2013 Medicare Proposal Outlines New Reporting Rules Proposed 2013 reimbursement levels and associated rules for Medicare outpatient services will adjust reimbursement rates, affect therapy payment, and require participation in quality reporting in 2013. The Centers for Medicare and Medicaid Services (CMS) published the proposed 2013 Medicare Physician Fee Schedule and associated rules for Medicare Part B services ... Bottom Line
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Bottom Line  |   August 01, 2012
2013 Medicare Proposal Outlines New Reporting Rules
Author Notes
  • Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at lsatterfield@asha.org.
    Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at lsatterfield@asha.org.×
  • Neela Swanson, associate director of health care economics and coding, can be reached at nswanson@asha.org
    Neela Swanson, associate director of health care economics and coding, can be reached at nswanson@asha.org×
  • Mark Kander, director of health care regulatory analysis, can be reached at mkander@asha.org
    Mark Kander, director of health care regulatory analysis, can be reached at mkander@asha.org×
Article Information
Practice Management / Regulatory, Legislative & Advocacy / Bottom Line
Bottom Line   |   August 01, 2012
2013 Medicare Proposal Outlines New Reporting Rules
The ASHA Leader, August 2012, Vol. 17, 8-9. doi:10.1044/leader.BML2.17102012.8
The ASHA Leader, August 2012, Vol. 17, 8-9. doi:10.1044/leader.BML2.17102012.8
Proposed 2013 reimbursement levels and associated rules for Medicare outpatient services will adjust reimbursement rates, affect therapy payment, and require participation in quality reporting in 2013.
The Centers for Medicare and Medicaid Services (CMS) published the proposed 2013 Medicare Physician Fee Schedule and associated rules for Medicare Part B services in the July 30, 2012,Federal Register [PDF, 25.4 MB]. The rule is not final, however, and changes are expected. ASHA will express concerns with several aspects of the rule in comments to CMS.
Therapy Caps and Reporting Requirements
The proposed rule briefly recognizes two legislative mandates enacted in 2012—the manual medical review process for claims reaching $3,700 (speech-language pathology and physical therapy combined) and the inclusion on the claim form of the National Provider Identifier of the physician (or physician assistant, nurse practitioner, or clinical nurse specialist) who approves the therapy plan of care. Guidelines issued after the proposed fee schedule was released outline the manual medical review process (see “Medicare Manual Review Rules to Affect Providers”).
Changes in therapy claims reporting were mandated by the Middle Class Tax Relief and Job Creation Act of 2012 in response to rising Medicare expenditures. CMS reports that 7.6 million Medicare beneficiaries received outpatient therapy services (speech-language treatment, physical therapy, and occupational therapy) in 2010. Expenditures for these services increased by 10.1% per year from 1998 to 2008; however, the number of Medicare beneficiaries receiving therapy services increased by only 2.9% per year in that same time.
In an effort to limit medically unnecessary services, Congress in 1997 began “capping” the amount of outpatient therapy services each beneficiary could receive in a year; however, Congress also has passed an exceptions process that allows beneficiaries to receive services beyond those caps.
The Act requires CMS to implement a claims-based data collection system for reforming the Medicare outpatient therapy payment system by Jan. 1, 2013.
The proposed 2013 rule outlines a system for reporting patient outcomes that is based on a 12-point, 10-percentage-point incremental scale to measure functional limitations.
Functional outcomes would be reported on the claim form, along with the Common Procedural Terminology (CPT, © American Medical Association) code for the service provided, using a series of G-codes with modifiers for up to two functional goals. The measures would be reported at the outset of therapy, at the earlier of the 10th treatment day or 30th calendar day, and at discharge. The proposed timing of the functional progress coding coincides with the current reporting timeline, which requires documentation at the start of care, at progress note intervals, and at discharge.
Implementation is scheduled for Jan. 1, 2013, with a “testing period” from Jan. 1 to July 1. Required reporting would begin on July 1, 2013 (claims without the appropriate G-codes and modifiers would be returned unpaid).
Reporting of the –GN modifier for all speech-language pathology services will continue, as will the –KX modifier for claims over the therapy cap amount (assuming Congress extends the exceptions process into 2013).
In its comments on the proposed rule, ASHA will address several concerns with the functional reporting system:
  • The system, including the 12-point severity scale, has not been subject to reliability or validity studies.

  • The administrative burden for providers to implement a complex system is excessive.

  • No standards exist to determine which claims will be rejected as inappropriate.

  • The resulting subjective data will likely not provide valid information needed to develop a new payment model.

  • There is a short time frame for implementation and education.

