Code of Massachusetts Regulations
101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES
Title 101 CMR 323.00 - Rates for Hearing Services
Section 323.03 - General Rate Provisions, Requirements, and Rates

Universal Citation: 101 MA Code of Regs 101.323

Current through Register 1531, September 27, 2024

(1) General Rate Provisions. Payment for the purchase of hearing aids and authorized related accessories and services for the care and maintenance of hearing aid instruments are the lowest of

(a) the provider's usual charge to persons other than publicly aided individuals and industrial accident patients;

(b) the provider's actual charge submitted; or

(c) the schedule or maximum fees listed in 101 CMR 323.03(5).

(2) Reimbursement as Full Payment. The payment rates under 101 CMR 323.03 are full compensation for care rendered to publicly aided individuals and industrial accident patients, as well as for any related administrative or supervisory duties and costs in connection with the services provided. Each provider must, as a condition of acceptance of payment made by the governmental unit purchasing audiological services or purchaser under M.G.L. c. 152 (the Workers' Compensation Act), accept the rate as full payment and discharge of all obligations for the services rendered.

(3) General Requirements and Services Included.

(a) Purchase of Hearing Aids. Payment for a hearing aid includes
1. the hearing aid and standard accessories for the proper operation of the hearing aid and proper fitting and instruction in the use, care, and maintenance of the hearing aid; and minor repairs and services as usually provided non-publicly aided individuals and industrial accident patients that may be necessary during the operational life of the hearing aid;

2. a mandatory one year manufacturer's warranty and/or insurance against loss or damage; and

3. the cost of a loaner hearing aid when necessary.

(b) Earmold. Payment for an earmold includes the proper fitting of the earmold on delivery, and adjustments as may be needed. The maximum fee stipulated in 101 CMR 323.03(5)(c) is not allowed if an earmold is included in the manufacturer's price of the aid or the client already has an earmold.

(c) Ear Impression. Payment for an ear impression includes one properly formed ear impression for each in-the-ear (ITE), in-the-canal (ITC), and behind-the-ear (BTE) aid purchased. The fee stipulated in 101 CMR 323.03(5)(d) is allowed only at the time an aid is purchased. The fee listed in 101 CMR 323.03(5)(d) includes provision for all associated costs.

(d) Batteries. Proper freshness of batteries must be ensured. The maximum fee listed in 101 CMR 323.03(5)(e) includes provision for all associated costs. Batteries must be new and unused at the time of purchase.

(e) Other Accessories or Options for a Hearing Aid. Proper fitting and adjustment of the accessory must be provided as needed. The maximum fee listed in 101 CMR 323.03(5)(g) includes provision for all associated costs. Accessories must be new and unused at the time of purchase.

(f) Refitting Services/Other Professional Services. Additional fitting/refitting services are reimbursed only if the hearing aid was dispensed more than one year prior to the date of service of the refitting services. These professional services include refitting of the aid, orientation, counseling the member or member's family, contact with interpreters, fitting of a loaner aid, and similar services. Reimbursement for such services must include a face-to-face encounter with the publicly aided individual or industrial accident patient.

(g) Minor Repairs and Office Visits for Evaluation and Management Services. An office visit for evaluation and management services is reimbursed only when one or more of the following services is required and is provided as part of the visit:
1. minor adjustments to the hearing aid to ensure a proper fitting, such as an earmold adjustment, when a provider is not the provider who initially fit the hearing aid, and the provider who initially fit the hearing aid no longer provides services to publicly aided individuals or industrial accident patients;

2. minor office repairs for which the provider customarily charges patients who are neither publicly aided individuals nor industrial accident patients;

3. cleaning of the hearing aid; or

4. replacement of parts such as, but not limited to, tubing, hooks, battery doors, and replacement. No fee is allowed when the provider does not customarily charge clients other than publicly aided individuals and industrial accident patients for these repairs.

(h) Major Repairs. A provider may submit a bill for major repairs to a hearing aid only after all warranties and/or insurance have expired. The hearing aid in need of a major repair must be sent directly to the repair facility or manufacturer that will perform the repair. Handling charges by an intermediary may not be submitted. Repair services must include a written warranty against all defects for a minimum of six months, unless otherwise documented by the repair facility or manufacturer. The provider of the repair services is responsible for the quality of the workmanship and parts, and for ensuring that the repaired aid is in proper working condition. The maximum fee listed in 101 CMR 323.03(5)(j) includes provision for all associated costs.

