Painful Changes in 2012 Medicare Fee Schedule Medicare reimbursement rates will fall by 27.4% beginning Jan. 1, unless Congress takes expected action to override the statutory formula used to compute fees. The final rule for the 2012 Medicare Physician Fee Schedule (MPFS), issued Nov. 1 by the Centers for Medicare and Medicaid Services (CMS), includes a conversion ... Bottom Line
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Bottom Line  |   November 01, 2011
Painful Changes in 2012 Medicare Fee Schedule
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.×
Article Information
Hearing Disorders / Practice Management / Bottom Line
Bottom Line   |   November 01, 2011
Painful Changes in 2012 Medicare Fee Schedule
The ASHA Leader, November 2011, Vol. 16, 8-9. doi:10.1044/leader.BML3.16152011.8
The ASHA Leader, November 2011, Vol. 16, 8-9. doi:10.1044/leader.BML3.16152011.8
Medicare reimbursement rates will fall by 27.4% beginning Jan. 1, unless Congress takes expected action to override the statutory formula used to compute fees.
The final rule for the 2012 Medicare Physician Fee Schedule (MPFS), issued Nov. 1 by the Centers for Medicare and Medicaid Services (CMS), includes a conversion factor—used to compute reimbursement rates—of $24.6712, a value almost 30% less than the current $33.9764. Although this reduction is mandatory because of a statutory formula known as the Sustainable Growth Rate (SGR), Congress will most likely enact legislation to prevent this reduction, as it has almost every year since the SGR was implemented.
For updated information, including ASHA’s complete analysis of the 2012 schedule with specific fees, go to ASHA’s Medicare fee schedule webpage.
Audiology Issues
Otoacoustic Emissions Codes
The 2012 schedule includes a new CPT (Current Procedural Terminology © American Medical Association) screening code, 92588, for evoked otoacoustic emissions (OAE) with automated analysis, and revisions to two OAE evaluation codes.
The screening code includes qualitative measurement of distortion product or transient evoked OAE. As a screening procedure, there are no relative value units (RVUs; the three components—physician work, practice expense, and malpractice expense—of patient care) assigned and the service will not be reimbursed by Medicare.
CPT 92587 is now termed a distortion product evoked OAE. The descriptor has been revised but remains a limited evaluation and now requires an interpretation and report. CPT 92588 remains a comprehensive evoked OAE but has been revised to require a minimum of 12 frequencies.
ASHA and other audiology organizations surveyed typical work time and other work factors associated with OAE evaluation. Using those survey results, the American Medical Association (AMA) advisory committee responsible for setting RVUs recommended 0.45 work RVUs for 92587 and 0.60 work RVUs for 92588. CMS, however, assigned 0.35 work RVUs for 92587 and 0.55 work RVUs for 92588 because of its interpretation of the amount of work involved in the procedures.
Non-Facility Rate Settings
In general, Medicare reimbursement for services in a private office is higher than that in skilled nursing and other facilities because the provider has overhead and equipment costs. An audiologist receives a lower rate for services provided in a facility because the facility incurs the overhead and equipment costs. However, the Medicare statute permits therapy services (speech-language, occupational, and physical) to be reimbursed at non-facility rates in all settings. ASHA asked CMS for clarification regarding audiology services; CMS responded succinctly that the exception does not apply to audiology services, and that the facility rate applies to all facility settings.
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. No audiology procedures are affected by MPPR. However, in the proposed 2012 MPFS regulation, CMS asked for comments on possible MPPR extensions, including the technical component of all diagnostic tests other than advanced imaging services. ASHA submitted comments on the number of bundled audiology CPT procedures that already include multiple procedure reductions. CMS noted that it is not expanding MPPR but “will take the comments into consideration as we develop future proposals.”
Physician Quality Reporting System
CMS will continue the current audiology measures under the Physician Quality Reporting System (PQRS) and is adding a fourth measure for 2012, referral for patients with acute or chronic dizziness. ASHA participated in the PQRS Measures Owners group in the development of the new measure. Other audiology measures are referral for otologic evaluation for patients with congenital or traumatic deformity of the ear; history of active drainage from the ear within the previous 90 days; and history of sudden or rapidly progressive hearing loss.
Providers reporting on claims-based measures must report on 50% of patients that fit into a measure. For 2012–2014, the incentive payment for satisfactorily reporting on measures is 0.5% of all allowable Medicare charges for that reporting period. Beginning in 2015, eligible professionals who fail to satisfactorily report on quality measures will be subject to a payment reduction of 1.5%. See ASHA’s audiology PQRS webpage for more information.
Speech-Language Pathology Issues
Therapy Caps
The current exceptions process for the therapy caps ($1,870 per beneficiary in each of two categories, occupational therapy services and combined speech-language and physical therapy services) will expire on Dec. 31, absent Congressional action. Congress is not expected to allow the caps to take effect in 2012 without a modification—another extension of the exceptions process or broader changes.
Under the final regulation, however, CMS has announced a therapy cap increase to $1,880. ASHA has been working with CMS-contracted research projects to develop alternatives to the cap over the past three years. Check ASHA’s Medicare fee schedule webpage for updates.
Reduction of Practice/Overhead Values
In 2012, CMS will carry out the third of a four-year transition in the reduction of practice expense (PE) RVUs resulting from updated practice cost surveys. Compounding the reductions is the phase-out of duplicative practice expense for procedures that were assigned professional work values in recent years. CPT 92506 shows a negligible reduction—it has never been reviewed for professional work and retains original physician work and speech-language pathology clinical staff time as PE.
Developmental Testing
The official descriptor of CPT 96110 has been revised from “Developmental testing; limited” to a screening procedure (testing examples in the code descriptor always have been screens). Based on the revision, Medicare is no longer covering the service. A similar code now in the Healthcare Common Procedure Coding System Level II (used to identify products, supplies, and services not included in the CPT coding system), G0451, “Developmental testing, with interpretation and report, per standardized instrument form,” also is not covered by Medicare.
Group Treatment
ASHA submitted survey data on group treatment work values to CMS and a CMS Medicare refinement panel on CPT codes. The ASHA data demonstrated that typical group size is three for CPT 92508 (treatment of speech, language, voice, communication, and/or auditory processing disorder group, two or more individuals). The refinement panel agreed with ASHA and the AMA and recommended a work value of 0.43. CMS, however, has maintained the current RVU of 0.33 and specified a group size of four members, using only anecdotal support for its position.
PQRS
CMS will continue the eight PQRS speech-language pathology measures related to stroke that are reported using National Outcomes Measures (NOMs) functional communication measures. Reporting is voluntary from 2010 to 2015. Participants must report on at least 80% of patients that fit into a measure. For 2012–2014, the incentive payment for satisfactorily reporting on measures is 0.5% of all allowable Medicare charges for that reporting period; beginning in 2015, eligible professionals who fail to satisfactorily report on quality measures will be subject to a payment reduction of 1.5%.
Endoscopic Procedure Supervision
Effective Oct. 1, 2011, the physician supervision level in the MPFS database was changed for speech-language pathologists performing videostroboscopy (CPT 31579) and nasopharyngoscopy (CPT 92511). The previous level of personal supervision (effective Jan. 1, 2011) was rescinded and not replaced. The supervision level can be restricted by state regulations or Medicare local coverage determinations (search “videostroboscopy faqs” at ASHA’s website).
MPPR
The eight speech-language procedures included in the 2011 Multiple Procedure Payment Reduction policy continue in 2012.
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November 2011
Volume 16, Issue 15