ASHA also will advocate in comments that speech-language pathology functional outcomes be reported through NOMS instead of the system proposed by CMS.
Proposed Fee Changes
Changes in reimbursement rates are based on a mandated formula and variations in the values of individual CPT codes.
Conversion Factor
To calculate reimbursement rates, CMS uses a conversion factor that is based on a statutory formula (the Sustainable Growth Rate).
Using that formula, the projected 2013 conversion factor is $24.8441, which is 27% less than the current $34.0376. However, Congress will most likely again enact legislation to prevent this reduction, as it has every year since 2003.
Practice Expense
The value of each CPT code is calculated by separating the cost of providing the service into relative value units (RVUs) in three components—professional work, technical expenses (practice expense), and professional liability insurance (malpractice). The total RVUs for each service is the sum of the three components (components are adjusted for geographical differences); the RVUs for any particular CPT code are multiplied by the conversion factor to determine the corresponding fee.
In 2013, audiologists and SLPs will experience the final year of a four-year phase-in of practice expense value changes, the result of updated practice cost surveys. These surveys reflect data on average practice expenses and mostly affect indirect practice costs (such as office overhead, billing, rent, and utilities).
These changes have decreased rates for many audiology and speech-language pathology procedures, mostly because the costs of operating an audiology or speech-language pathology practice are substantially less than those of a medical practice. If analysis of these changes reveals concerns about specific codes, ASHA will include these concerns in its comments.
Multiple Procedure Payment Reduction
Under the Multiple Procedure Payment Reduction (MPPR) policy, Medicare reduces payment for the second and subsequent therapy, surgical, nuclear medicine, and advanced imaging procedures furnished to the same patient on the same day.
Audiology. No audiology procedures are affected by MPPR. In the 2012 proposed rule, however, CMS asked for comments on possible expansion of the policy to other procedures, including all diagnostic tests. This approach would apply a payment reduction to the technical component of the second and subsequent diagnostic tests provided in the same encounter. In comments, ASHA noted that there is no evidence that audiology diagnostic procedures performed on the same day are overvalued, and provided information on bundled audiology procedures that already include multiple procedure reductions.
The 2013 proposed rule summarizes the 2012 MPPR expansion proposal, but does not propose changes for 2013. CMS indicates that any expansion of MPPR would be presented in future rulemaking and subject to public comment. Nevertheless, ASHA’s comments will reiterate its concerns about applying MPPR to audiology diagnostic services.
Speech-Language Pathology. The eight speech-language pathology procedures included in the 2012 MPPR policy will continue in 2013. The practice expense component of the second and subsequent therapy services furnished to the same patient on the same day will be reduced by 20% for services provided in office/noninstitutional settings and 25% for services provided in institutional settings. (For more information on the MPPR policy, see p. 6 of the 2012 Medicare Fee Schedule for Speech-Language Pathologists [PDF].)
Physician Quality Reporting System
CMS also has proposed changes to the Physician Quality Reporting System (PQRS), a voluntary quality reporting program that began in 2007 as an incentive payment program. PQRS will remain an incentive program through 2014, but will change to a penalty program in 2015. Providers must begin reporting in 2013 to avoid the 1.5% deduction in 2015 (see supplement below).
The rule also proposes to retire 14 PQRS measures, including two audiology measures and one speech-language measure.
  • The two audiology measures proposed for retirement—referral for otologic evaluation for patients with active drainage from the ear and for patients with history of sudden or rapidly progressive hearing loss—are noted as not endorsed by the National Quality Forum (NQF). The other two—referral for otologic evaluation for patients with congenital or traumatic deformity of the ear and for patients with acute or chronic dizziness—are also noted as not endorsed but remain as reportable measures.

  • One speech-language Functional Communication Measure—motor speech—is endorsed by NQF but recommended for retirement without explanation.

ASHA is requesting reconsideration of the retirement of these measures based on the inconsistent application of NQF endorsement.
Speech-Generating Devices
Under current Medicare regulations, a physician ordering a speech-generating device must have a written evaluation signed by a certified SLP. Under the proposed 2013 rule, the physician will need to document and communicate to the device supplier that the physician (or physician assistant, nurse practitioner, or clinical nurse specialist) met with the patient less than 90 days before or within 30 days after writing the order.
Speech-generating devices represent four of the 55 items on a CMS list of durable medical equipment items that that can cost more than $1,000 and/or are susceptible to fraud, waste, or abuse. These four speech-generating devices in the Healthcare Common Procedure Coding System would require the in-person meetings:
  • E2502: Speech-generating device, digitized speech, using pre-recorded messages, 8–20 minutes.

  • E2506: Speech-generating device, digitized speech, using pre-recorded messages, greater than 40 minutes.

  • E2508: Speech-generating device, synthesized speech, required message formulation by speech and access by physical contact with the device.

