Medicare’s 2018 Rules for Outpatient and Home Health Services Released

November 3, 2017

The Centers for Medicare & Medicaid Services (CMS) has released the 2018 Final Rules for the Medicare Physician Fee Schedule, Hospital Outpatient Prospective Payment System, and Home Health Prospective Payment System. The rules go into effect on January 1, 2018.

Medicare Physician Fee Schedule (MPFS)

Payment Rates

CMS uses a conversion factor (CF) to calculate the MPFS reimbursement rates. The 2018 CF is $35.9996. This represents a slight increase from the 2017 CF of $35.8887 and reflects the 0.5% payment update legislated by the Medicare Access and CHIP Reauthorization Act (MACRA) as well as other mandated adjustments that CMS implemented to maintain budget neutrality.

ASHA will publish final national rates in the full analysis of the 2018 MPFS.

New Code(s) for Cognitive Treatment

On January 1, 2018, a new CPT code 97127 (cognitive function intervention) will replace the current CPT code 97532 (cognitive skills development, each 15 minutes). However, CMS has assigned CPT code 97127 a status of “invalid”, meaning that it will not be recognized for Medicare payment. Instead, CMS has created the following G code to report cognitive treatment services.

G0515     Development of cognitive skills to improve attention, memory, problem solving (includes compensatory training), direct (one-on-one) patient contact, each 15 minutes

G0515 contains the same descriptor as former CPT code 97532 and the payment rate is very similar. If clinicians provide cognitive treatment services to Medicare patients, clinicians should report them with G0515 in the same manner 97532 was reported.

If clinicians bill cognitive treatment services to patients with a non-Medicare payer (i.e., Medicaid, Medicare Advantage, or private health insurance), check with each payer to verify whether you should submit CPT code 97127 or G0515 on the claim form.

Additional information regarding G0515 and 97127 is available on ASHA’s website.

Therapy Caps

The 2018 therapy cap for speech-language pathology services and physical therapy services (combined) is $2,010. The exception process—along with the manual medical review process for therapy services that exceed a $3,700 threshold—is set to expire on January 1, 2018. ASHA is working with Congress regarding action to avoid implementation of the cap.

Hospital Outpatient Prospective Payment System (OPPS)

Ambulatory Payment Classification for Basic Vestibular Evaluation

Medicare pays for outpatient hospital audiology services under the OPPS. ASHA submitted comments regarding CPT code 92540 (Basic vestibular evaluation), requesting a change to its current Ambulatory Payment Classification (APC). For CY 2017, CMS reduced payment for 92540 by over 40% by reclassifying the service to a different APC. CMS did not accept the comments from ASHA and other stakeholders for CY 2017 nor for CY 2018; therefore, CPT code 92540 will remain in its current APC.

Comprehensive Audiometry as an Ancillary Service

ASHA submitted comments urging CMS to reconsider the classification for CPT code 92557 (Comprehensive audiometry). Medicare classifies CPT code 92557 as an “ancillary” service under the OPPS, meaning that it is not separately paid when provided on the same day as other services. ASHA and other stakeholders have repeatedly requested the reclassification of 92557 in order for this key diagnostic test to be paid separately regardless of other services provided to the patient on the same day. CMS did not accept ASHA and other stakeholder comments and CPT code 92557 will remain classified as an “ancillary” service under OPPS.

Home Health Prospective Payment System (HH PPS)

ASHA is pleased that CMS did not finalize a proposal to implement a revised case-mix adjustment system known as the Home Health Groupings Model (HHGM). This model would have developed 144 case-mix groups based on patient clinical characteristics rather than types and amounts of various clinical services delivered, such as speech-language pathology. Reductions in payment to home health agencies under the HHGM proposal and shortening the episode of care from 60- to 30-days were estimated at $950 million in 2019 alone. ASHA will continue to engage CMS on the refinement of the HHGM.

Other provisions of interest in the final rule include:

  • Home health payments will be reduced by 0.4%, or $80 million, in 2018.
  • CMS finalized a proposal to remove 235 data elements from 33 OASIS items effective January 1, 2019 [PDF].
  • CMS finalized three new quality measures for the CY 2020 home health quality reporting program (HH QRP).
  • ASHA will continue to analyze the implications of the final rules and publish information as it becomes available.

Background

Every July, CMS releases proposed rules related to payment systems for comment, and is compelled to respond to public comment before publishing the final rules in November. ASHA monitors and analyzes rules related to the provision of audiology and speech-language pathology services and provides the analysis and comment to CMS for consideration. 

Resources

ASHA will publish detailed OPPS and MPFS analyses and rates for both audiology and speech-language pathology on ASHA's reimbursement website. For additional information, please contact ASHA’s health care economics and advocacy team at reimbursement@asha.org.


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