Proposed 2019 Medicare Outpatient Rule Keeps Rates Steady While the proposed fee schedule is under review, ASHA pushes to maintain code values and responds to changes in reporting requirements. Policy Analysis
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Policy Analysis  |   September 01, 2018
Proposed 2019 Medicare Outpatient Rule Keeps Rates Steady
Author Notes
  • Sarah Warren, MA, is ASHA director of health care policy for Medicare. swarren@asha.org
    Sarah Warren, MA, is ASHA director of health care policy for Medicare. swarren@asha.org×
  • Daneen Sekoni, MHSA, is ASHA director of health care policy for health care reform. dsekoni@asha.org
    Daneen Sekoni, MHSA, is ASHA director of health care policy for health care reform. dsekoni@asha.org×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   September 01, 2018
Proposed 2019 Medicare Outpatient Rule Keeps Rates Steady
The ASHA Leader, September 2018, Vol. 23, 26-28. doi:10.1044/leader.PA2.23092018.26
The ASHA Leader, September 2018, Vol. 23, 26-28. doi:10.1044/leader.PA2.23092018.26
Audiologists and speech-language pathologists who provide outpatient services to Medicare beneficiaries will see little change in reimbursement rates in the proposed 2019 Medicare Physician Fee Schedule (MPFS), but the rule makes several reporting changes.
Each year the Centers for Medicare and Medicaid Services (CMS) releases a proposed MPFS that indicates potential changes for the following year. The rule includes rates for each CPT code (Common Procedural Terminology © American Medical Association) and describes changes in Medicare reporting, quality improvement and other matters.
Medicare Part B outpatient audiology and speech-language pathology services fall under MPFS; most speech-language pathology services provided in hospital outpatient settings are also MPFS-based, whereas audiology outpatient hospital services are paid under the hospital outpatient prospective payment system.
Proposed rate changes
By law, the 2019 MPFS must include an overall 0.25-percent rate increase, but reimbursement for some individual CPT codes may change by a different amount because of adjustments to their assigned values. The rule contains no changes to the value of any audiology-related codes, but does address two speech-language evaluation codes.
The rule adopts ASHA’s recommendation to maintain current professional work values for codes related to standardized testing of aphasia (96105) and cognition (96125). Using data collected from professional work surveys of speech-language pathologists, ASHA was able to work with the American Medical Association to submit accurate recommendations to CMS that prevented significant work value reductions, and thus reimbursement cuts, for these codes.

ASHA is developing quality measures specifically for audiology and speech-language pathology for CMS to include in MIPS in coming years.

Quality Payment Program
The Quality Payment Program (QPP) is a two-track program that transitions Medicare payments away from fee-for-service to a quality- and outcomes-based payment system. Implemented in 2017, the program includes two tracks: the Merit-Based Incentive Payment System and Advanced Alternative Payment Models.
Merit-Based Incentive Payment System (MIPS)
MIPS focuses on quality improvement and efficiency. It comprises four categories: quality (measures developed through a qualified clinical data registry or legacy measures from the Physician Quality Reporting System), clinical practice improvement activities (CPIAs), meaningful use of an electronic health record (now known as Promoting Interoperability), and resource use.
CMS proposes not to include audiologists and SLPs in MIPS for 2019, because proposed measure deletions and consolidations bring the number of measures these professions are eligible to report to fewer than six, the minimum number required to participate.
The quality measures audiologists and SLPs can report are not specific to audiology or speech-language pathology—instead, they are interdisciplinary measures, which can be reported by multiple disciplines. Physical and occupational therapists, however, have the required number of quality measures and are proposed for inclusion in 2019 MIPS quality reporting.
CMS indicates that additional professionals (including audiologists and SLPs) may be added to MIPS for 2019 if the interdisciplinary measures are maintained or if the professions will be allowed to report fewer than six measures, as permitted under the previous quality reporting system. ASHA is developing quality measures specifically for audiology and speech-language pathology for CMS to include in MIPS in coming years.
However, even if audiologists and SLPs are included in 2019, less than 1 percent of ASHA members would be required to participate in the MIPS program based on their “low-volume” thresholds. Providers who bill less than $90,000 in Medicare services, treat fewer than 200 Medicare patients, or provide fewer than 200 covered services to Medicare beneficiaries are exempt.
CMS intends to allow clinicians who meet only one or two of these criteria to opt in to MIPS for the opportunity to compete for a payment incentive (as well as to take on the risk of receiving a penalty for failure to meet the measures).
Advanced Alternative Payment Models (APMs)
CMS is increasingly emphasizing APMs—Medicare approaches that provide incentives for quality and value. APMs take a variety of forms: accountable care organizations, patient-centered medical homes, bundled payments, and episodes of care (see “Show Us the Merit,” December 2016).
Audiologists and SLPs can participate in the Advanced APM option in 2019, and are eligible to receive a 5-percent lump-sum incentive payment on their Part B services in 2021—if at least 25 percent of the Advanced APM’s Medicare payments or at least 20 percent of the Advanced APM’s Medicare patients receive services through the advanced APM.
To allow more clinicians to qualify for the incentive payment, CMS proposes an option to include payments and patient counts of other payers—Medicaid, private insurance and Medicare Advantage—in the thresholds as well.

CMS has developed a new category of codes for communication technology-based services, including virtual check-ins and clinical evaluation of patient-submitted photos, but still restricts them to physicians.

Targeted manual medical review
Legislation in 2018 permanently repealed the hard caps on therapy services and permanently extended the targeted medical review process first applied in 2015. The proposed rule offers no additional information regarding the medical review process.
Functional limitation reporting (“G-codes”)
CMS proposes to eliminate functional limitation reporting effective Jan. 1, 2019. ASHA has, on numerous occasions, requested that CMS remove this requirement to reduce providers’ reporting burden. CMS has not used the data in any meaningful way since the requirement was added in 2011.
Telepractice
Federal law establishes narrow parameters for coverage of telehealth services and restricts reimbursement primarily to physicians. In the proposed rule, CMS has developed a new category of codes for communication technology-based services, including virtual check-ins and clinical evaluation of patient-submitted photos, but still restricts them to physicians. As these codes are not considered telehealth under federal law, ASHA supports their use by all Medicare-recognized providers, and is requesting explicit authorization for audiologists and SLPs to provide and bill these codes when clinically appropriate.
Comments on the proposed rule are due by Sept. 10, 2018, and anyone can submit comments. The final rule is expected in early November.
For more information, contact reimbursement@asha.org.
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September 2018
Volume 23, Issue 9