The Worth of Our Work AMA Affirms ASHA to Represent Professions in Valuation Process ASHA News
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ASHA News  |   January 01, 2009
The Worth of Our Work
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Hearing Disorders / Practice Management / Professional Issues & Training / Regulatory, Legislative & Advocacy / ASHA News & Member Stories / ASHA News
ASHA News   |   January 01, 2009
The Worth of Our Work
The ASHA Leader, January 2009, Vol. 14, 1-19. doi:10.1044/leader.AN1.14012009.1
The ASHA Leader, January 2009, Vol. 14, 1-19. doi:10.1044/leader.AN1.14012009.1
The American Medical Association (AMA) reaffirmed ASHA’s lead role in the coding and valuation process for audiology and speech-language pathology services at a meeting on Oct. 2, 2008. The AMA’s decision followed a challenge by the American Academy of Audiology (AAA).
The challenge related to ASHA’s role in representing audiology to the AMA committees that oversee the valuation of medical procedures—particularly the Health Care Professions Advisory Committee (HCPAC). A recent article in AAA’s A-T Extra questions how ASHA can fairly represent both audiology and speech-language pathology on the HCPAC. The article suggests that because speech-language pathologists have gained direct billing privileges under the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA), separate seats should be made available on HCPAC for audiology and speech-language pathology.
Because fair reimbursement rates are so important to both audiologists and SLPs, the following is a thorough explanation of how the coding and valuation system works, and why reimbursement for audiology codes dropped—not because of which organization represents a profession on an AMA committee, but because of a technical change in the reimbursement formula made independently by the Centers for Medicare and Medicaid Services (CMS).
The Coding and Valuation Process
Much of the payment for outpatient audiology and speech-language pathology services is based on a system developed by the federal government for reimbursing Medicare services. Other payers such as Medicaid and private health plans have adopted the system, in which the values of procedures are based on professional expertise, support staff, equipment, supplies, and malpractice insurance costs. The system strives to make payments of all medical procedures relative to one another—the intention is that if one procedure is twice as valuable as another, for example, it will be paid as such.
Since 1992 CMS has paid for services under the annual Medicare Physician Fee Schedule, which includes outpatient speech-language pathology and audiology services, using a resource-based relative value scale (RBRVS). Although medical specialties have the opportunity to provide input, CMS is entirely responsible for assigning the values. Revisions to the value scale occur through the annual CMS rulemaking process and are open for public comment.
CMS revisions to the relative value scale are based upon input from the AMA, which has overseen the coding of medical procedures since it first developed and published the Current Procedural Terminology© (CPT) coding system in 1966. Shortly afterward the AMA established the CPT Editorial Panel, which recommends new and updated codes to CMS.
Valuation
On the valuation side, the AMA established the Relative Value Update Committee (RUC) in 1992 to provide input to CMS on the values assigned to various procedures. The RUC has 26 voting members. Other medical specialties (of which there are some 109) may attend the RUC meetings and present recommendations to the RUC on codes performed by their specialties. The AMA also established the HCPAC, through which 11 nonphysician associations (e.g., audiology, occupational therapy, nursing, physical therapy, podiatry, psychology, and speech-language pathology) participate in the RUC process.
The RUC—and by extension, the HCPAC—was designed to serve as a nonpartisan expert panel and not a committee whose members are allowed to advocate for their specialties. The primary purpose of the RUC and HCPAC members is to provide socioeconomic expertise and knowledge sufficient to render appropriate valuation recommendations for any procedure that comes forward—not just those performed by members of their specialty.
The RUC does not choose an organization based on the number of members (although ASHA continues to represent the largest number of members from each profession), but rather on its ability to represent the constituencies of that and related organizations in a fair and equitable manner, to provide guidance to give “voice” on all coding issues, and to provide expertise. Organizations selected by AMA, including ASHA, are responsible for gathering input from all professional organizations in their area of expertise.
Coding
The CPT Editorial Panel also has a HCPAC. The panel has a chair, vice chair, and 17 members, including two from the CPT HCPAC.
In 1992 the AMA selected ASHA as the representative organization to the HCPACs for the RUC and the CPT Editorial Panel. Not long afterward, ASHA created the Health Care Economics Committee (HCEC) to ensure that audiology codes are developed and presented by audiologists, and speech-language pathology codes are developed and presented by SLPs. The HCEC convenes an annual meeting of interested audiology and speech-language pathology organizations and special interest divisions to discuss reimbursement and coding issues. Each profession reviews its concerns independent of the other.
