Policy Analysis: Audiologists-Heed New Medicare Quality Measures and Codes In 2014, billing for audiology includes new diagnosis codes, new quality measures and some fact-finding on procedures. Policy Analysis
Policy Analysis  |   March 01, 2014
Policy Analysis: Audiologists-Heed New Medicare Quality Measures and Codes
Author Notes
  • Lisa Satterfield, MS, CCC-A, is ASHA director of health care regulatory advocacy. ■lsatterfield@asha.org
    Lisa Satterfield, MS, CCC-A, is ASHA director of health care regulatory advocacy. ■lsatterfield@asha.org×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   March 01, 2014
Policy Analysis: Audiologists-Heed New Medicare Quality Measures and Codes
The ASHA Leader, March 2014, Vol. 19, online only. doi:10.1044/leader.PA.19032014.np
The ASHA Leader, March 2014, Vol. 19, online only. doi:10.1044/leader.PA.19032014.np
If you’re an audiologist sending out bills in 2014, you will notice two major changes: greater emphasis on Medicare quality reporting already in place and a complete overhaul of billing codes later in the year.
Quality reporting and other changes are the result of the Patient Protection and Affordable Care Act. New ACA provisions continue to roll out, and although many major changes receive full media attention—health care exchanges, for example—the audiology-specific modifications receive little notice.
From legislation to rule
Establishing rules to carry out federal Medicare legislation is the responsibility of the Centers for Medicare and Medicaid Services, which does so on a regular, annual cycle. Most regulations that affect audiologists begin with Congress passing a new law; CMS interprets the law and develops Medicare rules to implement the law. For example, the Tax Relief and Health Care Act of 2006 introduced the Physician Quality Reporting Initiative, now known as the Physician Quality Reporting System; the change to a new system of diagnosis codes is the result of the Health Insurance Portability and Accountability Act of 1996.
CMS staff spend the spring months analyzing laws scheduled to go into effect the following year. Every July, CMS releases the proposed Medicare Physician Fee Schedule rules and allows 60 days for public comments on the rules through regulations.gov. This set of rules includes proposed reimbursement rates and coding changes and all rules and regulations that apply to outpatient, fee-for-service providers, including audiologists. CMS considers all the comments and in November, publishes the final rule, which includes reimbursement rates, rules and regulations to be implemented Jan. 1 of the upcoming year.
Quality reporting
Under the Physician Quality Reporting System, CMS collects data from Medicare providers to help track quality. Congress initially legislated the system as an incentive-based program, offering a bonus payment to participants. The ACA, however, changed the program from incentive for participation to penalty for non-participation beginning in 2015. Under rules that CMS developed to carry out the law, the penalty in 2015 and subsequent years is based on participation in earlier years. Penalties in 2015, for example, are based on 2013 participation. This system gives CMS adequate time to process and analyze data. Congress is debating proposed Medicare payment reform bills that would keep PQRS through 2018 and call for a payment scale based on quality and outcome reporting for future years.
PQRS applies only to audiologists in private practices, group practices or university clinics that bill Medicare for fee-for-service outpatient services (Part B), and does not apply to services in facilities—such as medical centers, hospitals or skilled nursing facilities. CMS tracks providers’ participation in PQRS through two identifiers: the taxpayer identification number of the billing practice and the National Provider Identifier of the individual provider who performs the service.
Audiologists who work in two group practices with different tax identification numbers must meet the requirements of PQRS in each practice to avoid future penalties. Medicare does not allow audiologists to bill for their services under the physician number (called “incident to” billing), so it is critical that audiologists understand they are responsible for meeting benchmark requirements. Audiologists must meet current PQRS requirements for claims submitted with their National Provider Identifier to avoid Medicare reimbursement penalties in future years.
Providers, including audiologists, participate in PQRS by report on specific measures on the Medicare claim form. The quality measures are documented with a series of “G” codes.
To comply with the rules, audiologists must report on two quality measures: referral of patients diagnosed with benign paroxysmal positional vertigo or general dizziness for medical evaluation by a physician and documentation of medications in the chart. Screening for depression is an optional measure, but will not count toward the benchmark for satisfactory reporting. Each measure allows the audiologist to report a positive action, an exclusion, or a nonaction. To avoid future penalities, audiologists cannot always report nonaction on all claims. See the chart below for requirements for each of the three measures. Audiologists can find detailed measure specifications, with flowcharts and examples, at http://www.asha.org/Advocacy/audiologyPQRI/.
PQRS Measures for Audiologists
     PQRS Measures for Audiologists
    • Measure#261: Referral for otologic evaluation for patients with acute or chronic dizziness
    • Codes for Claim G8856: Referral to physician for dizziness G8857: Patient already under the care of physician for dizziness G8858: Referral not performed
    • RequirementsPatient must be diagnosed with ICD-9-CM 780.4 or ICD-9-CM 386.11
    • 2014 benchmark to avoid future penalitiesOne time per calendar year for 50 percent of the eligible Medicare patients

