trial Period
A 30-day trial period is the standard established by RCW 18.35.185. During this time, the provider supplying the aids must allow workers to have their hearing aids adjusted or be returned without cost for the aids and without restrictions beyond the manufacturer‘s requirements (for example, hearing aids are not damaged). Follow up hearing aid adjustments are bundled into the dispensing fee. If hearing aids are returned within the 30-day trial period, the provider must refund the hearing aid and dispensing fee.
Types of Hearing Aids Authorized
The insurer will purchase hearing aids of appropriate technology to meet the worker‘s needs (for example, digital). Decision will be based on recommendations from physicians, ARNPs, licensed audiologists or fitter/dispensers. Based on current technology, the types of hearing aids purchased for most workers are digital or programmable in the ear (ITE), in the canal (ITC) and behind the ear (BTE).
Any other types of hearing aids needed for medical conditions will be considered based on justifications from the physician, ARNP, licensed audiologist or fitter/dispenser. L&I will not purchase used equipment.
Hearing Aid Quality
All hearing aid devices provided to workers must meet or exceed all Food and Drug Administration (FDA) standards. All manufacturers and assemblers must hold a valid FDA certificate.
Masking Devices for Tinnitus
In cases of accepted tinnitus, the department or self-insurer may authorize masking devices. If masking devices are dispensed without hearing aids, providers will bill using code E1399.
When dispensed as a component of a hearing aid, providers will bill using code V5267.
Providers must bill masking devices at their acquisition cost. Refer to the Acquisition Cost Policy on page 123 for more detail. If masking devices are dispensed without hearing aids, the provider may also bill the appropriate dispensing fee code for monaural or binaural devices.
Special Authorization for Hearing Aids and Masking Devices over $900 per Ear
If the manufacturer‘s invoice cost of any hearing aid or masking device exceeds $900 per ear including shipping and handling, special authorization is required from the claim manager.
Exception: The cost of BTE ear molds does not count toward the $900 for special authorization. Initial BTE ear molds may be billed using V5264 and replacements may be billed using V5014 with V5264.
Authorized Testing
Testing to fit a hearing aid may be done by a licensed audiologist, fitter/dispenser, qualified physician or qualified ARNP. The provider must obtain prior authorization for subsequent testing. The insurer does not pay for testing after a claim has closed unless related to fitting of replacement hearing aids.
The insurer does not cover annual hearing tests.
If free initial hearing screenings are offered to the public, the insurer will not pay for these services.
Required Documentation
The insurer will authorize hearing aids only when prescribed or recommended by a physician or
ARNP and the claim for hearing loss has been allowed. State Fund claim managers use the
information outlined below to decide whether an individual worker has a valid work-related
hearing loss (a self-insurer or its third party administrator may use these or similar forms to
gather information).
- Report of Accident
- Occupational Disease Employment History Hearing Loss (F262-013-000; F262-013-111 continuation)
- Occupational Hearing Loss Questionnaire (F262-016-000)
- Valid audiogram
- Medical report
- Hearing Services Worker Information (F245-049-000)
- Authorization to Release Information (F262-005-000)
PAYMENT FOR AUDIOLOGY SERVICES
The insurer does not pay any provider or worker to fill out the Employment History Hearing Loss or Occupational Hearing Loss Questionnaire.
Physicians or ARNPs may be paid for a narrative assessment of work-relatedness to the hearing loss condition. Refer to the Attending Doctors Handbook table on Other Miscellaneous Codes and Descriptions.
The insurer will pay for the cost of battery replacement for the life of an authorized hearing aid.
No more than 1 box of batteries (40) will be paid within each 90-day period.
NOTE: Sending workers batteries that they have not requested and for which they do not have an immediate need is in violation of L&I‘s rules and payment policies.
The insurer will not pay for any repairs including parts and labor within the manufacturer‘s warranty period.
The insurer will not pay for the reprogramming of hearing aids.
Hearing Aid Parts and Supplies Paid at Acquisition Cost
Parts and supplies must be billed and will be paid at acquisition cost including volume discounts (manufacturers‘ wholesale invoice). Do not bill your usual and customary fee.
- Supply items for hearing aids include tubing, wax guards, and ear hooks. These can be billed within the warranty period.
- Parts for hearing aids include switches, controls, filters, battery doors and volume control covers. These can be billed as replacement parts only, but not within the warranty period.
- Shells ("ear molds" in HCPCS codes) and other parts can be billed separately at acquisition cost. L&I does not cover disposable shells.
