10-144-101 Me. Code R. § III-109
MaineCare coverage of Speech and Hearing Services is limited. Refer to Chapter II, Section 109.08 for specific limitations. Use the following modifiers whenever appropriate, as well as any other HIPAA compliant billing modifiers not listed below that apply to the service.
The Modifier(s) column below is for reference only. Professional judgment of Qualified Professional Staffing in accordance with 109-09.3 should make the final determination.
Modifier GN if services are delivered under an outpatient speech-language pathology plan of care.
Modifier TF applicable for Assistant services.
Modifier HQ for group services (two (2) to four (4) members with one clinician).
Modifier 52 if the service is reduced, or applied to one ear and not both.
Modifier TL for services performed under an Individualized Family Service Plan (IFSP).
Modifier TM if performed under an Individualized Education Plan(IEP) with MaineCare Addendum.
Modifier 22 if the work required to provide a service is substantially greater than typically required. (Documentation must be submitted with the provider claim that supports the substantial additional work and the reason for that additional work. If so, after manual clinical review by the Department or authorized agent, the provider will receive an additional twenty-percent (20%) reimbursement for the service.
The Independent Rate applies to organizations with either one or more Speech Language Pathologist or Audiologist.
Billing Code | Modifier(s) | Description | Agency Rate | Independent Rate | HIPAA compliant unit defined as |
92507 | GN | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual | $53.05* | $47.74* | per session |
92507 | TF,GN | Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual intermediate level of care (Assistant) | $44.55 | $40.10* | per session |
92508 | HQ,GN | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals | $19.80 | $17.82* | per member per session |
92508 | TF,HQ,GN | Treatment of speech, language, voice, communication, and/or auditory processing disorder; group, 2 or more individuals (Assistant) | $19.80 | $17.82* | per member per session |
92521 | GN | Evaluation of speech fluency (eg, stuttering, cluttering) | $76.93* | $69.24* | per session |
92522 | GN | Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria) | $62.33 | $56.10* | per session |
92523 | GN | Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)with evaluation of language comprehension and expression (eg, receptive and expressive language) | $133.38* | $120.04* | per session |
92524 | GN | Behavioral and qualitative analysis of voice and resonance | $64.52 | $58.07* | per session |
92526 | GN | Treatment of swallowing dysfunction and/or oral function for feeding | $69.35 | $62.42* | per session |
92537** | Caloric vestibular test with recording, bilateral; bithermal (ie, one warm and one cool irrigation in each ear for a total of four irrigations) | $27.26 | $19.69 | per session | |
92538** | Caloric vestibular test with recording, monothermal (ie, one irrigation in each ear for a total of two irrigations) | $13.83 | $9.98 | per session | |
92540** | Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording | $65.87 | $47.57 | per session | |
92541** | Spontaneous nystagmus test, including gaze and fixation | $36.30 | $26.21 | per session | |
92542** | Positional nystagmus test, minimum of 4 positions, with recording | $37.56 | $27.13 | per session | |
92544** | Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording | $30.16 | $21.78 | per session | |
92545** | Oscillating tracking test, with recording | $28.27 | $20.42 | per session | |
92546** | Sinusoidal vertical axis rotational testing | $50.53 | $36.49 | per session | |
92547** | Use of vertical electrodes | $3.00 | $2.17 | per session | |
92548** | Computerized dynamic posturography | $57.32 | $41.40 | per session | |
92550 | Tympanometry and reflex threshold measurements | $20.13 | $20.13 | per session | |
92551 | Screening test, pure tone, air only | $12.12 | $8.76 | per session | |
92552 | Pure tone audiometry (threshold); air only | $18.36 | $13.26 | per session | |
92553 | Pure tone audiometry (threshold); air and bone | $23.28 | $16.81 | per session | |
92555 | Speech audiometry threshold; | $13.43 | $9.70 | per session | |
92556 | Speech audiometry threshold; with speech recognition | $20.83 | $15.04 | per session | |
92557 | Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined) | $29.83 | $21.54 | per session | |
92561 | Bekesy audiometry; diagnostic | $23.53 | $16.99 | per session | |
92562 | Loudness balance test, alternate binaural or monaural | $22.79 | $16.46 | per session | |
92564 | Short increment sensitivity index (SISI) | $16.14 | $11.66 | per session | |
