Medicare Payments Stabilize in 2016 Proposed Fee Schedule Proposal addresses fees, quality reporting and values for some audiology codes. Bottom Line
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Bottom Line  |   September 01, 2015
Medicare Payments Stabilize in 2016 Proposed Fee Schedule
Author Notes
  • Neela Swanson is director of ASHA health care coding policy. nswanson@asha.org
    Neela Swanson is director of ASHA health care coding policy. nswanson@asha.org×
  • Lisa Satterfield, MS, CCC-A, is director of ASHA health care regulatory advocacy. lsatterfield@asha.org
    Lisa Satterfield, MS, CCC-A, is director of ASHA health care regulatory advocacy. lsatterfield@asha.org×
Article Information
Hearing Disorders / Practice Management / Regulatory, Legislative & Advocacy / Bottom Line
Bottom Line   |   September 01, 2015
Medicare Payments Stabilize in 2016 Proposed Fee Schedule
The ASHA Leader, September 2015, Vol. 20, 30-31. doi:10.1044/leader.BML.20092015.30
The ASHA Leader, September 2015, Vol. 20, 30-31. doi:10.1044/leader.BML.20092015.30
Audiologists and speech-language pathologists will see few changes in fees and other reimbursement-related issues in 2016 under the Centers for Medicare and Medicaid Services (CMS) proposed rules for outpatient services (Part B).
The 2016 rule is the first released since Congress passed the Medicare Access and Children’s Health Insurance Program Reauthorization Act of 2015 (MACRA) in April. The legislation changes the formula for establishing reimbursement rates, establishes the Merit-Based Incentive Payment System, and stabilizes the overall fee schedule rates. It also increases payment adjustments—positive and negative—based on the quality of services clinicians provide and their participation in alternative payment models.
Fee changes
When MACRA repealed the formula used to calculate fees, it also legislated an annual 0.5 percent payment update to the fee schedule, which will occur annually through 2019. This plan is designed to ensure relative fee stability as CMS implements alternative payment models and quality reporting programs. Fees from 2020 to 2025 will be frozen. After 2025, provider payment adjustments will be based on their participation in alternative payment models such as bundled payments and quality reporting.
The 0.5 percent update is applied to the conversion factor—a dollar amount that, combined with the “value” of the procedure code, determines the reimbursement for the procedure. CMS estimates that the conversion factor for 2016 will be $36.1096—a 0.5 percent increase over the 2015 factor.
Reimbursement for some codes may change by a different amount if the “value” of a code changes because of adjustments in malpractice and practice costs.
CMS predicts an overall 0 percent impact on reimbursement for audiology and speech-language pathology codes. ASHA’s analysis corroborates this assessment, revealing only small positive or negative rate adjustments for individual codes, indicating increased stability in audiology and speech-language pathology payment rates. No payment adjustments are final, however, until published in the final rule in November.
Potentially misvalued codes
CMS periodically identifies, reviews and adjusts potentially misvalued procedure codes in the fee schedule. For 2016, CMS identified 118 potentially misvalued codes, including two audiology codes—92557 (comprehensive audiometry) and 92567 (tympanometry). ASHA will work with other specialty societies and the American Medical Association’s Relative Value Update Committee to review the codes and recommend values to CMS.

ASHA’s analysis of the 2016 rule reveals only small positive or negative rate adjustments for individual codes, indicating increased stability in audiology and speech-language pathology payment rates.

New caloric vestibular testing codes
ASHA collaborated with the American Academy of Audiology, the American Academy of Otolaryngology-Head & Neck Surgery and the American Academy of Neurology to develop two new procedure codes that will replace the single code for caloric vestibular testing. The codes, approved and valued through the American Medical Association’s Current Procedural Terminology (CPT) Editorial Panel and Relative Value Update Committee, replace CPT 92543 as of Jan. 1, 2016.
The new codes represent binaural, bithermal testing and binaural, monothermal testing, both with recording.
Despite the recommendations of the Relative Value Update Committee, CMS assigned overall values to the new codes that are lower than that of the current code, resulting in lower reimbursement. ASHA will work with other stakeholders to address the CMS trend of rejecting values recommended through the American Medical Association’s rigorous valuation process.
Quality reporting programs
The three current quality reporting programs—Physician Quality Reporting System (PQRS), electronic health records meaningful use requirements, and the value-based payment modifier—remain in effect until 2019, when MACRA replaces them with a Merit-Based Incentive Payment System.
The current programs impose reimbursement penalties on providers who fail to participate at specified levels. Because the penalties are based on providers’ participation two years prior, the 2016 proposed rule dictates participation requirements that will affect reimbursement in the last year (2018) of these programs.
PQRS. CMS proposes to maintain the same requirements as 2015: Audiologists and SLPs in private practice, group practice and university clinic settings must report all applicable measures for at least 50 percent of qualifying Medicare Part B patient visits. CMS will apply a 2 percent penalty to 2018 claims of clinicians who fail to meet that requirement in 2016.
Value-based modifier. Because of the MACRA change, CMS eliminated the 2016 scheduled application of the value-based payment modifier to audiologists and SLPs. This program would have further penalized clinicians for failing to participate in PQRS at the specific levels. As a result, penalties for audiologists and SLPs will not exceed 2 percent.
As these programs are being converted to the MIPS, audiologists and SLPs need to prepare for additional quality and outcome measure requirements, and the substantial effect they will have on Medicare payment. ASHA is developing a qualified clinical data registry that will meet Medicare payment requirements and create a reliable process for reporting with minimal burden on clinicians.
‘Incident to’ billing
“Incident to” physician services refers to billing a procedure under a physician’s National Provider Identifier (NPI) when a different provider has performed the service under the physician’s direct supervision.
Audiologists may not bill hearing and balance services “incident to” a physician under Medicare; the audiologist must be enrolled as a provider and his or her NPI must be on the claim as the “rendering provider” of the service.
CMS and the federal Office of the Inspector General have recently focused on “incident to” billing, which SLPs may bill. The proposed rule reiterates that CMS can deny or recover funds paid “incident to” that do not comply with the following regulations:
  • Services are furnished in a non-institutional setting to outpatients.

  • The service is integral to the physician service.

  • The service is provided under the direct supervision of the physician.

  • The provider must meet state licensure requirements.

CMS is proposing additional oversight to ensure compliance, and suggests changes to provider enrollment, additional modifiers on the claims for reimbursement, or an increase in post-payment audits.
For now, SLPs may bill any speech-language services “incident to” a physician. SLPs should confirm that services they provide “incident to” meet the requirements above.
Therapy caps and manual medical review
MACRA extended through 2017 the process by which Medicare beneficiaries may receive therapy services that exceed a monetary “cap.” Under the proposed 2016 rules, claims beyond the cap ($3,700) continue to require functional outcome reporting (G-codes) and manual medical review.
However, CMS is revising the claims review process to target individual and group providers who have aberrant billing patterns and high claim denial rates. ASHA will keep members updated as information becomes available.
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September 2015
Volume 20, Issue 9