2014 Medicare Fee Schedule for Audiologists. American Speech-Language-Hearing Association

Transcription

1 2014 Medicare Fee Schedule for Audiologists American Speech-Language-Hearing Association 1 st Edition December 27, 2013

2 General Information This document was developed by the American Speech-Language-Hearing Association (ASHA) to provide an analysis of the 2014 Medicare Physician Fee Schedule, including comments on relevant policy changes, a list of Current Procedural Terminology (CPT American Medical Association) codes used by audiologists with their national average payment amounts, and useful links to additional information. Additional information regarding the MPFS including background information, how providers should calculate Medicare payment, and audiology-specific payment and coding rules can be found on ASHA s Billing and Reimbursement website at ASHA s Outpatient MPFS. For questions, contact reimbursement@asha.org.

3 Table of Contents Overview... 4 Analysis of the 2014 Medicare Physician Fee Schedule (MPFS)... 4 Reimbursement Rates... 4 Conversion Factor (CF)... 4 Practice Expense... 4 Multiple Procedure Payment Reductions (MPPR)... 5 Incident to Billing... 5 Physician Compare... 5 Physician Quality Reporting System (PQRS)... 5 Appendix Medicare Physician Fee Schedule (MPFS) for Audiology Services... 8 Table 1. Topical List of Codes... 8 Table 2. National Medicare Part B Rates for Audiology... 9 How to Read the MPFS Table... 16

4 Overview On November 27, 2013, the Centers for Medicare & Medicaid Services (CMS) released the final rule for the 2014 Medicare Physician Fee Schedule (MPFS) that included a 20.1% reduction to reimbursement rates. However, on December 26, 2013, President Obama signed into law the Pathway for SGR Reform Act of This law suspends the reduction and provides for a 0.5% increase in rates, but only through March 31, Audiologists should monitor ASHA s Outpatient MPFS website for future Congressional action on MPFS rates. This document includes regulations and rates for implementation on January 1, 2014, for audiologists providing services to Medicare Part B beneficiaries under the MPFS. A significant policy change addressed in this analysis is the Physician Quality Reporting System (PQRS). National payment rates for audiology-related services are also included. Additional information regarding the MPFS including background information, how providers should calculate Medicare payment, and audiology-specific payment and coding rules can be found on ASHA s Outpatient MPFS website. For questions, contact reimbursement@asha.org. Analysis of the 2014 Medicare Physician Fee Schedule (MPFS) ASHA s Health Care Economics and Advocacy Team reviewed relevant sections of the 2014 MPFS. The narrative below is an analysis of key issues for audiologists. Reimbursement Rates Audiologists will see changes in 2014 reimbursement rates because of two factors: the conversion factor (CF) established by a statutory formula and changes in the practice expense one of several costs factored into the value of any given procedure code for audiology codes. See the appendix (pp. 9-17) for a listing of audiologyrelated procedures and corresponding national payment rates. Visit ASHA s webpage on calculating Medicare fee schedule rates for information on how to access fees based on locality. Conversion Factor (CF) The CF is used to calculate MPFS reimbursement rates. CMS established a calendar year 2014 CF of $ , which is 0.5% higher than the 2013 CF of $ and reflects Congressional action that averted a 20.1% decrease in rates. However, the suspension of the reduction is only valid through March 31, Please monitor ASHA s Outpatient MPFS website for updates on additional Congressional action. Relative Value Units The value of each CPT code is calculated by separating the cost of providing the service into relative value units (RVUs) in three components professional work, technical expenses (practice expense), and professional liability (malpractice) insurance. The total RVUs for each service is the sum of the three components (components are adjusted for geographical differences); the RVUs for any particular CPT code are multiplied by the CF to determine the corresponding fee. In 2013, audiologists experienced the final year of a 4-year phase-in of practice expense value changes, the result of updated practice cost surveys. These surveys reflected data on average practice expenses and mostly affect indirect practice costs (such as office overhead, billing, rent, and utilities). The changes have decreased rates for many audiology procedures, mostly because the costs of operating an audiology practice are substantially less than operating costs of a medical practice. However, in the past few years, ASHA, through its Health Care Economics Committee, has worked with other audiology and physician groups to present data to the American Medical Association (AMA) Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC) to systematically transfer the audiologist s time and effort out of the practice expense and into professional work. Professional work RVUs do not typically change over time, unlike practice expense values that fluctuate according to CMS payment formula policies. This effort is not yet complete, leaving some codes with only practice expense and malpractice All CPT codes and descriptors are copyright 2013 American Medical Association 4

