2010 Medicare Fees Halted Congress Implements Multiple Procedure Fee Cuts, Likely to Stop 2011 Rates Policy Analysis
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Policy Analysis  |   December 01, 2010
2010 Medicare Fees Halted
Author Notes
  • Kate Romanow, JD, director of health care regulatory advocacy, can be reached at kromanow@asha.org.
    Kate Romanow, JD, director of health care regulatory advocacy, can be reached at kromanow@asha.org.×
  • Ingrida Lusis, director of federal and political advocacy, can be reached at ilusis@asha.org
    Ingrida Lusis, director of federal and political advocacy, can be reached at ilusis@asha.org×
  • Steven C White, PhD, CCC-A, e director of health care economics and advocacy, can be reached at swhite@asha.org.
    Steven C White, PhD, CCC-A, e director of health care economics and advocacy, can be reached at swhite@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
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   December 01, 2010
2010 Medicare Fees Halted
The ASHA Leader, December 2010, Vol. 15, 1-29. doi:10.1044/leader.PA1.15152010.1
The ASHA Leader, December 2010, Vol. 15, 1-29. doi:10.1044/leader.PA1.15152010.1
The “Physician Payment and Therapy Relief Act of 2010,” passed by Congress in November, provides a halt through the end of 2010 to the 23% reduction in Medicare reimbursement levels scheduled to take effect Dec. 1. To offset the cost of that legislation, however, lawmakers instituted a multiple procedure payment reduction (MPPR) policy similar to that announced in the 2011 Medicare Physician Fee Schedule (MPFS).
The 2011 MPFS also includes a 30% cut in current reimbursement rates. However, most Medicare observers expect Congress to enact legislation to prevent implementation of this dramatic cut; Senate Finance Chair Max Baucus (D-Mont.) and ranking member Charles Grassley (R-Iowa) have pledged to work together during the lame-duck session to develop a year-long Medicare package that would include the fee schedule and extension of the therapy cap exceptions process.
MPPR reduces payment for second and subsequent speech-language pathology, occupational therapy, or physical therapy procedures furnished to the same patient on the same day. The 2011 MPFS final rule issued by the Centers for Medicare and Medicaid Services (CMS) calls for a 25% reduction in the practice expense reimbursement for certain procedures. The November legislation changes that figure to 20%. This legislative maneuvering turned the projected regulatory savings into a legislative cost offset for extending the current Medicare fee schedule rates. Although the legislative action reduces the impact of the MPPR, it codifies the CMS regulations into law.
The 2011 MPFS rate reductions are the result of the application of a statutory formula known as the Sustainable Growth Rate (SGR). When the SGR has been applied in recent years, however, Congress has consistently acted to postpone or reduce the proposed decreases. The implementation of the SGR for 2011 creates considerable concern for all Medicare providers; ASHA and other organizations will work with Congress to alleviate the drastic cut.
2011 Reimbursement Rates
The fee schedule includes reimbursement rates for procedures described in Common Procedural Terminology (CPT,© American Medical Association). Because Congress is likely to enact legislation to prevent implementation of the 30% cut, the examples in Table 1 [PDF] illustrate the fees as proposed as well as estimated probable rates. The estimated rates are based on the assumption that Congress will prevent the SGR cuts and instead apply the Medicare Economic Index—an 8.2% rebasing of physician expenses—and a 0.45% budget-neutral adjustment. The examples in Table 1 [PDF] also reflect:
  • An increase in the professional work relative value units (RVUs) for certain procedures, including CPT 92507 and 92607. The increases are the result of recommendations from the American Medical Association’s (AMA) Specialty Society RVS Update Committee; the recommendations are based on new work RVUs supported by ASHA survey data.

  • A decrease in practice expense RVUs based on a five-year transitional formula affecting all Medicare procedures.

