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  Programming Denials

email: reimburse@cochlear.org





  • Physician Letters
    Physician letters supporting removal of supervision requirement for programming
  • Medicare Ruling
    Medicare Ruling on Speech Processor Programming Claims




Programming of the cochlear implant speech processor is covered by Medicare without a limit on the number of visits.

However, Medicare currently does not define programming as a diagnostic service. As a result it cannot be reimbursed when performed by an independent audiologist (using place of service code 64). Only audiologists that are employees of a physician or physician group may receive Medicare payment for programming.

This creates an obstacle to adequate programming services for patients at centers where physicians are not located on-site when these services are furnished by audiologists. In order for an audiologist employed by a physician to bill Medicare under the "incident to a physician's service" provisions of the Medicare Carriers Manual, it must be performed under the "general supervision" of a physician. This means that if a physician is not within the office suite, the service cannot be paid.

Until late 1999, these provisions were generally not enforced by Medicare carriers. However, several carriers began denying claims for programming whenever a physician is not within the office suite. In these cases, the centers are generally billing the patients for costs of programming, which ranges between $200-$300 per visit. Some are requiring payment from the patient up-front prior to rendering the service.

These denials have forced patients to seek programming services at other centers. Of course, in many parts of the country, this is not possible due to the limited numbers of cochlear implant centers outside of major metropolitan areas.

Since July 1999, Mark Hobratschk sought changes to these requirements as they relate to speech processor programming. The American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS) approved proposals he submitted through ASHA to maintain the current 92510 CPT code for diagnostic programming of the speech processor, and move aural rehabilitation following a cochlear implant back to the general speech therapy code 92507 (where it was prior to 1996).

Effective March 1, 2003, the new codes are as follows:

92601 Cochlear implant follow-up exam (under age 7)
92602 Reprogramming of cochlear implant (under age 7)
92603 Cochlear implant follow-up exam (age 7 or more)
92604 Reprogramming of cochlear implant (age 7 or more)

Medicare will only reimburse audiologists directly for these codes when performed in the non-facility setting. Payment under the 2003 Medicare physician fee schedule is as follows:

92601 $123.15
92602 $86.48
92603 $83.02
92604 $56.73

Payment under the 2003 Medicare physician fee schedule for aural rehabilitation under 92507 is $72.64 if performed in a non-facility setting, or $26.98 if performed in a facility setting (i.e. hospital, skilled nursing facility.)

As commenters acknowledged in the final Stark II regulations in January 2001, physicians do not supervise programming services furnished by audiologists. The AMA action would curtail mass denials by Medicare carriers for programming claims, as well as audits and civil penalties for centers that have been billing incorrectly for years.

Some State Medicaid agencies like Medi-Cal do define both programming and aural rehabilitation as an audiologic service.

In addition, Mr. Hobratschk successfully assisted a Medicare beneficiary in obtaining a 2001 ruling from a Medicare administrative law judge also defining these services as a diagnostic audiologic service.

If you are experiencing Medicare denials for programming, please contact reimburse@cochlear.org for further information. You may also report carriers that refuse to enforce the new policy directly to Dorothy Shannon, PhD with CMS Program Integrity Group.