2015 Hospital Outpatient Prospective Payment System for Audiologists. American Speech-Language-Hearing Association

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Sophie Merritt
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1 2015 Hospital Outpatient Prospective Payment System for Audiologists 1 st Edition November 17, 2014

2 General Information This document, developed by the (ASHA), provides an analysis of the 2015 Medicare Hospital Outpatient Prospective Payment System (OPPS), including Ambulatory Payment Classifications (APC) using CPT (Current Procedure Terminology American Medical Association) codes. The OPPS is used by audiologists providing services to outpatient Medicare beneficiaries in hospitals. The CPT codes are listed in their assigned APCs with the national payment rates. Please check ASHA s Billing and Reimbursement website for the most up-to-date information. For additional information or questions, please contact the Health Care Economics and Advocacy Team at reimbursement@asha.org.

3 Table of Contents Overview... 2 Analysis of the 2015 Hospital Outpatient Prospective Payment System for Audiology Services... 2 Table 1. Ambulatory Payment Classifications (APCs) and National Fees: Vestibular and Audiology Services... 3 Table 2. Ambulatory Payment Classifications (APCs) and National Fees: Cochlear Implant and Osseointegrated Implant Surgeries... 4 How to Read the OPPS Tables... 5

4 Overview Payment for hospital-based outpatient audiology services are made under the Outpatient Prospective Payment System (OPPS). Payment is determined by assignment of the CPT code to an Ambulatory Payment Classification (APC). This document includes regulations and rates for implementation on January 1, 2015, for audiologists providing services to Medicare Part B beneficiaries in the hospital setting under the OPPS. National payment rates for audiology-related services are also included. Additional information can be found on ASHA s Outpatient MPFS website. For questions, please contact reimbursement@asha.org. Analysis of the 2015 Hospital Outpatient Prospective Payment System for Audiology Services The hospital Outpatient Prospective Payment System (OPPS) pays for designated services performed in hospital outpatient departments, including audiology services. Units of payment are calculated in the Ambulatory Payment Classification (APC), which groups individual services to APCs based on similar characteristics and costs. The reimbursement for each service within the APC is the same. Some APCs are classified as ancillary, which indicates the services, when performed with other primary services, are seen as dependent on the primary service and not paid for separately. This method of bundling payment is referred to as packaging. In the 2015 proposed rule, CMS recommended reclassifying several APCs, including several audiology ones, as ancillary APCs that would result in bundled, packaged payment. In other words, if other services that are designated as primary are performed in the hospital outpatient clinic on the same day as an ancillary service, the ancillary audiology service will not receive separate payment. Most of the audiometric CPT codes are now classified as ancillary services. ASHA requested reconsideration for the APC 0364 that includes comprehensive audiology (92557), cochlear implant programming (92604), and auditory brainstem implant programming (92640). However, CMS disagreed that these services should be classified as primary services and finalized the reclassification of these codes as ancillary services. An example of how this affects audiology payment would be if a patient was scheduled for a comprehensive hearing and balance evaluation on the same day. The vestibular codes are within an APC that is classified as primary; therefore, those CPT codes would be reimbursed at the APC rate. However, the audiometric codes within the ancillary APC, though listed on the claim for the same date of service, would not be reimbursed. Likewise, if the patient came for a radiology study on the same day as a cochlear implant diagnostic/programming service, the cochlear implant service would not be reimbursed. See Table 1 for a listing of APC classifications and rates for audiology services, and Table 2 for APC classifications for cochlear implant and osseointegrated implant surgeries.

5 Table 1. Ambulatory Payment Classifications (APCs) and National Fees: Vestibular and Audiology Services The services listed below are paid under the hospital OPPS. Any audiology CPT codes not in Table 1 may be paid under the Outpatient MPFS when provided in a facility setting, or bundled into the hospital inpatient prospective payment system for patients admitted into a Part A inpatient stay. APC Descriptor National Fee Classification 0216 Level III Nerve and Muscle Services $ S ABR comprehensive Nerve conduction, Level II Nerve and Muscle Services $ S Electrocochleography ABR limited Nerve conduction, VEP 0363 Otorhinolaryngologic and related tests $ S Facial Nerve Function Vestibular Calorics OPK Tracking Rotational testing Posturography DPOAE - limited DPOAE - comprehensive 0364 Level I Audiometry $43.31 Q Speech audiometry threshold Speech threshold with discrim Tone decay SISI Stenger, pure tone Tympanometry Filtered speech test Sensorineural acuity level test Synthetic sentence identification Ear protector measurements

6 APC Descriptor National Fee Classification 0365 Level II Audiometry $ Q Tympanometry and reflexes Pure tone, air Pure tone, air and bone Comprehensive audometry VRA Conditioning play audiometry Diagnostic CI, <7 years old Subsequent reprogramming, < Diagnostic CI, 7 years old Subsequent reprogramming, Central auditory function, 60 min Assessment of tinnitus Eval of auditory rehab, 60 min Diagnostic ABI with programming Table 2. Ambulatory Payment Classifications (APCs) and National Fees: Cochlear Implant and Osseointegrated Implant Surgeries The following APCs may be of interest to audiologists in cochlear implant centers. However, the procedures in this table are for informational purposes only and are not for billing by audiologists. APC Descriptor National Fee Classification 0259 Level VII ENT Procedures $26, J Cochlear Implantation 0425 Level V Musculoskeletal Procedures $10, J Implant AOI, w/o mastoidectomy Implant AOI, w/mastoidectomy

7 How to Read the OPPS Tables The APC (Ambulatory Payment Classification) denotes the classification group with CPT codes based on similar characteristics and costs. The national fee is the remimbursement rate for each code within the APC. Classification Codes: J1 Hospital Part B service paid through a comprehensive APC All covered Part B services on the claim are packaged with the primary J1 service for the claim, except services with classification codes F,G, H, L and U; ambulance services; diagnostic and screening mammography; all preventive services; and certain Part B inpatient services. APCs and CPT codes with those classifications are paid separately and are not packaged with the J1 service. Q1 Packaged APC Payment APCs and CPT codes billed on the same date of service as those classified with S, T, or V are packaged and not paid for separately. If billed without the classified S, T, or V, payment is made at the APC rate. S Separate APC Payment Regardless of the services performed on the same date of service, the CPT code is paid at the APC classification rate

Hospital Outpatient Prospective Payment System for Audiologists and Speech-Language Pathologists

2018 Hospital Outpatient Prospective Payment System for Audiologists and Speech-Language Pathologists AMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION 1 General Information This document, developed by the