92565 | Stenger test, pure tone | $9.26 | $6.69 | per session | |
92567 | Tympanometry (impedance testing) | $9.28 | $6.70 | per session | |
92568 | Acoustic reflex testing, threshold | $11.65 | $11.65 | per session | |
92570** | Acoustic immittancetesting, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing. | $21.78 | $15.73 | per session | |
92579 | Visual reinforcement audiometry (VRA) | $32.19 | $23.25 | per session | |
92582 | Conditioning play audiometry | $37.07 | $26.77 | per session | |
92583 | Select picture audiometry | $25.75 | $18.59 | per session | |
92585 | Auditory evoked potentials for evoked response audiometryand/or testing of the central nervous system; comprehensive | $75.46 | $54.34 | per session | |
92586 | Auditory evoked potentials for evoked response audiometryand/or testing of the central nervous system; limited | $37.14 | $26.82 | per session | |
92587 | Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked optoacoustic emissions, with interpretation and report | $20.88 | $19.37 | per session | |
92588 | Distortion product evoked otoacoustic emissions; comprehensive or diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report | $31.98 | $31.98 | per session | |
92592 | Hearing aid check; monaural | $25.79 | $18.62 | per session | |
92593 | Hearing aid check; binaural | $25.79 | $18.62 | per session | |
92601 | Diagnostic analysis of cochlear implant, patient younger than 7 years of age, with programming | $107.70 | $77.78 | per session | |
92602 | Diagnostic analysis of cochlear implant, patient younger than 7 years of age, subsequent reprogramming | $66.33 | $47.90 | per session | |
92603 | Diagnostic analysis of cochlear implant, age 7 years or older, with programming | $105.15 | $75.94 | per session | |
92604 | Diagnostic analysis of cochlear implant, age 7 years or older; subsequent reprogramming | $62.27 | $44.97 | per session | |
92607 | GN | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; first hour | $88.11* | $79.30* | 60 mins |
92608 | GN | Evaluation for prescription for speech-generating augmentative and alternative communication device, face-to-face with the patient; each additional 30 minutes (List separately in addition to code for primary procedure) | $35.36* | $31.82* | 30 mins |
92609 | GN | Therapeutic services for the use of speech-generating device, including programming and modification | $73.85 | $66.47* | per session |
92610 | Evaluation of oral and pharyngeal swallowing function | $57.79* | $52.01* | per session | |
92611** | Motion fluoroscopic evaluation of swallowing function by cine or video recording | $58.89 | $53.00 | per session | |
92612** | Flexible endoscopic evaluation of swallowing by cine or video recording | $125.93 | $113.33 | per session | |
92620 | Evaluation of central auditory function, with report; initial 60 minutes | $34.11 | $29.20 | 60 mins | |
92621 | Evaluation of central auditory function, with report; each additional 15 minutes | $8.62 | $7.38 | 15 mins | |
92630 | GN | Auditory rehabilitation; prelingual hearing loss | $55.50 | $40.08 | per session |
92630 | HQ,GN | Auditory rehabilitation; prelingual hearing loss (Group) | $36.63 | $26.45 | per member per session |
92633 | GN | Auditory rehabilitation; postlingual hearing loss | $55.50 | $40.08 | per session |
92633 | HQ,GN | Auditory rehabilitation; postlingual hearing loss (Group) | $36.63 | $26.45 | per member per session |
96110 | GN | Developmental screening (eg,developmental milestone survey, speech and language delay screen) with scoring and documentation, per standardized instrument | $5.32 | $3.85 | per session |
V5008 | Hearing screening | $17.02 | $12.86 | 15 mins | |
V5008 | TF | Hearing screening (Assistant) | 15.32 | $11.57 | 15 mins |
V5010 | Assessment for hearing aid | $17.75 | $12.78 | 15 mins | |
V5011** | Fitting/orientation/checking of hearing aid | $56.85 | $51.17 | per session | |
V5264 | Ear mold/insert, not disposable, any type | $45.50 | $32.86 | per unit | |
V5362 | Speech screening | $17.76 | $12.87 | 15 mins | |
V5362 | TF | Speech screening (Assistant) | $14.65 | $10.58 | 15 mins |
V5363 | Language screening | $17.76 | $12.87 | 15 mins | |
V5363 | TF | Language screening (Assistant) | $14.65 | $10.58 | 15 mins |
V5364 | Dysphagia screening | $17.76 | $12.87 | 15 mins | |
V5364 | TF | Dysphagia screening (Assistant) | $14.65 | $10.58 | 15 mins |
* The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services of these changes with a January 12, 2019 effective date
**The Department is seeking and anticipates receiving approval from the federal Centers for Medicare and Medicaid Services of these changes with a May 19, 2019 effective date
10-144 C.M.R. ch. 101, § III-109
5/19/2019 - filing 2019-076