(i) Extended Insurance Covering Loss and Damage. The manufacturer's insurance policy must provide coverage for the loss or damage of a hearing aid for no less than one year and up to three years following purchase.

(j) Other Services. No payment is allowed when the provider does not customarily charge clients other than publicly aided individuals and industrial accident patients for such items.

(4) Two Audiologists. MassHealth pays for two audiologists working together to perform an evaluation of an individual member when the knowledge, skills, and experience of the primary audiologist have identified a need for a second audiologist to aid in completing the initial test battery, such as for the testing of very young children or those with other pertinent developmental, physical, cognitive, or maturational factors. Circumstances warranting the services of two audiologists must be fully documented in the member's medical record. To receive full payment, both audiologists must use the appropriate service code and modifier combination listed in Subchapter 6 of the MassHealth Audiologist Manual. MassHealth will pay 1/2 of the total allowable payment for two audiologists to each individual provider.

(5) Rates. 101 CMR 323.03(5) sets forth maximum fees for the items and services listed in 101 CMR 323.03(5).

(a) Maximum Fees for Audiological Services.
1. Vestibular Function Tests, with Recording and Medical Diagnostic Evaluation.

Code

Description

Rate

92541

Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording

$52.21

92542

Positional nystagmus test, minimum of four positions, with recording

$53.86

92544

Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording

$43.19

92545

Oscillating tracking test, with recording

$39.30

92546

Sinusoidal vertical axis rotational testing

$81.48

92547

Use of vertical electrodes (List separately in addition to code for primary procedure)

$24.52

2. Audiologic Function Tests with Medical Diagnostic Evaluation.

Code

Description

Rate

92551

Screening test, pure tone, air only

$9.49

92552

Pure tone audiometry (threshold); air only

$18.37

92553

Pure tone audiometry (threshold); air and bone

$26.26

92555

Speech audiometry threshold

$15.05

92556

Speech audiometry threshold; with speech recognition

$22.20

92557

Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)

$49.51

92562

Loudness balance test, alternate binaural or monaural

$18.73

92563

Tone decay test

$16.17

92565

Stenger test, pure tone

$14.31

92567

Tympanometry (impedance testing)

$20.36

92568

Acoustic reflex testing, threshold

$14.26

92572

Staggered spondaic word test

$8.39

92576

Synthetic sentence identification test

$18.61

92577

Stenger test, speech

$23.91

92579

Visual reinforcement audiometry (VRA)

$29.59

92582

Conditioning play audiometry

$31.82

92583

Select picture audiometry

$33.04

92584

Electrocochleography

$84.33

92587

Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report

$56.57

92588

Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report

$79.19

92590

Hearing aid examination and selection; monaural

$24.23

92591

Hearing aid examination and selection; binaural

$35.94

92592

Hearing aid check; monaural

$15.19

92593

Hearing aid check; binaural

$30.38

92594

Electroacoustic evaluation for hearing aid; monaural

$41.64

92595

Electroacoustic evaluation for hearing aid; binaural

$83.32

92596

Ear protector attenuation measurements

$26.62

92650

Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis

$67.81

92651

Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report

$67.81

92652

Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report

$94.37

92653

Auditory evoked potentials; neurodiagnostic, with interpretation and report

$94.37

V5020

Conformity evaluation

$90.94

3. Evaluative and Therapeutic Services.

Code

Description

Rate

92517

Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP)

I.C.

92518

Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; ocular (oVEMP)

I.C.

92519

Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) and ocular (oVEMP)

I.C.

92601

Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming

$143.78

92602

Diagnostic analysis of cochlear implant, patient younger than 7 years of age; subsequent reprogramming (do not report 92602 in addition to 92601)

$98.64

92603

Diagnostic analysis of cochlear implant, 7 years or older; with programming

$90.51

92604

Diagnostic analysis of cochlear implant, 7 years or older; subsequent reprogramming (do not report 92604 in addition to 92603)

$58.69

92620

Evaluation of central auditory function, with report; initial 60 minutes

$59.45

92621

Evaluation of central auditory function, with report; each additional 15 minutes (List separately in addition to code for primary procedure)

$14.87

92626

Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour

$59.45

92627

Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); each additional 15 minutes (List separately in addition to code for primary procedure)

$14.87

92700

Unlisted otorhinolaryngologic service or procedure

I.C.

