The scope of this page includes documentation of audiology services across settings and populations as well as basic information on coding, billing, and payment for audiology services. For information specific to documentation in educational settings, see the ASHA Practice Portal page on Documentation in Schools.
Documentation is critical in conveying essential clinical information about each client or patient and their evaluation, diagnosis, plan of care, intervention, and outcomes. It allows for accurate communication among clinicians during care coordination and transfer of care as well as between clinicians and payers. Any type of documentation to be shared with clients/patients or family members/care partners should be readable, understandable, and written in plain language. See ASHA’s resource on health literacy.
ASHA does not dictate a single format or time frame for documentation. State or federal agencies governing health care, education, or licensure for audiologists may have specific documentation requirements. If those requirements are more stringent, they supersede the requirements of facilities, payers, and employers.
Unclear, vague, or absent documentation can result in negative consequences such as missed provider referrals, inadequate intervention, reduced continuity of care, denials by payers, and misrepresentation of the clinical judgment underlying the given diagnosis and intervention. See the ASHA Code of Ethics (ASHA, 2023).
The acronym ACUTE can help in recalling five important principles in proper documentation for audiology services:
Documentation is read by individuals with varying backgrounds and experience, including clinicians, professionals, clients and patients, family members and care partners, and claims reviewers. It is important that notes and reports are clear, legible, and efficiently convey essential information needed for a variety of purposes. See the ASHA resource on interprofessional education/interprofessional practice (IPE/IPP) for more information regarding professional collaboration and communication.
Documentation supports clinical decisions, communicates to and between interested parties, establishes medical necessity, and helps ensure proper payment for services.
Demonstrating medical necessity is an essential component in documentation for audiology services. Medicare defines medical necessity by exclusion, stating that “services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member are not covered” (Centers for Medicare & Medicaid Services [CMS], 2014, p. 3). Medicare describes circumstances for reasonable and necessary services safe, effective, nonexperimental, and appropriate in duration, frequency, setting, and accepted standards of medical practice for the given diagnosis or treatment (CMS, 2019). Medicare stipulates that “the services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a [qualified health care professional]” (CMS, 2023, p. 154).
Justification for reasonable and necessary care and medical necessity can be achieved by addressing the following criteria:
Relevant documentation for establishing medical necessity may include the following details:
See the ASHA resource on medical necessity for audiology and speech-language pathology services for more information.
Most payers, including Medicare, stipulate that services eligible for payment must be at a level of complexity and sophistication that requires the specific expertise and clinical judgment of the qualified health care professional.
Unskilled services do not require the unique knowledge and skills of an audiologist. Skilled services that are not adequately documented may appear to be unskilled.
Audiologists use their expert knowledge and clinical reasoning to perform skilled services such as the following:
Recommendations for documenting skilled services include the following:
Clinical documentation helps justify the following service attributes:
Audiologists provide skilled services to clients/patients that contribute to the coordinated care of interprofessional teams. Documentation of outcomes should reflect professional competencies and high professional standards, especially as payment models move away from fee-for-service and toward value-based care models such as efficiency-based outcomes and quality-of-life models.
The required components of clinical documentation vary and are dependent upon factors such as setting, service(s) provided, and legalities. Documenting a clinical interaction, whether diagnostic or interventional, involves capturing the following details:
ASHA’s Preferred Practice Patterns for the Profession of Audiology (ASHA, 2006) may provide guidance.
Clinical documentation may include evaluation reports, intervention notes, progress notes, and discharge summaries. Documentation requirements are dependent upon the setting and the specific services provided. Not all audiologists will use all types of documentation.
The evaluation report is a summary of the evaluation process, the resulting diagnosis, and a plan for service or discharge. It may include the following components:
An intervention note is used to document a device fitting or other client/patient encounter following the diagnosis. The documentation must be sufficiently clear as to justify the services provided and recommendations given.