Hearing aid extra parts, options, circuits and switches, for example, T-coil and noise reduction switches, can only be billed when the manufacturer does not include these in the base invoice for the hearing aid.
Batteries
Only 1 box of batteries (40) is authorized within each 90 day period. Providers must document the request for batteries by the worker and must maintain proof that the worker actually received the batteries.
NOTE: Sending workers batteries that they have not requested and for which they do not have an immediate need is in violation of L&I‘s rules and payment policies.
Worker Responsible for Devices That Are Not Medically Necessary
The insurer is responsible for paying for hearing related services and hearing aids that are deemed medically necessary. In the event a worker refuses the recommendations given in his/her case and wants to purchase different hearing aids, the worker then becomes totally responsible for the purchase of the hearing aid, batteries, supplies and any future repairs.
Worker Responsible for Some Repairs, Losses, Damages
Workers are responsible to pay for repairs and batteries for hearing aids not authorized by the insurer. The worker is also responsible for nonwork related losses or damages to their hearing aid(s), for example, worker‘s pet eats/chews the hearing aid, etc. In no case will the insurer cover this type of damage. In these instances, the worker will be required to buy a hearing aid consistent with current L&I guidelines.
After purchase and submission of the new warranty to the insurer, the insurer will resume paying for batteries and repairs following the hearing aid payment policies.
REPAIRS AND REPLACEMENTS
The provider who arranges for repairs to hearing aid(s) authorized or purchased by the insurer must submit records of all repairs to these aids to the insurer. These records are required, even during the warranty period.
Warranties
Hearing aid industry standards provide a minimum of a 1 year repair warranty on most hearing devices, which includes parts and labor. Where a manufacturer provides a warranty greater than 1 year, the manufacturer‘s warranty will apply.
The manufacturer‘s warranty and any additional provider warranty must be submitted in hard copy to the insurer for all hearing devices and hearing aid repairs.
The warranty should include the make, model and serial number of the individual hearing aid.
Some wholesale companies‘ warranties also include a replacement policy to pay for hearing aids that are lost. If the hearing aid loss is covered under the warranty, the provider must honor the warranty and replace the worker‘s lost hearing aid without charge.
The insurer does not purchase or provide additional manufacturers‘ or extended warranties beyond the initial manufacturer‘s warranty (or any additional provider warranty).
The insurer will not pay for any repairs including parts and labor within the manufacturer‘s warranty period.
- The warranty begins on the date the hearing aid is dispensed to the worker
- For repairs, the warranty begins when the hearing aid is returned to the worker
Repairs
Prior authorization is required for all billed repairs.
The insurer will repair hearing aids and devices when needed due to normal wear and tear.
- At its discretion, the insurer may repair hearing aids and devices under other circumstances
- After the manufacturer‘s warranty expires, the insurer will pay for the cost of appropriate repairs for the hearing aids they authorized and purchased
- If the aid is damaged in a work-related incident, the worker must file a new claim to repair or replace the damaged aid
Audiologists and fitters/dispensers may be paid for providing authorized in-office repairs.
Authorized in-office repairs must be billed using V5014 and V5267.
For authorization of in-office repairs or repairs by the manufacturer, or an all-make repair company, providers must submit a written estimate of the repair cost to the State Fund Provider Hotline or to the self-insurer‘s claim manager.
Replacement
The insurer does not provide an automatic replacement period.
Replacement requests must be sent directly to the claim manager or self-insured employer.
Documentation that a hearing aid is not repairable may be submitted by licensed audiologists, fitter/dispensers, all-make repair companies or FDA certified manufacturers. Documentation to support a hearing aid as not repairable must be verified by:
- All-make repair companies or
- FDA certified manufacturers/repair facilities
If only 1 of the binaural hearing aids is not repairable and if, in the professional‘s opinion both hearing aids need to be replaced, the provider must submit logical rationale for the claim manager‘s consideration.
The insurer will replace hearing aids when they are not repairable due to normal wear and tear.
- At its discretion, the insurer may replace hearing aids in other circumstances
- Replacement is defined as purchasing a hearing aid for the worker according to L&I‘s most current guidelines
- The insurer may replace the hearing aid exterior (shell) when a worker has ear canal changes or the shell is cracked. The insurer will not pay for new hearing aids when only new ear shell(s) are needed.
- The insurer will not replace a hearing aid due to hearing loss changes, unless the new degree of hearing loss was due to continued on-the-job exposure. A new claim must be filed with the insurer if further hearing loss is a result of continued work-related exposure or injury, or the aid is lost or damaged in a work-related incident.