4. Miscellaneous.

Code

Description

Rate

V5008

Hearing screening

$30.83

V5010

Assessment for hearing

$62.53

(b) Maximum Fees for Hearing Aids. The maximum fees are the adjusted acquisition cost (AAC) of the hearing aid, plus the appropriate dispensing fee.
1. Hearing Aid Dispensing Fees.

Code

Description

Rate

V5090

Dispensing fee, unspecified hearing aid

$331.26

V5110

Dispensing fee, bilateral

$662.73

V5160

Dispensing fee, binaural

$662.73

V5200

Dispensing fee, CROS contralateral, monaural

$662.73

V5240

Dispensing fee, contralateral routing system, binaural

$662.73

V5241

Dispensing fee, monaural hearing aid, any type

$331.26

2. Hearing Aid Purchases.

Code

Description

Rate

V5030

Hearing aid, monaural, body worn, air conduction

AAC

V5040

Hearing aid, monaural, body worn, bone conduction

AAC

V5050

Hearing aid, monaural, in the ear

AAC

V5060

Hearing aid, monaural, behind the ear

AAC

V5070

Glasses, air conduction

AAC

V5080

Glasses, bone conduction

AAC

V5095

Semi-implantable middle ear hearing prosthesis

AAC

V5100

Hearing aid, bilateral, body worn

AAC

V5120

Binaural, body

AAC

V5130

Binaural, in the ear

AAC

V5140

Binaural, behind the ear

AAC

V5150

Binaural, glasses

AAC

V5171

Hearing aid, contralateral routing device, monaural, in the ear (ITE)

I.C.

V5172

Hearing aid, contralateral routing device, monaural, in the canal (ITC)

I.C.

V5181

Hearing aid, contralateral routing device, monaural, behind the ear (BTE)

I.C.

V5190

Hearing aid, contralateral routing, monaural, glasses

AAC

V5211

Hearing aid, contralateral routing device, monaural, behind the ear (BTE)

I.C.

V5212

Hearing aid, contralateral routing system, binaural, ITE/ITC

I.C

V5213

Hearing aid, contralateral routing system, binaural, ITE/BTE

I.C.

V5214

Hearing aid, contralateral routing system, binaural, ITC/ITC

I.C.

V5215

Hearing aid, contralateral routing system, binaural, ITC/BTE

I.C.

V5221

Hearing aid, contralateral routing system, binaural, BTE/BTE

I.C.

V5230

Hearing aid, contralateral routing system, binaural, glasses

AAC

V5242

Hearing aid, analog, monaural, CIC (completely in the ear canal)

AAC

V5243

Hearing aid, analog, monaural, ITC (in the canal)

AAC

V5244

Hearing aid, digitally programmable analog, monaural, CIC

AAC

V5245

Hearing aid, digitally programmable analog, monaural, ITC

AAC

V5246

Hearing aid, digitally programmable analog, monaural, ITE (in the ear)

AAC

V5247

Hearing aid, digitally programmable analog, monaural, BTE (behind the ear)

AAC

V5248

Hearing aid, analog, binaural, CIC

AAC

V5249

Hearing aid, analog, binaural, ITC

AAC

V5250

Hearing aid, digitally programmable analog, binaural, CIC

AAC

V5251

Hearing aid, digitally programmable analog, binaural, ITC

AAC

V5252

Hearing aid, digitally programmable, binaural, ITE

AAC

V5253

Hearing aid, digitally programmable, binaural, BTE

AAC

V5254

Hearing aid, digital, monaural, CIC

AAC

V5255

Hearing aid, digital, monaural, ITC

AAC

V5256

Hearing aid, digital, monaural, ITE

AAC

V5257

Hearing aid, digital, monaural, BTE

AAC

V5258

Hearing aid, digital, binaural, CIC

AAC

V5259

Hearing aid, digital, binaural, ITC

AAC

V5260

Hearing aid, digital, binaural, ITE

AAC

V5261

Hearing aid, digital, binaural, BTE

AAC

V5262

Hearing aid, disposable, any type, monaural

AAC

V5263

Hearing aid, disposable, any type, binaural

AAC

V5298

Hearing aid, not otherwise classified

AAC

(c) Maximum Fees for Earmolds. Provider's adjusted acquisition cost (AAC), plus a dispensing fee as set forth below.