An intervention note may include
A progress note is written for clients/patients who are receiving regular habilitation or rehabilitation. Progress notes are composed at given intervals (often determined by payers) and assess the progress toward long- and short-term goals. These notes typically include
A discharge summary may be required to detail the intervention provided, the reason for discontinuing services, and the client/patient status at the time of discharge if the plan of care covers multiple client/patient encounters. Not all cases will require a discharge summary.
Discharge summary notes typically include
The language used to describe a client/patient when documenting services and writing reports is important. The wording should appropriately reflect the name and pronouns provided to the clinician by the client/patient. When documenting for recordkeeping, consider the following:
For more information, see Supporting and Working With Transgender and Gender-Diverse People and Supporting Chosen Names and Pronouns.
Although Medicare does not reimburse audiologists for audiologic treatment services (e.g., vestibular rehabilitation, auditory rehabilitation), Medicare documentation guidelines for audiologic diagnostic testing and therapy services may serve as minimum standards adopted by other payers.
Medicaid is a joint federal- and state-funded program to assist states in providing medical care to low-income individuals and to those who are categorized as “medically needy.” Medicaid services are included as part of a free and appropriate public education for those children who are eligible. Medically necessary services can be delivered in health care settings or in schools. Documentation requirements for Medicaid may follow Medicare guidelines. State-specific guidelines can be found in the state’s Medicaid plan and/or Medicaid guidance documents (e.g., the state provider handbook). For more information, go to ASHA’s Medicaid Toolkit and the CMS resource on Medicaid Documentation for Medical Professionals [PDF].
Private payers do not use a universal documentation template, and requirements vary. Medicare documentation requirements may be useful as a set of basic guidelines, but it is important to check with individual insurers and your provider contract to verify documentation requirements.
Correct coding is the key to submitting valid claims for payment for health care services. Proper clinical documentation provides the justification for the codes submitted. If information presented in the documentation is inadequate or does not align with the billing codes, claims may be denied. The Healthcare Common Procedure Coding System (HCPCS) and the International Classification of Diseases (ICD) are the primary coding systems used by health care providers and third-party payers in the United States:
Procedure and diagnosis codes are recorded on a claim form submitted either electronically or on paper to third-party payers. Medicare, Medicaid, and most private health insurance plans use the CMS-1500 [PDF] claim form for noninstitutional providers (i.e., office setting) and the CMS-1450 [PDF]—or UB-04—form for institutional providers (e.g., hospital, comprehensive outpatient rehabilitation facility). See Medicare Part B Claims Checklist: Avoiding Simple Mistakes on the CMS-1500 Claim Form.
ASHA has a resource providing superbill templates for audiologists and speech-language pathologists.
Documentation in educational settings is used to convey essential clinical information about each student’s diagnosis, intervention, and outcomes and to address the questions that payers and/or stakeholders may ask about each student encounter:
When billing Medicaid for services provided in the school setting, the standards of Medicaid documentation apply. Separate documentation may be needed to address educational requirements (e.g., for the individualized education program [IEP]).
See the ASHA Practice Portal page on Documentation in Schools for more information on documentation in educational settings, the IEP process, and educational record retention.
The ICF is a categorization of health and health-related domains and is a framework for measuring health and disability at both individual and population levels (World Health Organization, 2001). ASHA developed the Preferred Practice Patterns for the Profession of Audiology (ASHA, 2006) to be consistent with this framework. See the ASHA page on International Classification of Functioning, Disability, and Health (ICF) for more information.
By engaging in a comprehensive plan of care, audiologists address the following components within the ICF framework:
ASHA does not prescribe a specific format for documentation, in either paper-based or electronic records. However, health care professionals often use a common documentation format—known as the SOAP note—to ensure that they have captured all relevant information related to a client/patient encounter. The SOAP note captures the following information:
Any acronyms or abbreviations used in documentation should be consistent with facility policy on accepted medical abbreviations (see ASHA’s list of Common Medical Abbreviations).
Health care facilities and other health care providers have adopted electronic medical records to standardize the collection of patient data, improve coordination of care, and facilitate reporting of quality measures.
