Medicare Proposes Fee Cuts—Again The proposed rule for the 2011 Medicare Physician Fee Schedule (MPFS) suggests an overall fee reduction and includes several substantive first-time issues that will affect speech-language pathologists and audiologists. The Centers for Medicare and Medicaid Services (CMS) requested comments on the 1,200-page rule, which was released in June. ASHA has ... Policy Analysis
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Policy Analysis  |   August 01, 2010
Medicare Proposes Fee Cuts—Again
Author Notes
  • 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.×
  • Kate Romanow, director of health care regulatory advocacy, can be reached at kromanow@asha.org.
    Kate Romanow, director of health care regulatory advocacy, can be reached at kromanow@asha.org.×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   August 01, 2010
Medicare Proposes Fee Cuts—Again
The ASHA Leader, August 2010, Vol. 15, 1-8. doi:10.1044/leader.PA1.15102010.1
The ASHA Leader, August 2010, Vol. 15, 1-8. doi:10.1044/leader.PA1.15102010.1
The proposed rule for the 2011 Medicare Physician Fee Schedule (MPFS) suggests an overall fee reduction and includes several substantive first-time issues that will affect speech-language pathologists and audiologists. The Centers for Medicare and Medicaid Services (CMS) requested comments on the 1,200-page rule, which was released in June. ASHA has analyzed the rule and submitted a response in compliance with the Aug. 24 comment deadline.
ASHA’s comments focused on key issues: reimbursement levels, the Physician Quality Reporting Initiative (PQRI), timing of claim submissions, the multiple procedure payment reduction (MPPR) policy, canalith repositioning codes, and alternatives to the therapy cap.
Reimbursement
The 2011 rule proposes a 6.1% fee reduction from the 2010 fee schedule, which included a 21.2% reduction from 2009 levels. Congress, however, has delayed implementation of the 2010 schedule three times, with the current postponement set to expire Dec. 1, and has temporarily boosted the 2009 rates by 2.2%.
The proposed 2011 reduction would be devastating to ASHA members who participate as Medicare providers. Most of the cut is based on the sustainable growth rate (SGR) formula used to set fees, implemented by law in 1997. However, Congress is expected to act once again to prevent implementation of the proposed reductions.
PQRI
The Physician Quality Reporting Initiative (PQRI) is a voluntary CMS program that tracks practice patterns in an effort to improve the quality of care to Medicare beneficiaries. Medicare-enrolled health care providers who participate in PQRI report on approved quality measures and are eligible for an incentive payment at the end of the year.
CMS proposes to continue the current audiology and speech-language pathology PQRI measures through 2011. (For further information on the audiology measures and reporting, see ASHA’s information on PQRI; for further information on the speech-language pathology measures and reporting, see ASHA’s information on research and NOMS).
The current incentive payment for satisfactorily reporting on measures is 2% of all allowable Medicare charges for that reporting period; the proposed rule sets an incentive payment of 1% for 2011 and 0.5% for 2012–2014. Beginning in 2015, eligible providers who do not report on quality measures satisfactorily will be subject to a penalty; this penalty will be a reduction in payments of 1.5% in 2015 and 2% in 2016 and subsequent years.
Providers participating in PQRI this year must report on 80% of patients for whom a measure would apply. In the proposed rule, providers would need to report on 50% of the cases in which a measure applies. This change should make it easier for SLPs and audiologists to report PQRI measures satisfactorily.
Claim Submission
In order to implement changes mandated by the new health care reform law, CMS will require providers to submit Medicare claims within 12 months for services furnished on or after Jan. 1, 2010. Claims for services provided in the last three months of 2009 must be submitted by Dec. 31, 2010. Previously, SLPs and audiologists could submit claims on or before Dec. 31 of the calendar year following the year in which the services were furnished.
Canalith Repositioning
A Current Procedural Terminology (CPT, ©American Medical Association) code for canalith repositioning (95992) was added in 2009, but CMS has refused to cover the new code, requiring physicians to include it as part of an evaluation and management code and physical therapists to report CPT 97112 (Neuromuscular reeducation). Audiologists may not bill Medicare for CPT 95992 because it is a treatment service rather than a diagnostic service. The proposed rule now directs physicians and therapists to use CPT 95992 instead of CPT 97112.
Multiple Procedure Payment Reduction Policy
The MPPR policy, which reduces payment for multiple procedures performed on the same patient on the same day, is now in effect for surgical and nuclear medicine diagnostic procedures. The concept of applying MPPR to therapy services—especially timed therapy services—was first discussed in detail in 2009 in a Government Accountability Office (GAO) report [PDF].
CMS proposes to follow GAO’s recommendation and expand MPPR to therapy services in the 2011 rule. Under the policy, CMS would fully reimburse the therapy unit with the highest practice expense value (MPFS reimbursement rates are based on practice expense, professional work, and malpractice components). For additional procedures on the same day, the practice expense (i.e., support personnel time, supplies, equipment, and indirect costs) of each fee would be reduced by 50%. The professional work and malpractice expense components of the payment would not be affected.
Under the 2011 rule, the MPPR would be a per-day policy that would apply across disciplines and across settings. For example, if an SLP and a physical therapist both provided treatment to the same patient on the same day, the MPPR would apply to all codes billed that day, regardless of provider.
Codes Affected by MPPR
Nine speech-language pathology procedure codes would be affected by 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 AAC device, first hour)

  • 92608 (Evaluation [92607], each additional 30 minutes)

  • 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)

ASHA and other professional organizations have requested CMS to provide the data it used to determine the 50% reduction in practice expense values for subsequent therapy services. ASHA plans to contest the MPPR proposal based on CMs’ lack of full disclosure of how the reduction was calculated, the unreasonableness of applying the policy across disciplines, and the impact of the policy on patients and providers (e.g., staffing reductions created by reduced revenue).
Therapy Cap Alternatives
In 2006 Congress passed legislation implementing caps on the amount of therapy services an individual Medicare beneficiary may receive in a year, but also authorized CMS to create an exceptions process to permit medically necessary services above cap levels that meet specified criteria. Every year, Congress has enacted the exceptions process, which allows patients to exceed the $1,860 cap for combined speech-language pathology and physical therapy and the $1,860 cap for occupational therapy. The current exceptions authorization expires Dec. 31.
ASHA has been working with CMS contractors on research projects for two years to develop alternatives to the therapy cap, and developed three specific proposals. CMS is requesting comments on the three proposals as well as any other additional suggestions.
The three alternatives include:
  1. Reporting codes based on the concepts of the World Health Organization’s International Classification of Functioning, Disability and Health.

  2. Development of code edits regarding medical necessity.

  3. Creation of per-session codes that reflect the relative severity and complexity of the services being delivered.

Until an alternative is enacted, Congress has indicated that the exceptions process will be authorized for yet another year.
In planning its comments to CMS, ASHA consulted with several member groups, including the Health Care Economics Committee, State Medicare Administrative Contractor Network, and Member Advisory Group on Health Care Reform. Background and rationales for the CMS proposals are in the June 25 Federal Register (57.1MB) pp. 40096–40100.
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August 2010
Volume 15, Issue 10