Medicare Direct Access Attestation (Audiology AB Modifier)

Medicare Direct Access Attestation (AB Modifier)

(Use this add-on attestation only when billing Medicare diagnostic audiology services under the limited direct access pathway with the AB modifier and no physician/NPP order was used. Do not use for disequilibrium/vestibular evaluations or hearing aid-related encounters.)

Patient: [Patient name], [DOB], [MRN]

Date of Service: [Date of service]

Rendering Audiologist: [Audiologist name and credentials]

Associated Audiology Report: [Reference to base evaluation note]

Direct Access Eligibility Attestation

(All elements in this section are mandatory and must be stated explicitly.)

[Attestation statement confirming that the patient accessed audiology services without a physician/NPP order for the services billed today, and that the diagnostic tests billed with the AB modifier were personally furnished by the rendering audiologist.]

12-Month Frequency Verification: [Verification method used, e.g., internal billing history review, patient report]. [Prior AB-modifier direct access audiology visit identified within the preceding 12 months: yes / no]. (Include date if prior visit identified. If verification was not possible, explicitly state inability to verify and the billing decision made.)

Non-Acute Presentation: [Onset timing: gradual / sudden], [duration], [course: stable / progressive / fluctuating]. [Explicit absence of acute red flags including sudden hearing loss, ear pain, drainage, bleeding, recent trauma, and neurologic symptoms]. [Affirmative statement that the presentation is consistent with a non-acute hearing condition.]

Exclusion Screening:

• [Explicit confirmation that this encounter is not for disequilibrium or imbalance evaluation]
• [Explicit confirmation that this encounter is not for hearing aid fitting, prescribing, changing, or exam purposes related to hearing aids]

Services Furnished Under AB Modifier

(List each diagnostic test performed and billed with the AB modifier.)

• [Test name and laterality]: [Reference to where full test results/artifacts are stored]. [Brief interpretive summary if clinically appropriate.]
• [Additional test name and laterality]: [Reference to storage location]. [Brief interpretive summary if clinically appropriate.]

Medical Necessity

[Patient-reported functional complaint(s) related to hearing and communication]. [Clinical rationale linking the complaint(s) to the specific diagnostic tests performed.]

Unexpected Acute Finding

(Include this section ONLY if an acute concern was unexpectedly identified during the encounter that was not apparent from pre-test screening; otherwise omit this entire section.)

• Acute concern discovered: [Description of acute finding]
• Pre-test screening: [Red-flag screening performed prior to testing and why the acute issue was not initially apparent]
• Action taken: [Referral(s) placed and follow-up instructions provided to the patient]

Follow-Up and Referrals

Referrals: [Referrals placed, or "None indicated"]

Patient Instructions: [Instructions provided]. (If additional audiology testing is anticipated within 12 months, note that a physician/NPP order will be required for subsequent Medicare-covered testing.)

Audiologist Signature: [Electronic signature with date/time and credentials]