Medicare requires electronic submission of billing information if the practice employs more than 10 full-time employees. Solo practitioners or small practices may require less complex software solutions for documentation than those purchased for a large health care facility.
Within medical facilities, audiologists may participate in the development of the templates used for billing and clinical documentation. Documentation templates that rely exclusively on multiple-choice checkboxes may cue the clinician to complete the required aspects of documentation; however, this will risk less differentiation of the patient’s unique clinical characteristics and intervention plan. Templates and documentation systems should include a mechanism to ensure that the information is personalized for the patient receiving care by reflecting their needs, goals, or recommendations. See Electronic Medical Records (EMRs) and Practice Management Software for Audiologists. The audiogram as a stand-alone document is no longer acceptable documentation.
ASHA’s Code of Ethics Principle I, Rule O, states, “Individuals shall protect the confidentiality and security of records of professional services provided, research and scholarly activities conducted, and products dispensed. Access to these records shall be allowed only when doing so is legally authorized or required by law” (ASHA, 2023). Furthermore, the Issues in Ethics: Misrepresentation of Services for Insurance Reimbursement, Funding, or Private Payment statement prohibits misrepresenting coding or clinical information for the purposes of obtaining reimbursement (ASHA, 2018).
A medical record is a legal document. Changes made to the medical record should be dated and initialed by the original documenter. Erroneous text may have a single line placed through it and may not be erased, deleted, scratched out, or whited out. The corrected text can be written next to it or as an addendum before that entry. See the ASHA Practice Portal page on Documentation in Schools for information on IEPs as legal documents.
Each state may have unique medical record retention laws that vary by setting or type of record. Federal law, such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA, 1996), must be considered. Payers and regulatory or accrediting agencies may have regulations governing record retention (e.g., Occupational Safety and Health Administration). Audiologists should know all applicable regulations and should abide by the most stringent one(s).
CMS requires that patient records for Medicare beneficiaries be retained for a period of 5 years (Code of Federal Regulations § 482.24 [PDF]). Medicaid requirements may vary by state. For additional information, see Medical Record Maintenance & Access Requirements [PDF], a CMS fact sheet.
ASHA does not have a policy on retention of video or digital images, such as vestibular recordings. Audiologists should consult their facility’s policy for guidance.
The purpose of the Health Insurance Portability and Accountability Act of 1996—commonly known as HIPAA—is to improve the efficiency and effectiveness of the nation’s health care system by ensuring the confidentiality and security of protected health information (PHI). Health care providers and other entities who handle PHI must comply with certain HIPAA regulations, such as rules surrounding patient privacy and PHI, the use of the National Provider Identifier (NPI), and the use of the 10th revision of the ICD. HIPAA regulations do not include medical record retention requirements. However, they do require the application of appropriate administrative, technical, and physical safeguards to protect the privacy of information for as long as the records are maintained. The 2013 HIPAA update strengthened enforcement activities and penalties for HIPAA violations that apply to covered entities and their business associates. See the ASHA resource on the Health Insurance Portability and Accountability Act for more information.
The Family Educational Rights and Privacy Act (1974)—commonly known as FERPA—is the federal law that addresses access to student records. See the ASHA Practice Portal page on Documentation in Schools for more information.
The Joint Commission’s revised set of standards on patient-centered communication outlined “effective communication, cultural competence, and patient- and family-centered care as important components of safe, quality care” (The Joint Commission, 2010, p. 4). Compliance with The Joint Commission standards includes considerations on documentation. Per The Joint Commission (2010), documented information should include
In October 2022, the U.S. Food and Drug Administration (FDA) finalized regulations [PDF] regarding over-the-counter (OTC) hearing aids. The newly regulated OTC hearing aid category led to a change in the labeling of professionally fit hearing aids to “prescription hearing aids.” Both the OTC hearing aid and the prescription hearing aid have distinct conditions for sale and dispensing. For more information, see ASHA’s Over-The-Counter (OTC) Hearing Aids: Frequently Asked Questions [PDF] and the FDA resource on hearing aids.
Prescription hearing aids are devices professionally fitted by either a licensed audiologist or a hearing aid professional. Prior to the fitting and sale of prescription hearing aids, the hearing care provider must complete a hearing evaluation to determine the individual needs of the patient. The specific requirements for hearing evaluation testing, documentation of the hearing evaluation results, and notation on the bill of sale for hearing aids are specified by each state’s licensing board.
Written documentation of the hearing aid purchase is a legal document provided to the patient and retained for recordkeeping. A bill of sale or purchase agreement for prescription hearing aids may include, but not be limited to, the following information:
Contact your state Attorney General’s office for state-specific laws governing hearing aid sales and stated or implied warranties. The ASHA state-by-state resource provides state-specific requirements regarding hearing aid evaluation and fitting documentation. For more information, see the ASHA document on State Audiology Licensure Laws & Regulations for Prescription (Rx) and Over The Counter (OTC) Hearing Aids [PDF].
The FDA ruling in 2022 allows for OTC hearing aids to be sold to individuals without having an initial consultation with a hearing specialist or obtaining a hearing test. Unlike prescription hearing aids, where return policies may be established at the state level, there is no required trial period for OTC hearing aids. Trial periods for OTC hearing aids are determined by the manufacturer. OTC hearing aids are recommended for individuals with a self-perceived mild to moderate hearing loss who are over the age of 18 years. For those with a greater degree of hearing loss and for children, OTC hearing aids are not recommended. OTC hearing aids are required by the FDA to have specific package labeling for consumers to review before purchase.
Audiologists offering professional services to assist patients with OTC hearing aids may consider documentation to specify the services offered and to differentiate OTC hearing aids from prescription hearing aids. An audiologist or a physician cannot require an individual to have a hearing evaluation prior to the purchase of OTC hearing aids, as this would violate the FDA regulations.
It is essential that all audiometric equipment be calibrated, be functioning properly, and be used in an acceptable test environment to ensure accurate test results as specified in ANSI/ASA S3.6-2018 (American National Standards Institute/Acoustical Society of America, 2018). The audiologist may be responsible for keeping records for verification that these standards are being met and applicable state laws are being followed.
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
American National Standards Institute/Acoustical Society of America. (2018). Specification for audiometers (ANSI S3.6-2018).
American Speech-Language-Hearing Association. (2006). Preferred practice patterns for the profession of audiology [Preferred practice patterns]. https://www.asha.org/policy/
American Speech-Language-Hearing Association. (2018). Issues in ethics: Representation of services for insurance reimbursement, funding, or private payment [Ethics]. https://www.asha.org/practice/ethics/misrepresentation-of-services/
American Speech-Language-Hearing Association. (2023). Code of ethics [Ethics]. https://www.asha.org/policy/
Centers for Medicare & Medicaid Services. (2014). Medicare benefit policy manual: Chapter 16, Section 20. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c16.pdf [PDF]
Centers for Medicare & Medicaid Services. (2019). Medicare program integrity manual: Chapter 13, Section 13.5.4. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c13.pdf [PDF]
Centers for Medicare & Medicaid Services. (2023). Medicare benefit policy manual: Chapter 15, Section 220.2B. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf [PDF]
Family Educational Rights and Privacy Act of 1974, 20 U.S.C. § 1232g (1974).
Health Insurance Portability and Accountability Act of 1996. Pub. L. No. 104-191, 110 Stat. 1938 (1996).
The Joint Commission. (2010). Advancing effective communication, cultural competence, and patient- and family-centered care. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/aroadmapforhospitalsfinalversion727pdf.pdf [PDF]
World Health Organization. (2001). International Classification of Functioning, Disability and Health (ICF). https://www.who.int/classifications/icf/en/
Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Documentation of Audiology Services page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Documentation of audiology services [Practice portal]. https://www.asha.org/Practice-Portal/Professional-Issues/Documentation-of-Audiology-Services/
Content Disclaimer: The Practice Portal, ASHA policy documents, and guidelines contain information for use in all settings; however, members must consider all applicable local, state and federal requirements when applying the information in their specific work setting.