ASHA nominates a representative to the HCPAC for both CPT Editorial Panel and RUC, and the AMA reviews and approves each nominee. One member of ASHA’s HCEC serves as the advisor to the HCPAC and another member is the alternate representative. The alternate must be from the profession other than that of the advisor. The current advisor is from audiology and the alternate is from speech-language pathology (see sidebar for a list of members and the current advisor and alternate).
Why Valuations Have Dropped
Recently some audiology values have dropped—by double digits in 2009 for some codes (e.g., comprehensive audiometry) with another cut possible next year. The same is true for some speech-language pathology procedures such as the clinical swallowing examination. The AAA’s A-T Extra stated that the reductions are the fault of ASHA, claiming that values are dropping because AAA does not have direct representation on HCPAC and, as such, that audiology does not have a direct voice in the process.
This accusation is not grounded in fact. ASHA has a long record of strong advocacy for equitable valuation of audiology procedures. The basis for the drop in reimbursement has nothing to do with who has the seat, who represents the profession, or who can perform greater advocacy on behalf of audiology.
Instead the reduction is attributable to a technical change by CMS in its reimbursement formula. Here is the background—for most physician services, a fee was based on the value for the professional work, a value for practice expenses (PE), and a value for professional liability insurance (PLI). The value for professional work was based on the relative resources (time and complexity) required to perform the services.
At the inception of the Medicare Physician Fee Schedule, PE and PLI were based on historic reasonable charge levels. Audiology and other nonphysician services were paid under the PE component and were therefore not resource-based. However, the law changed and CMS was directed to base the practice expense values on the actual resources (time, supplies, and equipment used) required to perform the service.
CMS discovered that services without a professional work value, such as audiology and many diagnostic and imaging procedures, would take severe reductions in payment. To avoid this undesirable impact, in 1999 CMS established a special provision known as the nonphysician work pool (NPWP), which insulated audiology and other technical services from large reductions in payment.
This measure was intended to be temporary until a more equitable and permanent solution could be found. This temporary measure actually stayed in effect from 1999 through 2006. It helped the newer speech-language pathology procedure values, such as speech-generating device evaluation, as well. CMS finally decided to eliminate the NPWP and began phasing it out over a four-year period beginning in 2007.
The Professional Work Factor
ASHA recognized that this change would be devastating to audiology and lobbied CMS to have the services of audiologists valued under the professional work component. ASHA’s advocacy was successful—all audiology codes are now eligible for professional work values, including nine codes presented (by HCEC) for revaluation in 2007.
The HCEC did present survey results with higher time and work values than were ultimately recommended by the RUC and assigned by CMS. However, in large part because otolaryngologists have a different perspective regarding these procedures and because they bill for the majority of these services, their data were more consistent with physician reporting of the procedures. We believe the variance in views is in part due to the fact that otolaryngologists consider audiology procedures “tests,” and audiologists consider them “evaluations” that require additional time for a more extensive history and for post-test counseling. We note that otolaryngologists generally also bill a visit code (i.e., evaluation and management) covering the history and physical exam as well as counseling, in addition to the audiology procedure. Medicare rules prohibit audiologists from billing visit codes.
It is important to understand that if professional work had not been assigned to audiology codes, the Medicare payment reductions would have been much greater. All audiology organizations were aware of ASHA advocacy on professional work, and AAA supported the strategy to have the professional expertise of the audiologist reflected in the professional component rather than the technical component of practice expense.
“The Health Care Economics Committee will continue to push for equitable payment for audiology and speech-language pathology services,” said audiologist Robert Fifer, HCEC member and ASHA’s representative to the RUC HCPAC.
“We will bring back codes to the RUC or CMS for reevaluation where feasible, establish new and revised codes when appropriate, and as always, we will give accurate guidance to audiologists and speech-language pathologists on billing for services,” he said.
“Reimbursement is a critical bread-and-butter issue. Too much is at stake to engage in misleading comments that lead audiologists to believe that payment cuts have any connection to representation on an AMA committee,” Fifer said.
Stuart Trembath, who became the HCEC chair on Jan. 1, said the committee will continue to work collaboratively to ensure that the best proposals are brought to the CPT Editorial Panel and the best data are brought to the RUC. The HCEC will continue to work closely with AAA and other organizations interested in coding and reimbursement for audiologists and SLPs.
The AMA RUC and CMS
Fact and Fiction

