Medicare Changes Vestibular Codes, ‘Incident To’ Billing The final 2016 outpatient therapy rules keep reimbursement stable, extend the therapy caps and delineate quality reporting measures. Policy Analysis
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Policy Analysis  |   January 01, 2016
Medicare Changes Vestibular Codes, ‘Incident To’ Billing
Author Notes
  • 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×
  • 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×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   January 01, 2016
Medicare Changes Vestibular Codes, ‘Incident To’ Billing
The ASHA Leader, January 2016, Vol. 21, 24-26. doi:10.1044/leader.PA.21012016.24
The ASHA Leader, January 2016, Vol. 21, 24-26. doi:10.1044/leader.PA.21012016.24
Two small—but significant—changes for Medicare audiology and speech-language outpatient treatment will take effect in 2016. The new rules released by the Centers for Medicare and Medicaid Services (CMS) are generally unchanged from 2015, but modifications will affect payment for caloric vestibular evaluation and for services provided by speech-language pathologists in a physician’s office.
Fee schedule rates
Federal legislation signed in April changed the way Medicare calculates provider reimbursement for Medicare Part B (outpatient) services. It repealed the sustainable growth rate (SGR) formula in favor of a payment system based on outcomes and quality. Until that system is fully developed and implemented, however, Medicare fee schedule rates will increase by 0.5 percent annually through 2019 and remain frozen through 2025. Additional payment changes apply after 2025 based on providers’ participation in alternative payment models.
Reimbursement levels will still fluctuate slightly. The value of individual procedures—defined by Current Procedural Terminology (CPT® American Medical Association) codes—may continue to vary due to adjustments the various values included in the fee calculation.
The conversion factor used to calculate reimbursement rates in 2016 is $35.8279, which is slightly lower than the 2015 factor of $35.9335. This change reflects the elimination of the SGR formula.
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 codes for caloric vestibular testing, which were approved and valued through the American Medical Association’s (AMA) code review process. The new codes, effective Jan. 1, 2016, replace CPT code 92543 (Caloric vestibular testing, with recording). They are:
  • 92537, Caloric vestibular test with recording, bilateral; bithermal (one warm and one cool irrigation in each ear for a total of four irrigations).

  • 92538, Caloric vestibular test with recording, bilateral; monothermal (one irrigation in each ear for a total of two irrigations).

Despite the cooperating organizations’ strong objections, the new payment rates do not reflect the full values the organizations and the AMA recommended to CMS. Audiologists need to prepare for an overall decrease in payment for caloric irrigations.
ASHA will continue to work with the other specialty organizations to address the CMS rejection of code values recommended through the AMA’s rigorous valuation process.
Visit ASHA’s website for information on appropriate use of the new codes.
Potentially misvalued audiology codes
CMS must periodically identify, review and adjust potentially misvalued procedure codes in the fee schedule. In its proposed rule published earlier this year, CMS identified 118 potentially misvalued codes, including two audiology codes—92557 (Comprehensive audiometry) and 92567 (Tympanometry)—which would have required re-review of their values.
ASHA and the AMA requested that CMS remove the two codes from the list because they did not meet the CMS criteria. CMS agreed, and has removed the codes from the list, averting a potential decrease in payment rates for the entire family of audiometric and immittance testing codes.

CMS has averted a potential decrease in payment rates for the entire family of audiometric and immittance testing codes.

Physician Quality Reporting System (PQRS)
PQRS applies to audiologists and SLPs in private practices, group practices, and university clinics providing services to Part B Medicare beneficiaries and billing for services under the fee schedule. Providers who do not participate in PQRS for at least 50 percent of eligible patient visits may incur a 2-percent reduction in reimbursement on all claims they submit in 2018.
The following measures apply to audiologists:
  • #261, referral for otologic evaluation for patients with acute or chronic dizziness

  • #134, screening for clinical depression and follow-up plan

  • #154 and #155, risk assessment for falls and plan of care for falls for patients who have fallen twice in two years or once with injury

One measure applies to SLPs only:
  • #131, pain assessment and follow-up.

The following measures apply to SLPs and audiologists:
  • #130, documentation of current medications in the medical record

  • #226, screening and cessation intervention for tobacco use.

Audiologists and SLPs can find technical specifications and instructions for each measure on ASHA’s website.
‘Incident to’ services
“Incident to” services are those generally provided by auxiliary personnel under the direct supervision of a physician and billed under the physician’s National Provider Identifier (NPI).
  • Audiologists are not permitted to bill “incident to” a physician for hearing and balance services and must be enrolled in Medicare.

  • SLPs, though permitted to bill rehabilitation services “incident to,” gain no advantages in doing so and must adhere to physician-supervision rules. The 2016 final rule clarifies that a physician must be onsite for any services an SLP bills “incident to” and that the services must be billed under the NPI of that physician.

SLPs, though permitted to bill rehabilitation services “incident to,” gain no advantages in doing so and must adhere to physician-supervision rules.

Because SLPs can enroll as Medicare providers and transfer the payment of their services to several offices at once, “incident to” is not considered necessary, only convenient.
“Incident to” billing is intended for providers—such as technicians—who render integral, incidental services but who are not eligible for Medicare enrollment.
Additionally, an SLP gains no financial advantage by billing under a physician’s NPI; in fact, if the service is billed “incident to” a nurse practitioner, clinical nurse specialist or physician’s assistant, reimbursement is reduced by 15 percent.
Therapy caps
Limits on the amount of outpatient therapy a Medicare beneficiary can receive remain in effect for 2016. The cap for combined physical therapy and speech-language pathology services will increase from $1,940 to $1,960. Outpatient therapy use is calculated using the Medicare rate for the services, including any deductible or coinsurance paid by the beneficiary.
The current exceptions process—which allows providers to use the “KX” modifier to indicate medical necessity for services that exceed the therapy cap—has been extended until Dec. 31, 2017.
Also extended is the manual medical review process for therapy services provided above a $3,700 threshold. And hospital outpatient departments continue to be included in the therapy cap provisions. Read more information on the exceptions and manual medical review processes.
Hospital Outpatient Audiology Services Score Big Win

A change in the 2016 hospital Outpatient Prospective Payment System (OPPS) will allow audiologists to receive payment for cochlear implant follow-up services.

The OPPS classifies outpatient services as “primary” or “ancillary,” and does not reimburse for ancillary services when they are performed on the same date as a primary service, whether or not the services are related. Under this policy, hearing and cochlear implant services provided by audiologists were largely unpaid in hospital outpatient clinics if the patient was seen in the hospital for another service.

ASHA spearheaded an effort to push for coverage of audiology services in hospital outpatient clinics. ASHA staff met on several occasions with CMS staff, collected and analyzed data, and convened a group of interested stakeholders. As a result, CMS reversed its position on cochlear implant follow-up services. Although this decision did not address the audiometric coding issues, it is a significant victory for hospital-based cochlear implant centers.

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January 2016
Volume 21, Issue 1