    • Measure#130: Documentation of current medications in the medical record
    • Codes for Claim G8427: Documentation of medications OR no medications taken G8430: Patient in ER G8428: Medications not documented
    • Requirements
      • Reported based on procedure, not diagnosis
      • Medication list should include name, frequency, dosage, route as reported by patient
    • 2014 benchmark to avoid future penalities50 percent of every eligible Medicare patient visit

    • Measure♯134: Screening for clinical depression and follow-up plan
    • Codes for ClaimG8431: Positive screen and follow-up plan noted G8510: Negative screen G8433: Screen not appropriate G8433: No screen performed G8511: Positive screen, no follow-up plan noted
    • Requirements
      • Report based on procedure, not diagnosis
      • Screen for depression must be a standardized screening tool
      • Audiologists should not screen for depression if not in state scope of practice
    • 2014 benchmark to avoid future penalitiesOne time per calendar year for 50 percent of the eligible Medicare patients

The information on the website was developed by the Audiology Quality Consortium, a group of representatives from 10 audiology organizations whose mission is to monitor the status of audiology quality measures in PQRS, respond to proposed CMS rules and measure changes, develop new measures for PQRS/CMS use, and educate audiologists about PQRS. The consortium is working on developing measures that are clinically meaningful to audiologists and will meet the future needs of payment reform.
New diagnosis codes
The International Classification of Diseases, 10th Revision, Clinical Modification, in use throughout the world, takes effect Oct. 1 in the United States. This diagnostic coding system was developed by the World Health Organization, and became available for implementation in 1994. The United States has been working to adopt the expanded diagnosis code set—replacing IDC-9—since HIPAA passed in 1996.
The ICD-10-CM diagnostic code set contains more than 68,000 codes, compared to 14,000 in the current ICD-9-CM. Each updated code use a combination of three to seven numbers and letters, with three to five digits to allow more specificity (see chart below). The change is abrupt—claims for services on Sept. 30 require ICD-9-CM codes, and claims for services on Oct. 1 require ICD-10-CM codes. ASHA recommends the following steps to prepare for the conversion:
  • Look at the ICD-9-CM codes you typically use in your practice, and start converting them to ICD-10-CM using ASHA’s free mapping tool or mapping spreadsheets (http://www.asha.org/Practice/reimbursement/coding/ICD-10) developed specifically for audiologists.

  • Contact clearinghouses, billing services, practice management vendors and payers to get their transition and testing plans.

  • Check your payer contracts to see what services are dependent on diagnosis and prepare to defend coverage for the new codes.

  • Develop an implementation plan now that includes staff training, revised paperwork/documentation and revised office processes.

  • If you submit on paper claims, use the new CMS-1500 form prior to the April 1, 2014, deadline for transition to this form.

Example of ICD-9-CM to ICD-10-CM
     Example of ICD-9-CM to ICD-10-CM
    • ICD-9 386.11: Benign Paroxysmal Positional Ver-tigo (BPPV)
    • ICD-10 H81.10: BPPV, unspecified H81.11: BPPV, right ear H81.12: BPPV, left ear H81.13: BPPV, bilateral

Fee schedule
The Medicare Physician Fee Schedule sets rates for each procedure designated by a Current Procedural Terminology code (CPT, ©American Medical Association). The codes are calculated based on relative value units that are based on three components: professional work, practice expense, and professional liability insurance. To arrive at the reimbursement for the code, CMS multiplies the code’s total units (adjusted for geography) by a mandated “conversion factor.” Relevant 2014 codes and rates for audiologists are available at www.asha.org/Practice/reimbursement/medicare/feeschedule.htm.
The conversion factor, which varies each year, is based on a calculation called the Sustainable Growth Rate. Using the SGR to determine the conversion factor typically threatens a decrease of 20 to 25 percent in rates. To avert the cut—and the resulting disruption of services to senior adults—Congress will pass last-minute legislation. The Medicare reform bills making their way through Congress would fix this annual problem.
Reimbursement rates for audiologists change because of the variable SGR, the conversion factor, and the phase-in of a new practice expense values. Practice expense includes indirect costs, such as rent, utilities and billing expenses. Surveys of audiologists indicated that the cost of operating an audiology practice have decreased in comparison to a medical practice, and relative value units were revised to reflect that change.
ASHA’s Health Care Economics Committee is working with other audiology organizations and physician groups to increase the professional work factor relative to practice expenses to stabilize audiologist payments.
The American Medical Association is surveying several existing audiology codes, and audiologists should be prepared to participate in surveys of procedures they regularly perform. In the survey process, ASHA and other professional organizations contact audiologists to compare the time, complexity and overall work of a procedure to a reference procedure. The survey is an opportunity for audiologists to represent the professional and skilled work they provide, and they should respond accurately and consider all factors relative to the reference procedure.
The AMA uses the information—which estimates the time and complexity required to perform a procedure—to recommend professional work value to CMS, which then uses the information for resource allocation.
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March 2014
Volume 19, Issue 3