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Insurance, Coding, and Audiology

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Hello!

I am still very new to the world of audiology and hearing loss. I was tested at the beginning of April and diagnosed with cookie bite loss, hearing aids were recommended for me, and I immediately started the insurance process. (I have Tricare Prime Active Duty and got full approval)

The office I was originally seen at is no longer an option, as there is a contractual issue with their NPI number behind the scenes. (that is making a real long story short)

Throughout all of this confusion on whether they were in network or out of network, I was charged a fee for the code 99204 in order to see the doc at my initial visit. My insurance paid their claim for this visit, minus that code because “audiologist is not certified to perform E&M services”. I did a quick googling, and it turns out that it is a restricted code that audiologists aren’t allowed to use. My real concern for this billing is that, prior to ever seeing the Doc, I was informed by the billing specialist that insurance never pays for this, but the Doc is owed for their time. So, they know they can’t use it, but do anyway??

I guess my question is - Has anyone else who uses insurance for their and office visits been charged for this code, or, even if not using insurance, are you being charged for this service as a cash paying patient?

Did you ask the provider to resubmit the claim using coding suitable to audiologists?

If the provider will not cooperate the choices are not great, especially if you wan to keep seeing this provider. You could appeal the claim denial and explain the provider insists on incorrect coding. You could not pay if the EOB says you do not owe it. You could file a grievance with the insurer about the provider practice. You may be able to make a board licensing complaint. It sounds like the provider is not informed or has tried personally and/or through the billing staff aimed to circumvent being paid less.

If you’re on Medicare, like many of us with hearing loss, you’re out of luck getting insurance to pay. Insurance companies only pay if Medicare approves/pays first, which they don’t other than maybe $100 towards the exam. Apparently that is a bit more “medical” than the devices.

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