Multiple Procedure Policy
Under MPPR, full payment will be made for the therapy service or unit with the highest practice expense value (MPFS reimbursement rates are based on professional work, practice expense, and malpractice components), and payment reductions will apply to any other additional speech-language treatment, physical therapy, or occupational therapy procedures performed on the same day. The rule calls for a 25% reduction in the practice expense (i.e., support personnel time, supplies, equipment, and indirect costs) for each additional procedure provided on the same day beginning Jan. 1, 2011. (The November legislation, however, changes the date to Dec. 1, 2010, and the reduction to 20%.) The professional work and malpractice expense components of the payment are unaffected.
MPPR will primarily affect physical therapists and occupational therapists because these professions commonly bill timed procedures more than once per visit and/or multiple procedures on the same day. The policy, however, applies across disciplines and settings, and MPPR applies to eight speech-language procedures.
For example, if a speech-language pathologist and a physical therapist provide treatment to a single patient on the same day, the MPPR will apply to all therapy codes billed that day. If a single speech-language service is provided with other therapy, that service will usually be paid in full because of the higher practice expense values of speech-language procedures over physical and occupational therapy procedures. This sidebar [PDF] describes the effects of MPPR in two different scenarios.
Eight speech-language pathology procedures are included in MPPR:
  • 92506 (Evaluation of speech, language, voice, communication, and/or auditory processing)

  • 92507 (Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual)

  • 92508 (Group treatment, two or more individuals)

  • 92526 (Treatment of swallowing dysfunction and/or oral function for feeding)

  • 92597 (Evaluation for use and/or fitting of the voice prosthetic device to supplement oral speech)

  • 92607 (Evaluation for the prescription of speech-generating device, first hour)

  • 92609 (Therapeutic services for use of speech-generating device, including programming and modification)

  • 96125 (Standardized cognitive performance testing [e.g., Ross Information Processing Assessment] per hour)

Tracking Practice Patterns—PQRI
The voluntary Physician Quality Reporting Initiative (PQRI)—to be known as the Physician Quality Reporting System beginning in 2011—tracks practice patterns in an effort to improve the quality of care to Medicare beneficiaries. Medicare-enrolled providers report on approved quality measures and are eligible for an incentive payment at the end of the year. CMS will continue the current speech-language pathology and audiology PQRI measures through 2011.
In 2010, the incentive payment for satisfactorily reporting on measures is 2% of all allowable Medicare charges for that reporting period. The 2011 final rule affirms the incentive payment structure outlined in the Affordable Care Act: 1% in 2011 and 0.5% in 2012–2014. Beginning in 2015, eligible professionals who do not satisfactorily report on quality measures will be subject to a payment adjustment.
Under current rules, providers participating in PQRI must report on 80% of patients who fit into a measure. In 2011, providers reporting on audiology measures will need to report on only 50% of patients who fit into a measure. Providers reporting on speech-language pathology measures will still need to report on 80% of patients who fit into a measure. Further information on participation in PQRI is available at ASHA’s Physician Quality Reporting Initiative Measures webpage and at its National Outcomes Measurement System (NOMS) webpage.
Therapy Cap Alternatives
Therapy caps (limits on the amount of occupational therapy, physical therapy, and speech-language services an individual Medicare beneficiary may receive annually) have been in effect since 1997. In 2006—and every year since then—Congress authorized an exceptions process to allow beneficiaries to receive medically necessary services that meet specified criteria beyond the cap (in 2011, the cap is $1,870 for combined speech-language treatment and physical therapy and $1,870 for occupational therapy). Without congressional action, the current exceptions process will expire on Dec. 31, 2010.
CMS is attempting to develop an alternative to the therapy caps, and ASHA has been working with CMS contractors for two years on research projects to develop three proposals: modify the current exceptions process by capturing additional patient information about severity and complexity; develop edits regarding medical necessity; or create per-session bundled payments.
None of the proposed alternatives is sufficiently developed to warrant immediate implementation. However, CMS stated that the first option (severity and complexity) “may have the greatest potential for rapid implementation that could yield useful information in the short term.” CMS acknowledged that any option would require further study before implementation, which would require congressional action.
ASHA will continue to monitor actions by CMS and Congress and to advocate for equitable reimbursement for providers and greater access to services for Medicare beneficiaries. For up-to-date information, visit The ASHA Leader online.
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December 2010
Volume 15, Issue 15