- The insurer will not replace hearing aids based solely on changes in technology.
- The insurer will not pay for new hearing aids for hearing loss resulting from: noise exposure that occurs outside the workplace; nonwork related diseases and conditions or the natural aging process
The worker must sign and be given a copy of the Worker Information Form (F245-049-000).
The provider must submit a copy of the signed form with the replacement request.
The provider must inform the insurer of the type of hearing aid dispensed and the codes they
are billing.
Linear Non-Programmable Analog Hearing Aid Replacement Policy
Linear non-programmable analog hearing aids may be replaced with non-linear digital or analog hearing when the worker returns a linear analog hearing aid to their dispenser or audiologist because:
- The hearing aid is inoperable or
- The worker is experiencing an inability to hear, and
- The insurer has given prior authorization to replace the hearing aid.
The associated professional fitting fee (dispensing fee) will also be paid when the replacement of linear analog with non-linear digital or analog hearing aid is authorized.
Providers must use modifier RP with the appropriate hearing aid HCPCS code to be paid for the replacement aid. The RP modifier is required to help the insurer track utilization of the replacement hearing aids.
Who Can Bill
Audiologists, physicians, ARNPs and fitter/dispensers who have current L&I provider account numbers may bill for hearing aid replacement. You may bill for the acquisition cost of the nonlinear aids and the associated professional fitting fee (dispensing fee).
Authorization Requirements
Prior authorization must be obtained from the insurer before replacing linear analog hearing aids. The insurer will not pay for replacement hearing aids issued prior to authorization.
For State Fund claims
- Call the claim manager or
- Fax the request to the State Fund‘s Provider Hotline at 360-902-6490.
For Self-Insured claims
Contact the self-insured employer or their third party administrator for prior authorization.
Authorization Documentation and Record Keeping Requirements
Before authorizing replacement, the insurer will require and request the following documentation from the provider:
- A separate statement (signed by both the provider and the injured worker): "This linear analog replacement request is sent in accordance with L&I‘s linear analog hearing aid replacement policy." (required)
- Completed Hearing Services Worker Information form (required for State Fund claims). Available at: http://www.Lni.wa.gov/FormPub/Detail.asp?DocID=2032
- Serial number(s) of the current linear analog aid(s), if available.
- Make/Model of the current linear analog aid(s), if available.
- Date original hearing aid(s) issued to injured worker, if available.
DOCUMENTATION AND RECORD KEEPING REQUIREMENTS
Documentation to Support Initial Authorization
Providers must keep all of the following information in the worker‘s medical records and submit a copy to the insurer:
- Name and title of referring practitioner, if applicable and
- Complete hearing loss history, including whether the onset of hearing loss was sudden or gradual and
- Associated symptoms including, but not limited to, tinnitus, vertigo, drainage, earaches, chronic dizziness, nausea and fever and
- A record of whether the worker has been treated for recent or frequent ear infections; and
- Results of the ear examination and
- Results of all hearing and speech tests from initial examination and
- Review and comment on historical hearing tests, if applicable and
- All applicable manufacturers‘ warranties (length and coverage) plus the make, model and serial number of any hearing aid device(s) supplied to the worker as original or as a replacement and
- Original or unaltered copies of manufacturers‘ invoices and
- Copy of the Hearing Services Worker Information form signed by the worker and provider and
- Invoices and/or records of all repairs.
Documentation to Support Repair
The provider who arranges for repairs to hearing aid(s) authorized and purchased by the insurer must submit records of all repairs to these aids to the insurer. These records are required, even during the warranty period.
Documentation to Support Replacement
The following information must be submitted to the insurer when requesting authorization for hearing aid replacement.
- The name and credential of the person who inspected the hearing aid and
- Date of the inspection and
- Observations, for example, a description of the damage, and/or information on why the device cannot be repaired or should be replaced.
Correspondence with the Insurer
The insurer may deny payment of the provider‘s bill if the following information has not been received.
- Original or unaltered wholesale invoices from the manufacturer are required to show the acquisition cost and must be retained in the provider‘s office records for a minimum of 5 years. The insurer will not accept invoices printed from email or the internet.
- A hard copy of the original or unaltered manufacturer‘s wholesale invoice must be submitted by the provider when an individual hearing aid, part or supply costs $150.00 or more, or upon the insurer‘s request
NOTE: Electronic billing providers must submit a hard copy of the original or unaltered manufacturer‘s wholesale invoice with the make, model and serial number for individual hearing aids within 5 days of bill submission.
To avoid delays in processing, all correspondence to the insurer must indicate the worker‘s name and claim number in the upper right hand corner of each page of the document.