The coding section of the AMA Web site includes a brief written by William Rich, MD, RUC chair, describing what the RUC—and by extension, its advisory committee, HCPAC—is and is not. The following points are based upon his brief:

Independence
  • The RUC is an independent group exercising its First Amendment right to petition the federal government.

  • The RUC is not an advisory committee to CMS. CMS is entirely responsible for the RBRVS. All modifications to the RBRVS are made through rulemaking and are open to public comment.

Expertise
  • The RUC is an expert panel on which individuals exercise their independent judgment. The RUC relies on socioeconomic expertise and objectivity.

  • The RUC is not a political, representative committee. RUC members are not advocates for their specialty.

Inclusion and Scope of Practice
  • The RUC is inclusive of all health care professionals. Non-MD/DOs (e.g., nursing, podiatry, physical therapy) have an advisory committee and one voting seat on the RUC, and participate on RUC subcommittees.

  • The RUC is not interested or involved in scope of practice issues. The RUC understands its responsibility to be open and fair to all health care professionals who independently bill the Medicare program under the Medicare Physician Fee Schedule. While some very real scope of practice issues exist between specialty societies and health care professional organizations involved in the RUC process, these discussions are not permitted at RUC meetings.

Review and Recommendations
  • The RUC is involved in reviewing direct practice expense inputs and submitting these recommendations to CMS.

  • The RUC is not even able to recalculate the CMS practice expense relative value units, let alone establish them. The RUC submits recommendations on clinical staff (type and time); medical supplies (type and number of units); and medical equipment (type). All other elements of the data and the actual methodology have been developed by CMS. CMS prices the wages, supplies, and equipment. CMS has accepted supplemental over practice expense data directly from specialties. The RUC’s recommendations to improve both the practice expense and professional liability insurance methodology have not yet been adopted.

Fighting for Fair Reimbursement
The Health Care Economics Committee
2008 HCEC Members
  • Nancy Swigert, CCC-SLP, chair and ASHA RUC HCPAC alternate

  • Thomas Rees, CCC-A, vice chair

  • Robert Fifer, CCC-A, ASHA RUC HCPAC advisor

  • R. Wayne Holland, CCC-SLP, ASHA CPT Editorial Panel advisor

  • Becky Sutherland Cornett, CHC

  • Bernard Henri, CCC-SLP

  • Dee Adams Nikjeh, CCC-SLP

  • Neil Shepard, CCC-A

  • Stuart Trembath, CCC-A

  • Robert Woods, CCC-A

  • Steven White, CCC-A, ex officio

2009 HCEC Members
  • Stuart Trembath, CCC-A, chair

  • Dee Adams Nikjeh, CCC-SLP, vice chair and ASHA RUC HCPAC alternate

  • Robert Fifer, CCC-A, ASHA RUC HCPAC advisor

  • R. Wayne Holland, CCC-SLP, ASHA CPT Editorial Panel advisor

  • Gretchen Bebb, CCC-SLP

  • Becky Sutherland Cornett, CHC

  • Bernard Henri, CCC-SLP

  • Richard Hogan, CCC-A

  • Neil Shepard, CCC-A

  • Robert Woods, CCC-A

  • Steven White, CCC-A, ex officio

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January 2009
Volume 14, Issue 1