5 components. ASHA will continue to work collaboratively with the American Academy of Audiology (AAA) and other audiology and specialty societies to address these issues. For a detailed chart of final 2014 RVUs, contact reimbursement@asha.org. Multiple Procedure Payment Reductions (MPPR) Under the MPPR policy, Medicare reduces payment for the second and subsequent therapy, surgical, nuclear medicine, and advanced imaging procedures furnished to the same patient on the same day. Currently, no audiology procedures are affected by MPPR. ASHA submitted comments to reiterate that there is no evidence that audiologic diagnostic procedures performed on the same day are over-valued and provided information on the bundled audiology procedures that already included multiple procedure reductions. The 2014 final rule indicated that expansion of MPPR to other diagnostic tests, including audiologic tests, will be addressed in future rulemaking. ASHA will continue to express its concerns regarding application of MPPR to audiologic diagnostic services. Incident to Billing Medicare proposed, and finalized in the 2014 rule, the alignment of incident to regulations with applicable state laws. Audiology services, having their own defined benefit category, cannot be billed incident to a physician service when performed by an audiologist. ASHA agrees that all services, including those for Medicare beneficiaries, should be performed (a) by appropriate licensed and otherwise regulated personnel and (b) compliant with state laws. The final rule adds language to the regulations stating that to state, Services and supplies must be furnished in accordance with applicable State law where necessary; this language is consistent with Medicare policy and ASHA s ethical guidelines. Physician Compare ASHA has been working closely with CMS contractor Westat in regards to the Physician Compare website, the CMS provider search website intended for beneficiary use. In its comments, ASHA noted that the most recent iteration of the site that includes audiologists as a search option was lacking in detail for the training, certification, and specialty board recognition many of our members possess. CMS indicated that the Physician Compare website is primarily populated by the online enrollment tool, the CMS Internet-based Provider Enrollment, Chain and Ownership System (PECOS), and providers should ensure that the information in PECOS is current and complete. For categories not captured in PECOS such as language spoken, hospital affiliation, or other credentials providers are encouraged to contact the Physician Compare contractor at physiciancompare@westat.com. As proposed, Physician Compare will publicly report the Physician Quality Reporting System (PQRS) data collected from 2014 claims for individual eligible providers as early as Physician Quality Reporting System (PQRS) PQRS, designed to support improvements in quality of care for Medicare Part B patients by tracking practice patterns, began as a voluntary incentive payment program for reporting patient data. As the program has continued, however, the incentive payment has decreased to the current 0.5% incentive payment based on total claims. PQRS will remain an incentive program through 2014, but is simultaneously transitioning to a deduction program. Providers who reported nothing in 2013 will receive a 1.5% deduction on their Medicare Part B claims in In the final rule, CMS reiterated that the benchmark for satisfactory reporting to avoid 2016 penalties is 50% of all eligible patient encounters in All eligible providers in private or group practices submitting claims as rendering providers (with individual National Provider Identification (NPI) numbers and as rendering providers on the claim providing Part B services under the MPFS) are subject to the -2.0% adjustment to claims submitted in 2016 if they do not meet benchmark requirements in Audiologists participate by adding non-payable Healthcare Common Procedure Coding System (HCPCS) G-codes on the claim form for eligible patients and visits. Patient eligibility is determined by the CPT code for the procedure performed by the audiologist and the International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) code assigned to the patient on the claim form. All CPT codes and descriptors are copyright 2013 American Medical Association 5

