1. Chapter 538 School-Based Health Services
Audiology Billing Form
Effective August 1, 2019

2. Consent to Bill Medicaid
Prior to billing parents must provide written consent to release information and to bill for Medicaid reimbursement.
Consent is valid for one calendar year from the signature date.
Parents are to be provided an annual notice.

3. Plan of Care
Services must be documented on the Plan of Care signed by the parent and therapist.
Effective August 1, 2019 Service Care Plan is now called a Plan of Care. This provides more consistency and avoids a terminology conflict with private school service plans. There is not a need to have a new one signed if it says Service Care Plan
The IEP Program has been adjusted to reflect the change in terminology.
Specific ICD-10 diagnosis codes are required. ICD-10 codes must relate to the specific type of therapy being provided. Think of these more as treatment diagnosis codes. All appropriate diagnosis codes need to be listed on the Plan of Care.
A global code such as Autism would not be appropriate.

4. Physician Authorization Form
Physician Authorization (PAF) is required annually to bill for occupational therapy.
The Audiologist is to document suggested ICD-10 diagnosis codes that specifically relate to the therapy being provided.
When the physician signs the authorization form they are confirming the therapist’s code(s).
Authorizations can be signed by a Physician (MD or DO), Physician’s Assistant (PA) or by an Advanced Practice Registered Nurse (APRN).
Should still obtain PAF even if the student will be working with an SSLPA.

5. Student Demographics Use the student’s real name as listed in WVEIS
The diagnosis code is to be an ICD-10 code that matches the need for audiology.
County and school names can be written out or use the county and school WVEIS codes.
For provider name print the name of the person providing the service.

6. Service Record – School Based Audiological Billing Form
Medicaid Number
Last Name
First Name
WVEIS Number
Date of Birth
Provider Name
County
School
Month/Year

7. Service Record – School Based Audiological Billing Form
Medicaid Number
Last Name
First Name  
Doe
Finley
WVEIS Number
Date of Birth
Provider Name
Marion Downs
County
School
Month/Year
59 
301
Sept/2019

8. Diagnosis Codes
Enter the Audiological specific ICD 10 Diagnosis Codes on the form starting with box number one.
Enter the codes that are directly associated with the therapy sessions and/or assessments.

9. LIST ALL DIAGNOSIS CODES RELATED TO AUDIOLOGICAL SERVICES
ICD 10 Diagnosis Codes
LIST ALL DIAGNOSIS CODES RELATED TO AUDIOLOGICAL SERVICES 1. 2. 3. 4. 5. 6.

10. LIST ALL DIAGNOSIS CODES RELATED TO AUDIOLOGICAL SERVICES
ICD 10 Diagnosis Codes
LIST ALL DIAGNOSIS CODES RELATED TO AUDIOLOGICAL SERVICES 1.
H93.25 2. 3. 4. 5. 6.

11. Procedure Code Changes
The following is no longer a valid CPT code for billing audiological services in West Virginia.
92561 – Bekesy Diagnostic

12. Audiological Services: Physician’s authorization on file
Audiological Services: Physician’s authorization on file. Must be on Plan of Care. Part One
CPT
Description
Service Cap
92540
Basic Vestibular Evaluation
2 per calendar year
92555
Speech Audiometry: Threshold
1 per calendar year
92556
Speech Audiometry Threshold with Speech Recognition
92557
Basic Comprehensive Audiometry (Cannot be billed with & 92556)
92562
Loudness Balance Test Alternate Binaural or Monaural
92567*
Tympanometry Impedance Testing
92568*
Acoustic Reflex Testing
92570
Acoustic Admittance Test (cannot be billed with and 92568)
4 per calendar year
92571
Filtered Speech Test
92582
Conditioning Play Audiometry
92583
Select Picture Audiometry
92587
Evoked Otoacoustic Emissions; Limited

13. Audiological Services: Physician’s authorization on file
Audiological Services: Physician’s authorization on file. Must be on Plan of Care. Part Two
92590
Hearing Aid Exam – Monaural
2 per calendar year
92591
Hearing Aid Exam – Binaural
92592
Hearing Aid Check – Monaural
4 per calendar year
92593
Hearing Aid Check – Binaural
92594
Electro-acoustic Evaluation for Hearing Aid - Monaural
92595
Electro-acoustic Evaluation for Hearing Aid - Binaural
1 per calendar year
* Procedures performed during Audiology Hearing Evaluations
**Unit is one encounter/visit (with no time limit) unless otherwise specified

14. Enter Claim Documentation
Use the CPT codes and caps from slides to complete the claim documentation section of the billing form.
In the first column list the service date.
Column two - enter one or more of the diagnosis code numbers that directly relates to the service. (examples 1, 1 & 3, 2)
Column three - enter the CPT code.
Columns four and five - enter the start and end time.
In the last column enter the total number of event(s).

15. List Diagnosis Code Number(s)
Claim Documentation
Service Date
List Diagnosis Code Number(s)
Procedure code
Start Time
End Time
Units/Event
Sept 15, 2019 1  1

16. List Diagnosis Code Number(s)
Claim Documentation
Service Date
List Diagnosis Code Number(s)
Procedure code
Start Time
End Time
Units/Event

17. Third Party Billing
At times a student may be eligible for Medicaid as the secondary insurance.
Medicaid is the payer of last resort for direct services (OT, PT, Speech, Audiology, Psychological, and Nursing).
If the student has special transportation services, the direct billing should be submitted. The claim will be denied but will justify claiming transportation billing for that instructional day.
Medicaid will pay ancillary services (TCM, personal care aide and special transportation) as the secondary insurance.
Occasionally a student may be eligible for Medicaid under two numbers. In this case district’s should always use the primary Medicaid number.

18. Signature and Credentials
_____________________ ______________ Signature/Credentials Date

19. Signature and Credentials
__Marion Downs___ AUD___ October 1, 2019 Signature/Credentials Date

20. Kelley Johnson – Coordinator Office of Special Education kelley
Kelley Johnson – Coordinator Office of Special Education ext WVDE Medicaid Website: