Medicare Announces Reimbursement Rules for 2015 ASHA advocacy saves auditory osseointegrated implants and an audiology quality reporting measure, and postpones participation in a quality-based payment program. Policy Analysis
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Policy Analysis  |   December 01, 2014
Medicare Announces Reimbursement Rules for 2015
Author Notes
  • Lisa Satterfield, MS, CCC-A, is ASHA director of health care regulatory advocacy. lsatterfield@asha.org
    Lisa Satterfield, MS, CCC-A, is ASHA director of health care regulatory advocacy. lsatterfield@asha.org×
  • Neela Swanson is ASHA director of health care coding policy. nswanson@asha.org
    Neela Swanson is ASHA director of health care coding policy. nswanson@asha.org×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   December 01, 2014
Medicare Announces Reimbursement Rules for 2015
The ASHA Leader, December 2014, Vol. 19, 24-25. doi:10.1044/leader.PA1.19122014.24
The ASHA Leader, December 2014, Vol. 19, 24-25. doi:10.1044/leader.PA1.19122014.24
Changes in Medicare regulations for 2015 are generally positive for audiologists and speech-language pathologists providing outpatient and home health care, according to Centers for Medicare and Medicaid Services rules released in late October.
Some reimbursement levels drop under the new rule, however, and some hospital-based outpatient audiometry codes are reclassified.
The rules address several issues, including reimbursement rates, new codes, quality reporting, reassessment timeframes and reclassification of some codes for audiology hospital outpatient services.
Reimbursement rates
The Medicare Physician Fee Schedule sets rates for each procedure designated by a Current Procedural Terminology code (CPT, ©American Medical Association). The fee for each code is determined by its value (professional work, practice expense and professional liability insurance) multiplied by an annually adjusted conversion factor. However, federal legislation enacted in March extended the use of the 2014 conversion factor through March 31, 2015.
On April 1, 2015, a mandatory reduction of more than 20 percent could go into effect. Congress extended the current conversion factor in anticipation of passing a Medicare payment reform bill. If no Medicare reform is enacted by April 1, Congress is expected to craft new legislation to prevent this reduction, as it has in the past.
With the current conversion factor, CMS predicts no impact on fee changes for audiology services, and a cumulative 1 percent decrease on speech-language pathology services. The decrease comes from adjustments to factors that contribute to the value of certain procedures. Click here for the fee schedules for audiologists and SLPs.
Therapy caps
The 2015 therapy cap—the maximum amount a Medicare beneficiary can accrue in speech-language and physical therapy services combined in a year—is $1,940. A therapy cap exceptions process, however, allows beneficiaries to continue to receive medically necessary services beyond that ceiling. The same legislation that set the conversion factor through March 31 also extends the therapy cap exceptions process to that date.
New rates for vestibular testing codes
The American Medical Association’s Relative Value Update Committee called for the update of several vestibular testing codes for 2015. The goal was to set payment rates for these codes based on the professional work of audiologists (clinical judgment, mental effort, risk) rather than considering the audiologist’s work as an extension of the physician’s role without independent value. To do so, ASHA and the American Academy of Audiology surveyed audiologists earlier this year to update the professional work value of vestibular testing codes 92541 (spontaneous nystagmus test), 92542 (positional nystagmus test), 92543 (caloric vestibular test), 92544 (optokinetic nystagmus test) and 92545 (oscillating tracking test).
The Relative Value Update Committee used the data to develop and submit recommendations to CMS, which accepted the RUC recommendations for four of the five codes surveyed. However, in accepting the increased professional work value, CMS also significantly—and, ASHA believes, inappropriately—reduced the practice expense for these codes. The result is lower reimbursement rates for four of the codes, with CPT 92543 remaining at the 2014 reimbursement level.
ASHA staff plan to meet with CMS officials to discuss their decision to decrease the overall reimbursement of the vestibular codes, which now are severely undervalued.
Physician Quality Reporting System
Under PQRS, Medicare providers report data to CMS to help track quality. Initially legislated as an incentive-based program, PQRS now imposes penalties on providers who fail to participate at benchmark levels.
PQRS requires audiologists and SLPs who bill fee-for-service outpatient Medicare Part B beneficiaries using the CMS 1500 or electronic equivalent in four settings—private practices, group practices, university clinics and critical access hospitals—to meet 2015 benchmarks or face a 2 percent deduction on their 2017 claims.
The benchmark for SLPs is to record or review medications in the records of 50 percent of their Medicare patient visits (Measure #130).
Audiologists also must record or review medications for 50 percent of their Medicare visits (Measure #130), and refer patients who present with dizziness or benign paroxysmal positional vertigo to a physician (Measure #261). The dizziness measure was proposed for retirement in 2015, but CMS restored the measure in response to advocacy by ASHA, the Audiology Quality Consortium and other audiology stakeholders.
Value-based modifier
The value-based modifier program imposes penalties of up to an additional 4 percent on providers whose quality and quantity of PQRS participation is less than that of other clinicians in the same discipline. According to statute, CMS can apply the value-based modifier to all eligible professionals beginning in 2017. The proposed 2015 rule would have added audiologists and SLPs to this program, which already applies to physicians.
ASHA and other stakeholders presented effective arguments against including SLPs and audiologists in the value-based modifier program program: It focuses on physician measures, not speech-language or audiology measures, so audiologists and SLPs do not have the option to earn rewards under the program.
CMS postponed the program for nonphysician professionals for one year. The postponement gives audiologists and SLPs a year to hone their PQRS reporting processes so that they will meet reporting benchmarks in 2016 and avoid the 6 percent reduction on all 2018 claims.
Auditory osseointegrated implants
In a move lauded by the audiology community, CMS reversed a proposal to reclassify osseointegrated implants as “hearing aids,” rather than as prosthetics. The reclassification would have disqualified the devices from Medicare coverage, because of a statute that excludes Medicare from covering any devices classified as hearing aids.
In the final rule, CMS noted that the reversal was in response to comments to the proposed rule from ASHA and other stakeholders, who met with CMS officials to advocate for continued coverage of the medically necessary devices. The final rule states that “osseointegrated implants in the skull bone” will remain under the prosthetic definition, and the hearing aid definition will include “bone conduction hearing aids that provide mechanical stimulation of the cochlea via stimulation of the scalp.”
Home health
SLPs will find it easier to track reassessment timeframes and physician narratives in 2015. A beneficiary still must have a documented face-to-face encounter with a physician to be eligible for home health services, but a separate narrative completed by the physician is no longer required.
The reassessment timeframe and process have also changed. Current rules require patients to be reassessed after 13 to 19 total visits for speech-language, occupational therapy and physical therapy, requiring SLPs to coordinate reassessments with physical and occupational therapy colleagues. The 2015 rules call for each therapy provider to reassess on or before every 30th calendar day, tracked individually by each provider beginning with the provider’s first date of service. This change affects episodes of care ending on or after Jan. 1, 2015.
Hospital outpatient audiology services
Audiology services provided in hospitals are paid under the prospective payment system, which categorizes CPT codes into Ambulatory Payment Classifications for rates and bundled payment options. ASHA opposed a proposal to reclassify several audiology services as part of a “bundle”—and, therefore, not separately payable—when performed on the same day as other, sometimes unrelated “primary” services, such as dialysis or radiology studies.
The final rule, however, includes audiometry codes—including comprehensive audiology (92557) and diagnostic and programming of cochlear implants (92601–92604)—as part of the “bundled” prospective payment. Vestibular testing, auditory brainstem response and otoacoustic emissions remain as separately payable primary services.
Under this rule, the audiometry services are not separately reimbursed when any “primary” service—including vestibular evaluation, ABR, OAE or unrelated service—is performed on the same day.
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December 2014
Volume 19, Issue 12