6 Beginning October 1, 2014, PQRS will transition to the International Classification of Disease, 10th edition, Clinical Modification (ICD-10-CM) as required. The final rule retired several measures, including one audiology measure: Measure #188, Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of the Ear. This measure will not be available for audiologists to report in In 2014, audiologists are eligible to report three measures: one is audiology specific and requires an ICD-9-CM/ICD-10-CM code and the others are medication management and preventative care for specific procedures: Audiology/Ear Disorder Measures Measure #261 Referral for Otologic Evaluation for Patients With Acute or Chronic Dizziness Medication/Preventative Care Measures Measure #130 Measure #134 Documentation of Current Medications in the Medical Record Preventative Care and Screening: Screening for Clinical Depression and Follow-Up Plan The final rule includes different benchmark requirements based on qualification for receiving the 0.5% incentive payment or avoiding the deductions later. The -2.0% payment adjustment will be applied to 2016 Part B payments to health care providers who did not report on at least three measures (or fewer if measures are not applicable) for 50% of the eligible services during the 2014 calendar year. The benchmark for qualifying for incentive payments in 2014 includes reporting at least 50% of the eligible services for nine measures or as many measures as are available for a given professional. Any providers who report fewer than nine measures will be subject to the Measures Applicability Validation (MAV) process, which will determine if the provider reported on the appropriate measures. In 2013, Measure #130 and Measure #134 were not assessed in the MAV process; however, the 2014 MAV process has not yet been released. Audiologists are cautioned that, in order for them to report Measure #134, the state licensure scope of practice must allow audiologists to screen for clinical depression, a standardized screening tool must be routinely performed, and follow-up referral sources for positive results must be established. Audiologists should not report on Measure #134 for the sole purpose of meeting PQRS requirements. Measure #261 must be reported one time per qualifying beneficiary, based on the reported ICD-9-CM/ICD-10- CM code and CPT code combination, for the calendar year. Documentation of current medications in the medical record (Measure #130) must be reported on 50% of the eligible patients for each visit. For the technical specifications and instructions for each measure, see ASHA s step-by-step guide for reporting audiology quality measures. Avoid Penalties Report 50% of qualifying patients for three measures (or as many as available) Receive Incentives Report 50% of qualifying patients for nine measures (or as many as available) It is important to note that patient eligibility for reporting is not determined by a match between patient characteristics and the description of the measure, but rather the diagnosis and the procedure that was performed and submitted on the claim. Visit the Audiology Quality Consortium (AQC) PQRS site for educational materials. All CPT codes and descriptors are copyright 2013 American Medical Association 6

7 Appendix All CPT codes and descriptors are copyright 2013 American Medical Association 7

8 2014 Medicare Physician Fee Schedule (MPFS) for Audiology Services Table 1. Topical List of Codes Table 1 is a topical list of procedure codes used by, or of interest to, audiologists. The codes are grouped to differentiate the categories according to major audiology practices. Audiometric Tests Nerve Conduction/Evoked Potentials Vestibular Function Studies Implant Services Aural Rehabilitation Intraoperative Monitoring Physician Procedures of Interest G G All CPT codes and descriptors are copyright 2013 American Medical Association 8

9 The following table contains full descriptors and national payment rates for audiology-related services. Calculations were made using the 2014 CF ($ ), reflecting a 0.5% increase to MPFS rates due to Congressional action to avert a 20.1% reduction. However, the suspension of the reduction is only valid through March 31, Audiologists should monitor ASHA s Outpatient MPFS website for future Congressional action on MPFS rates. Please see ASHA s Outpatient MPFS site for other important information on Medicare CPT coding rules and Medicare fees calculations, including information on how to find rates by locality. Table 2. National Medicare Part B Rates for Audiology Audiology services are paid at both facility and non-facility rates, depending on setting. Note that a separate payment system applies to hospital outpatient departments. See also: How to Read the MPFS Table (p. 16). CPT Code Mod Descriptor Removal of impacted cerumen (separate procedure), 1 or both ears Facial nerve function studies (eg, electroneuronography) National Fee Valid through 3/31/2014 Non-Facility Facility $0.00 $0.00 $70.57 $ Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, $ N/A optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording TC Basic vestibular evaluation $21.85 N/A Basic vestibular evaluation $80.60 $ Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording $30.81 N/A TC Spontaneous nystagmus test $9.67 N/A Spontaneous nystagmus test $21.14 $21.14 Notes Medicare does not allow use of this code by audiologists. All CPT codes and descriptors are copyright 2013 American Medical Association 9