  • E2510: Speech-generating device, synthesized speech, permitting multiple methods of message formulation and multiple methods of device access.

In compiling the list, CMS cites a 2007 Government Accountability Office report that estimated $700 million in improper payments for durable medical equipment, prosthetics, orthotics, and supplies from April 2005 through March 2006.
ASHA will express concern for the inclusion of speech-generating devices on the CMS list.
Telehealth Services
Although CMS addresses telehealth services in the proposed rule, these services are covered only when provided by disciplines authorized by Congress—physicians and physician extenders, nurse-midwives, clinical psychologists, clinical social workers, and registered dieticians—for specific CMS-approved procedure codes. Congress has not changed this provider list in recent years, and ASHA continues to lobby Congress and CMS to include audiologists and SLPs for the coverage and reimbursement of telehealth under Medicare.
ASHA’s Comments
ASHA has been working closely with CMS officials on legislative mandates and will continue to advocate, analyze the proposed rules, and prepare comments (due Sept. 4) for all issues related to speech-language pathology and audiology services.
Audiologists and SLPs who provide Medicare Part B services should prepare to participate in PQRS in 2013, ensure appropriate documentation, and remain informed by signing up to receive ASHA Headlines announcements. Revising billing systems and updating fee schedules, however, are premature. Final rules for 2013 are expected to be published by November 2012.
ASHA will continue to inform members of fee schedule developments through Headlines,Leader articles, and updates on the ASHA website).
Quality Reporting in 2013 Affects Medicare Payments in 2015

by Lisa Satterfield

Audiologists and speech-language pathologists who don’t participate in the 2013 Physician Quality Reporting System (PQRS) will see the effects of their nonparticipation in their 2015 Medicare reimbursement rates.

According to a proposed 2013 rule, the Centers for Medicare and Medicaid Services (CMS) will deduct 1.5% from all 2015 Part B payments to health care providers who did not report on at least one measure in 2013.

PQRS, designed to support improvements in quality of care by tracking practice patterns, began in 2007 as a voluntary incentive payment program. Providers earn an incentive payment for reporting their patient data; as the program has continued, however, the incentive payment has decreased incrementally to the current 0.5% percent of total claims. PQRS remains an incentive program through 2014, but changes to a deduction program beginning in 2015.

The proposed rule includes two different levels of PQRS participation in 2013 and 2014. The first level is required to qualify for incentive payments in 2013 and 2014; the second level of participation is required to avoid deductions in 2015 and 2016.

  • Audiologists. To receive incentive payments in 2013 and 2014, audiologists must report on 50% of eligible cases reported on claim forms for at least three measures (or for the number of measures available for reporting if fewer than three). To avoid the 1.5% deduction on 2015 and 2016 claims, audiologists must report on the claims forms for at least one measure for audiologists in 2013 and 2014.

  • Speech-language pathologists. To receive incentive payments in 2013 and 2014, SLPs must report 80% of eligible cases reported by a registry for a minimum of three measures. To avoid the 1.5% deduction on 2015 and 2016 claims, SLPs must report by registry for at least one measure in 2013 and 2014.

Clinicians who don’t meet the 2013 requirements for full 2015 payment and who bill services under the Medicare Physician Fee Schedule in 2015 will be paid at 98.5% of the fee schedule amount; those who don’t meet the 2014 benchmarks will be paid 98% the fee schedule amount in 2016.

All eligible providers (those providing services to Part B Medicare beneficiaries for certain conditions, and billing for services under the Medicare Physician Fee Schedule) are subject to this adjustment.

The PQRS reporting process differs for audiologists and SLPs:

  • Audiologist participation is based on claim form submission, which includes a Healthcare Common Procedure Coding System “G” code on the claim form. Audiologists report physician referrals if a patient presents with sudden or rapidly decreased hearing loss, dizziness, ear drainage, or outer ear deformity.

  • SLPs report their measures for adult patients with a diagnosis related to stroke through ASHA’s National Outcomes Measurement System (NOMS), an official PQRS registry. ASHA submits NOMS data on behalf of PQRS-registered participants. SLPs report on functional communication measures including spoken language comprehension, spoken language expression, motor speech, writing, reading, attention, memory, and swallowing.

Clinicians should note that CMS may change the PQRS measures in each year’s Medicare Physician Fee Schedule. The 2013 proposed rule includes changes to measures in audiology and speech-language pathology (see article above).

The ASHA website offers assistance on PQRS participation to audiologists and SLPs.

Lisa Satterfield, MS, CCC-A, director of health care regulatory advocacy, can be reached at lsatterfield@asha.org.

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August 2012
Volume 17, Issue 10