For State Fund claims, providers are required to send warranty information to:
Department of Labor and Industries
PO Box 44291
Olympia, WA 98504-4291
For self-insured claims, send warranty information to the employers designated address for the mailing of all claims-related correspondence. http://www.Lni.wa.gov/ClaimsIns/Insurance/SelfInsure/EmpList/Default.asp
ADVERTISING LIMITS
L&I can deny a provider‘s application to provide services or suspend or revoke an existing provider account if the provider participates in false, misleading or deceptive advertising or misrepresentations of industrial insurance benefits. See RCW 51.36.130 and WAC 296-20-015 for more information.
False advertising includes mailers and advertisements that:
- Suggest a worker‘s hearing aids are obsolete and need replacement
- Do not clearly document a specific hearing aid‘s failure
- Make promises of monetary gain without proof of disability or consideration of current law.
BILLING REQUIREMENTS
Billing for Binaural Hearing Aids
When billing the insurer for hearing aids for both ears, providers must indicate on the CMS-1500 or Statement for Miscellaneous Services form the following:
- In the diagnosis/nature of injury description box, list the diagnosis, as appropriate, for each side of the body (right/left)
- Bill the appropriate HCPCS code for binaural aids
- Only 1 unit of service should be billed even though 2 hearing aids (binaural aids) are dispensed
NOTE: Electronic billers are to use the appropriate field for the diagnosis code and side of body, specific to their electronic billing format.
Billing for a Monaural Hearing Aid
When billing the insurer for 1 hearing aid, providers must indicate on the CMS-1500 or
Statement for Miscellaneous Services form the following:
- In the diagnosis/nature of injury description box, list the diagnosis, as appropriate, for the side of the body (right/left) affected
- Bill the appropriate HCPCS code for monaural aid
- Only 1 unit of service should be billed
NOTE: Electronic billers are to use the appropriate field for the diagnosis code and side of body, specific to their electronic billing format
Billing for Hearing Aids, Devices, Supplies, Parts and Services
All hearing aids, parts and supplies must be billed using HCPCS codes. Hearing aids and devices are considered to be durable medical equipment and must be billed at their acquisition cost. Refer to the Acquisition Cost Policy , page 123, for more detail.
The table below indicates what services and devices are covered by provider type.
| Provider Type | Service/Device |
| Fitter/dispenser | HCPCS codes for all hearing related services and devices |
| Durable Medical Equipment providers | Supply and battery codes |
| Physician, ARNP, Licensed Audiologist | HCPCS codes for hearing related services and devices; and CPT® codes for hearing-related testing and office calls |
AUTHORIZED FEES
Dispensing Fees
Dispensing fees cover a 30-day trial period during which all aids may be returned. Also included:
- Up to 4 follow up visits (ongoing checks of the aid as the wearer adjusts to it) and
- 1 hearing aid cleaning kit and
- Routine cleaning during the first year and
- All handling and delivery fees.
Restocking Fees
The Washington State Department of Health statute (RCW 18.35.185) and rule (WAC 246-828- 290) allow hearing instrument fitter/dispensers and licensed audiologists to retain $150 or 15% of the total purchase price, whichever is less, for any hearing aid returned within the rescission period (30 calendar days). This fee is sometimes called a "restocking" fee. Insurers without hearing aid purchasing contracts will pay this fee when a worker rescinds their purchase agreement.
The insurer must receive form F245-050-000 or a statement signed and dated by the provider and the worker. The form must be faxed to L&I at (360) 902-6252 or forwarded to the selfinsurer within 2 business days of receipt of the signatures. The provider must submit a refund of the full amount paid by the insurer for the dispensing fees and acquisition cost of the hearing aid that was provided to the worker. The provider may then submit a bill to the insurer for the restocking fee of $150 or 15% of the total purchase price, whichever is less. Use code 5091V. Restocking fees cannot be paid until the insurer has received the refund.
