Medicare Rates, Code Values Change Two Medicare rules that take effect Jan. 1 affect reimbursement rates for audiologists and speech-language pathologists in outpatient settings and audiologists in hospital outpatient departments. Rules under the Medicare Physician Fee Schedule (MPFS) apply to audiology and speech-language services provided in nonhospital outpatient settings. Rates. Outpatient reimbursement is calculated ... News in Brief
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News in Brief  |   January 01, 2017
Medicare Rates, Code Values Change
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Healthcare Settings / Practice Management / News in Brief
News in Brief   |   January 01, 2017
Medicare Rates, Code Values Change
The ASHA Leader, January 2017, Vol. 22, 10-11. doi:10.1044/leader.NIB1.22012017.10
The ASHA Leader, January 2017, Vol. 22, 10-11. doi:10.1044/leader.NIB1.22012017.10
Two Medicare rules that take effect Jan. 1 affect reimbursement rates for audiologists and speech-language pathologists in outpatient settings and audiologists in hospital outpatient departments.
Medicare Physician Fee Schedule
Rules under the Medicare Physician Fee Schedule (MPFS) apply to audiology and speech-language services provided in nonhospital outpatient settings.
Rates. Outpatient reimbursement is calculated using an annually revised conversion factor (CF). The 2017 CF of $35.8887—a slight increase from the 2016 CF of $35.8279—reflects the 0.5 percent mandated payment update under federal law. Audiologists and SLPs will experience only minor shifts in payment rates for 2017.
Diagnostic laryngoscopy codes. Although SLPs will see overall stability in payment rates, two diagnostic laryngoscopy procedures have been revalued. Despite ASHA’s opposition to the changes, the Centers for Medicare and Mediciaid Services (CMS) has lowered the value of two Current Procedural Terminology (CPT) codes:
  • 31575, Laryngoscopy, flexible fiberoptic; diagnostic (3-percent decrease).

  • 31579, Laryngoscopy, flexible or rigid fiberoptic, with stroboscopy (18-percent decrease).

Medicare Advantage enrollment. All Medicare Advantage (MA) providers must enroll in Medicare and maintain an approved status beginning in 2019. Providers in all types of MA plans, as well as “incident to” providers who bill under a physician, are included in this requirement. Out-of-network providers are not required to enroll in Medicare at this time.
“Incident to” services. Although the final rule does not directly address services delivered by an SLP but billed under the physician’s National Provider Identification number (known as “incident to” billing), CMS continues to stress that services can be billed incident to a physician only when the appropriate level of supervision is provided by the physician. For most outpatient speech-language services billed “incident to,” the physician listed on the claim as the rendering provider must be available in the office suite—but not necessarily in the same room as the SLP—when services are provided. (ASHA encourages SLPs to enroll in and independently bill Medicare).
CMS has indicated it will carefully scrutinize “incident to” billing claims. Audiologists may not bill their services “incident to”a physician.
Hospital Outpatient Prospective Payment System
The Hospital Outpatient Prospective Payment System (HOPPS) applies to outpatient hospital audiology services.
Basic vestibular evaluation. As part of the revision to APCs, and despite opposition from ASHA and other stakeholders, CMS has reclassified CPT 92540 (basic vestibular evaluation), reducing payment by more than 40 percent when performed in an outpatient hospital setting.
Site-neutral payment. Services provided in certain off-campus provider-based departments—not in the same building or complex but still considered part of the hospital and therefore required to meet hospital participation and payment conditions—are now paid under a new fee-schedule rate. This change affects audiologists working in certain hospital-connected, off-campus physicians’ offices. Under the new fee schedule, which is generally 50 percent of the HOPPS rate for most items or services, the physician will be paid the facility fee component of the schedule rate for the professional component of their services, and the hospital will be paid the associated technical component. Off-campus departments may be exempte if they began billing for services prior to Nov. 2, 2015, and have continued to bill from the same address since that date.
Both rules
The therapy cap rules apply to both fee schedules. The 2017 therapy cap for combined speech-language pathology services and physical therapy services is $1,980. The exceptions process—and the manual medical review process for services that exceed a $3,700 threshold—remain to allow for medically necessary services beyond the cap. CMS intends to conduct targeted reviews above the threshold based on factors such as a high claims-denial rate or billing practices that differ substantially from those of similar providers.
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January 2017
Volume 22, Issue 1