10 CPT Code Mod Descriptor Positional nystagmus test, minimum of 4 positions, with recording National Fee Valid through 3/31/2014 Non-Facility Facility $26.51 N/A TC Positional nystagmus test $8.96 N/A Positional nystagmus test $17.55 $ Caloric vestibular test, each irrigation (binaural, bithermal stimulation constitutes 4 tests), with recording $16.12 N/A TC Caloric vestibular test $10.39 N/A Caloric vestibular test $5.73 $ Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording $24.00 N/A TC Optokinetic nystagmus test $10.03 N/A Optokinetic nystagmus test $13.97 $ Oscillating tracking test, with recording $20.78 N/A TC Oscillating tracking test $8.60 N/A Oscillating tracking test $12.18 $ Sinusoidal vertical axis rotational testing $ N/A TC Sinusoidal vertical axis rotational testing $88.12 N/A Sinusoidal vertical axis rotational testing $15.40 $ Use of vertical electrodes (List separately in addition to code for primary procedure) $6.09 N/A Computerized dynamic posturography $ N/A TC Computerized dynamic posturography $78.45 N/A Computerized dynamic posturography $26.15 $ Tympanometry and reflex threshold measurements $21.14 N/A Screening test, pure tone, air only $0.00 $0.00 Not covered under the audiology benefit Pure tone audiometry (threshold); air only $30.81 N/A Pure tone audiometry (threshold); air and bone $36.90 N/A Notes All CPT codes and descriptors are copyright 2013 American Medical Association 10

11 CPT Code Mod Descriptor National Fee Valid through 3/31/2014 Non-Facility Facility Speech audiometry threshold; $22.93 N/A with speech recognition $36.54 N/A Comprehensive audiometry threshold evaluation and speech recognition (92553 and combined) Evoked otoacoustic emissions, screening (qualitative measurement of distortion product or transient evoked otoacoustic emissions), automated analysis $37.97 $32.96 Notes $0.00 $0.00 Not covered under the audiology benefit Audiometric testing of groups $0.00 $0.00 Not covered under the audiology benefit Bekesy audiometry; screening $0.00 $0.00 Not covered under the audiology benefit Bekesy audiometry; diagnostic $37.61 N/A Loudness balance test, alternate binaural or monaural $46.21 N/A Tone decay test $30.45 N/A Short increment sensitivity index (SISI) $28.30 N/A Stenger test, pure tone $16.48 N/A Tympanometry (impedance testing) $14.69 $ Acoustic reflex testing, threshold $15.76 $ Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing $32.60 $ Filtered speech test $26.87 N/A Staggered spondaic word test $51.23 N/A Sensorineural acuity level test $74.87 N/A Synthetic sentence identification test $34.75 N/A Stenger test, speech $19.34 N/A Visual reinforcement audiometry (VRA) $42.63 $ Conditioning play audiometry $68.42 N/A Select picture audiometry $51.94 N/A All CPT codes and descriptors are copyright 2013 American Medical Association 11

12 CPT Code Mod Descriptor National Fee Valid through 3/31/2014 Non-Facility Facility Electrocochleography $70.57 N/A Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive $ N/A TC Auditory evoked potentials comprehensive $ N/A Auditory evoked potentials comprehensive $26.87 $ Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; limited $84.18 N/A Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3 6 frequencies) or $22.21 N/A transient evoked otoacoustic emissions, with interpretation and report TC Distortion product evoked otoacoustic emissions limited $2.87 N/A Distortion product evoked otoacoustic emissions limited $19.34 $ Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear $33.67 N/A mapping, minimum of 12 frequencies), with interpretation and report TC Distortion product evoked otoacoustic emissions comprehensive $3.94 N/A Distortion product evoked otoacoustic emissions comprehensive $29.73 $ Ear protector attenuation measurements $42.63 N/A Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming $ $ Notes All CPT codes and descriptors are copyright 2013 American Medical Association 12

13 CPT Code Mod Descriptor National Fee Valid through 3/31/2014 Non-Facility Facility subsequent reprogramming $83.11 $ Diagnostic analysis of cochlear implant, age 7 years or older; with programming $ $ subsequent reprogramming $89.56 $ Evaluation of central auditory function, with report; initial 60 minutes each additional 15 minutes (List separately in addition to code for primary procedure) Assessment of tinnitus (includes pitch, loudness matching, and masking) $94.93 $84.90 $22.57 $19.34 $70.57 $ Evaluation of auditory rehabilitation status; first hour $90.99 $ each additional 15 minutes (List separately in addition to code for primary procedure) $21.85 $ Auditory rehabilitation; prelingual hearing loss $0.00 $0.00 Not covered under the audiology benefit Auditory rehabilitation; prelingual hearing loss $0.00 $0.00 Not covered under the audiology benefit Diagnostic analysis with programming of auditory brainstem implant, per hour $ $ Nerve conduction studies; 1 2 studies $95.29 N/A Covered under the supervision of a physician TC 1 2 studies $41.55 N/A studies $53.73 $ Nerve conduction studies; 3 4 studies $ N/A Covered under the supervision of a physician TC 3 4 studies $50.51 N/A studies $66.99 $ Nerve conduction studies; 5 6 studies $ N/A Covered under the supervision of a physician TC 5 6 studies $61.26 N/A studies $80.24 $ Nerve conduction studies; 7 8 studies $ N/A Covered under the supervision of a physician Notes All CPT codes and descriptors are copyright 2013 American Medical Association 13