Fee Schedule
The insurer will only purchase the hearing aids, devices, supplies, parts and services described in the fee schedule.
| HCPCS Code | Description | Maximum Fee |
| V5008 | Hearing screening | $ 76.55 |
| V5010 | Assessment for hearing aid | Bundled |
| V5011 | Fitting/orientation/checking of hearing aid | Bundled |
| V5014 | Hearing aid repair/modifying visit per ear (bill repair with code 5093V) | $ 51.04 |
| V5020 | Conformity evaluation (1 visit allowed after the 30-day trial period) | Bundled |
| V5030 | Hearing aid, monaural, body worn, air conduction | Acquisition cost |
| V5040 | Body-worn hearing aid, bone | Acquisition cost |
| V5050 | Hearing aid, monaural, in the ear | Acquisition cost |
| V5060 | Hearing aid, monaural, behind the ear | Acquisition cost |
| V5070 | Glasses air conduction | Acquisition cost |
| V5080 | Glasses bone conduction | Acquisition cost |
| V5090 | Dispensing fee, unspecified hearing aid | Not covered |
| V5100 | Hearing aid, bilateral, body worn | Acquisition cost |
| V5110 | Dispensing fee, bilateral | Not covered |
| V5120 | Binaural, body | Acquisition cost |
| V5130 | Binaural, in the ear | Acquisition cost |
| V5140 | Binaural, behind the ear | Acquisition cost |
| V5150 | Binaural, glasses | Acquisition cost |
| V5160 | Dispensing fee, binaural (includes up to 1 conformity eval and 2 follow up visits during the 30-day trial period) |
$ 1449.38 |
| V5170 | Hearing aid, cros, in the ear | Acquisition cost |
| V5180 | Hearing aid, cros, behind the ear | Acquisition cost |
| V5190 | Hearing aid, cros, glasses | Acquisition cost |
| V5200 | Dispensing fee, cros (includes up to 1 conformity eval and 2 follow up visits during the 30-day trial period) |
$ 868.72 |
| V5210 | Hearing aid, bicros, in the ear | Acquisition cost |
| V5220 | Hearing aid, bicros, behind the ear | Acquisition cost |
| V5230 | Hearing aid, bicros, glasses | Acquisition cost |
| V5240 | Dispensing fee, bicros (includes up to 1 conformity eval and 2 follow up visits during the 30-day trial period) |
$ 868.72 |
| V5241 | Dispensing fee, monaural hearing aid, any type (includes up to 1 conformity eval and 2 follow up visits during the 30-day trial period) |
$ 724.69 |
| V5242 | Hearing aid, analog, monaural, cic (completely in the ear canal) | Acquisition cost |
| V5243 | Hearing aid, monaural, itc (in the canal) | Acquisition cost |
| V5244 | Hearing aid, digitally programmable analog, monaural, cic | Acquisition cost |
| V5245 | Hearing aid, digitally programmable, analog, monaural, itc | Acquisition cost |
| V5246 | Hearing aid, digitally programmable analog, monaural, ite (in the ear) | Acquisition cost |
| V5247 | Hearing aid, digitally programmable analog, monaural, bte (behind the ear) | Acquisition cost |
| V5248 | Hearing aid, analog, binaural, cic | Acquisition cost |
| V5249 | Hearing aid, analog, binaural, itc | Acquisition cost |
| V5250 | Hearing aid, digitally programmable analog, binaural, cic | Acquisition cost |
| V5251 | Hearing aid, digitally programmable analog, binaural, itc | Acquisition cost |
| V5252 | Hearing aid, digitally programmable, binaural, ite | Acquisition cost |
| V5253 | Hearing aid, digitally programmable, binaural, bte | Acquisition cost |
| V5254 | Hearing aid, digital, monaural, cic | Acquisition cost |
| V5255 | Hearing aid, digital, monaural, itc | Acquisition cost |
| V5256 | Hearing aid, digital, monaural, ite | Acquisition cost |
| V5257 | Hearing aid, digital, monaural, bte | Acquisition cost |
| V5258 | Hearing aid, digital, binaural, cic | Acquisition cost |
| V5259 | Hearing aid, digital, binaural, itc | Acquisition cost |
| V5260 | Hearing aid, digital, binaural, ite | Acquisition cost |
| V5261 | Hearing aid, digital, binaural, bte | Acquisition cost |
| V5262 | Hearing aid, disposable, any type, monaural | Not covered |
| V5263 | Hearing aid, disposable, any type, binaural | Not covered |
| V5264 | Ear mold (shell)/insert, not disposable, any type | Acquisition cost |
| V5265 | Ear mold (shell)/insert, disposable, any type | Not covered |
| V5266 | Battery for hearing device | $ 0.88 |
| V5267 | Hearing aid supply/accessory | Acquisition cost |
| 5091V | Hearing aid restocking fee (the lesser of 15% of the hearing aid total purchase price or $150 per hearing aid) |
By report |
| 5092V | Hearing aid cleaning visit per ear (1 every 90 day, after the first year) |
$ 23.81 |
| 5093V | Hearing aid repair fee. Manufacturer‘s invoice required | By report |