Code

Description

Rate

V5264

Ear mold/insert, not disposable, any type

AAC+ $15.74

V5265

Ear mold/insert, disposable, any type

AAC+ $15.74

(d) Maximum Fee for Ear Impressions.

Code

Description

Rate

V5275

Ear impression, each

$15.74

(e) Maximum Fees for Batteries.

Code

Description

Rate

V5266

Battery for use in hearing device

$1.67

L8621

Zinc air battery for use with cochlear implant device and auditory osseointegrated sound processors, replacement, each

AAC

L8622

Alkaline battery for use with cochlear implant device, any size, replacement, each

AAC

L8623

Lithium ion battery for use with cochlear implant device speech processor, other than ear level, replacement, each

AAC

L8624

Lithium ion battery for use with cochlear implant or auditory osseointegrated device speech processor, ear level, replacement, each

AAC

(f) Maximum Fees for Bone-anchored Hearing Aids (BAHA).

Code

Description

Rate

L8691

Auditory osseointegrated device, external sound processor, excludes transducer/actuator, replacement only, each

$1,931.37

L8692

Auditory osseointegrated device, external sound processor, used without osseointegration, body worn, includes headband or other means of external attachment

I.C.

L8693

Auditory osseointegrated device abutment, any length, replacement only

$1,700.57

L8694

Auditory osseointegrated device, transducer/actuator, replacement only, each

$1,059.11

(g) Maximum Fees for Other Accessories. Provider's adjusted acquisition cost (AAC), plus a 45% markup.

Code

Description

Rate

V5267

Hearing aid or assistive listening device/supplies/accessories, not otherwise specified

AAC+ 45%

V5274

Assistive listening device, not otherwise specified

AAC+ 45%

(h) Maximum Fee for Refitting Services.

Code

Description

Rate

V5011

Fitting/orientation/checking of hearing aid

$37.35

(i) Maximum Fee for Minor Repairs.

Code

Description

Rate

99499

Unlisted evaluation and management service

$5.38

(j) Maximum Fee for Major Repairs.

Code

Description

Rate

V5014

Repair/modification of a hearing aid

AAC+ 45%

(k) Maximum Fees for Cochlear Implant Services.

Code

Description

Rate

L7510MS

Repair of prosthetic device, repair or replace minor parts (six-month maintenance and servicing fee for reasonable and necessary parts and labor that are not covered under any manufacturer or supplier warranty) (I.C.) (for use only for the purchase of a cochlear implant service contract in accordance with 130 CMR 426.416: Reimbursable Services.)

I.C.

L8615

Headset/headpiece for use with cochlear implant device, replacement

$337.44

L8616

Microphone for use with cochlear implant device, replacement

$78.60

L8617

Transmitting coil for use with cochlear implant device, replacement

$68.65

L8618

Transmitter cable for use with cochlear implant device or auditory osseointegrated device, replacement

$19.62

L8619

Cochlear implant, external speech processor and controller, integrated system, replacement

$7,259.54

L8627

Cochlear implant, external speech processor, component, replacement

$6,518.03

L8628

Cochlear implant, external controller component, replacement

$1,130.05

L8629

Transmitting coil and cable, integrated, for use with cochlear implant device, replacement

$163.56

L9900

Orthotic and prosthetic supply, accessory, and/or service component of another HCPCS L code

I.C.

(l) Maximum Fee for Other Services.

Code

Description

Rate

V5299

Hearing service, miscellaneous

I.C.

(6) Medical Services. The payment rates for medical services are set forth in 101 CMR 317.00: Rates for Medicine Services.

(7) Therapeutic Services. The payment rates for therapeutic services are set forth in 101 CMR 339.00: Rates for Restorative Services.

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