14 CPT Code Mod Descriptor National Fee Valid through 3/31/2014 Non-Facility Facility TC 7 8 studies $78.81 N/A studies $ $ Nerve conduction studies; 9 10 studies $ N/A Covered under the supervision of a physician TC 9 10 studies $92.06 N/A studies $ $ Nerve conduction studies; studies $ N/A Covered under the supervision of a physician TC studies $ N/A studies $ $ Nerve conduction studies; 13 or more studies $ N/A Covered under the supervision of a physician TC 13 or more studies $ N/A or more studies $ $ Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper limbs TC Short-latency somatosensory evoked potential study in upper limbs Short-latency somatosensory evoked potential study in upper limbs Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in lower limbs TC Short-latency somatosensory evoked potential study in lower limbs Short-latency somatosensory evoked potential study in lower limbs Notes $ N/A Covered under the supervision of a physician $ N/A $28.30 $28.30 $ N/A Covered under the supervision of a physician $ N/A $28.30 $28.30 All CPT codes and descriptors are copyright 2013 American Medical Association 14

15 CPT Code Mod Descriptor National Fee Valid through 3/31/2014 Non-Facility Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in upper $ N/A Covered under the supervision of a physician and lower limbs TC Short-latency somatosensory evoked potential study in upper and lower limbs $ N/A Short-latency somatosensory evoked potential study in upper and lower limbs $46.57 $ Short-latency somatosensory evoked potential study, stimulation of any/all peripheral nerves or skin sites, recording from the central nervous system; in the $ N/A Covered under the supervision of a physician trunk or head TC Short-latency somatosensory evoked potential study in the trunk or head $ N/A Short-latency somatosensory evoked potential study in the trunk or head $27.94 $ Visual evoked potential (VEP) testing central nervous system, checkerboard or flash $ N/A Covered under the supervision of a physician TC Visual evoked potential (VEP) testing checkerboard or flash $ N/A Visual evoked potential (VEP) testing checkerboard or flash $18.63 $ Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method $81.68 N/A Covered under the supervision of a physician TC Neuromuscular junction testing $46.21 N/A Neuromuscular junction testing $35.46 $35.46 Facility Notes All CPT codes and descriptors are copyright 2013 American Medical Association 15

16 CPT Code Mod Descriptor National Fee Valid through 3/31/2014 Notes Non-Facility Facility Continuous intraoperative neurophysiology monitoring in the operating room, one on one monitoring requiring personal attendance, each 15 minutes (List separately in addition to code for primary procedure) Continuous neurophysiology monitoring, from outside the operating room (remote or nearby) or for monitoring of more than one case while in the operating room, per hour (List separately in addition to code for primary procedure) Continuous intraoperative neurophysiology monitoring, from outside the operating room (remote or nearby), per patient, (attention directed exclusively to one patient) each 15 minutes (list in addition to primary procedure) N/A $22.57 Covered under the supervision of a physician $0.00 $0.00 Not covered under the audiology benefit. See G0453 below. G0453 N/A $18.99 Covered under the supervision of a physician How to Read the MPFS Table Modifiers: 26 = Professional component, the portion of diagnostic test that involves a physician s work and allocation of the practice expense TC = Technical component, for diagnostic tests, the portion of a procedure that does not include a physician s participation The TC value is the difference between the global value and the professional component (26). No Modifier = Global value, includes both professional and technical components. N/A in Fee Columns: Non-Facility No rate established because service is typically performed in the hospital. If the contractor determines the service can be performed in the non-facility setting, it will be paid at the facility rate. Facility No rate established because service is not typically paid under the MPFS when provided in a facility setting. These services, including incident to and the TC portion of diagnostic tests, are generally paid under the hospital OPPS or bundled into the hospital inpatient prospective payment system. In some cases, these services may be paid in a facility setting at the MPFS rate, but there would be no payment made to the practitioner under the MPFS in these situations. All CPT codes and descriptors are copyright 2013 American Medical Association 16