Although SLPs and audiologists will see little difference in Medicare outpatient reimbursement rates in 2005, there is some good news. Audiologists will have three more codes to report, two for central auditory function assessment and one for tinnitus assessment. Moreover, the Medicare hospital outpatient prospective payment system better reflects costs for providing cochlear implant surgery and diagnostic programming.
The Centers for Medicare and Medicaid Services (CMS) published both the outpatient Medicare Physician Fee Schedule (MPFS) and the hospital Outpatient Prospective Payment System (OPPS) on Nov. 15, 2004, in the Federal Register. The fee schedule rates apply to speech-language pathologists in all Medicare outpatient (Part B) settings and to audiologists in all but hospital settings. The OPPS determines the rates for audiology hospital outpatient services.
One of the most important aspects of the fee schedule in setting new rates is the conversion factor. This factor determines how much the reimbursement will be, and is calculated as a factor multiplied by the total relative value units (RVUs) of a procedure. As part of the Medicare Prescription Drug, Improvement and Modernization Act (MMA) of 2003, the conversion factor for 2005 was set as a 1.5% increase over the 2004 rates.
For example, speech-language evaluation (CPT 92506) had an RVU of 3.52 in 2004. The 2004 conversion factor of $37.3374 resulted in a rate of $131.43. For 2005, the same procedure has a lower RVU of 3.48 but the 2005 conversion factor-$37.8975-is higher. Combined, the two produce little net change in the rate for 92506-just five cents more per assessment in 2005, for a rate of $131.38. In audiology, the comprehensive hearing test (CPT 92557) RVU of 1.31 for 2004 did not change at all. Therefore, the rate shows the 1.5% increase: from $48.91 in 2004 to $49.65 in 2005.
Exceptions to the 1.5% increase for speech-language pathology exist because of changes in the RVUs of some procedures. There is only a 0.6% increase for swallowing treatment and a 0.3% increase for speech-language treatment.
The fee schedules include:
- Higher rates for vestibular testing. Audiologists will benefit from surprising increases of 6.5% for vestibular testing and 4% for acoustic reflex testing. Conversely, cochlear implant diagnostic procedures are reduced by 3% to 5%.
- New audiology CPT codes. Through the efforts of the ASHA Health Care Economics Committee, new CPT codes for central auditory function evaluation and tinnitus assessment are effective Jan. 1, 2005 (see related article in The ASHA Leader, Nov. 16, 2004, p. 1). The Medicare Physician Fee Schedule rates are as follows: CPT 92620: Evaluation of central auditory processing, with report; initial 60 minutes, $45.48; CPT 92621: each additional 15 minutes, $11.75. CPT 92625: Tinnitus assessment (includes pitch, loudness, matching, and masking), $44.72.
- Cochlear implant and implant follow-up fees in hospital outpatient settings. This is a success for members. In 2004 ASHA argued that reimbursement for cochlear implant programming (CPT 92601-92604) for hospital outpatients was unreasonably low given the time, complexity, and resources involved. CMS agreed and created a new Ambulatory Payment Classification (APC), Level III Audiometry, reimbursed at $104.92. This is a 58% increase over the 2004 rate. The payment rate for cochlear implantation is increased by almost 15% to $26,000. ASHA had argued that after cost of the device, the 2004 payment amount did not cover associated surgical expenses.
- Qualifications of therapists in physician offices/groups. CMS affirmed that current qualification and training standards for therapists under Medicare apply to services rendered by employees or contractors of physicians. Although Medicare law does not require licensure of clinicians in physician practices, CMS now requires the following qualifications for SLPs, an adoption of regulations in effect for home health agencies (42 CFR 484.4): "Speech-language pathologist. A person who: meets the education and experience requirements for a Certificate of Clinical Competence in speech-language pathology granted by the American Speech-Language-Hearing Association; or meets the educational requirements for certification and is in the process of accumulating the supervised experience required for certification." When an SLP is a physician's employee or contractor, Medicare rules require that a physician, physician assistant, nurse practitioner, or clinical nurse specialist be in the office suite when therapy services are rendered. In states that authorize those providers to provide one or more therapy services, they need not meet the training requirements applicable to clinicians.
- Coding to identify rehabilitation discipline. CMS reiterated the requirement that a modifier must be added to each CPT code to identify whether the services are speech-language pathology (GN), occupational therapy (GO), or physical therapy (GP). The requirement applies to physician offices as well as facilities. The GN modifier indicates that the service was rendered under a speech-language pathology or dysphagia plan of treatment.
- Initial preventive physical examinations. The Medicare law enacted in 2003 mandated that, effective Jan. 1, 2005, Medicare will cover preventive physical exams during a beneficiary's first six months of coverage under Medicare Part B. The examination may be administered by a physician, physician assistant, nurse practitioner, or clinical nurse specialist and must include a review of hearing impairment as part of the "review of the individual's functional ability and level of safety." ASHA submitted references to peer-reviewed articles supporting the use of a screening audiometer for hearing screens. The use of a standardized screening questionnaire was shown to be less reliable. Nevertheless, CMS determined that the physician can perform the screen through the use of appropriate screening questions or a standardized hearing screening questionnaire. If abnormalities are identified, CMS stated that the physician is to render education, counseling, and referral, as deemed appropriate.
- Telehealth services. CMS responded to requests submitted in 2003 for new covered telehealth services. ASHA's request described many successful telehealth applications in speech-language pathology and audiology. The agency listed 10 professional societies that argued for inclusion of services as reimbursable for telehealth services, but singled out audiology, speech-language pathology and dialysis services to be considered for inclusion in a report to Congress due in January 2005, with recommendations for new telehealth coverage.
- Medicare therapy cap. The $1,590 shared financial limit on speech-language pathology and physical therapy services is in the second year of the two-year moratorium enacted under the 2003 Medicare law. ASHA is advocating with CMS and Congress that the cap be eliminated and ensure that any replacement payment policy is equitable to providers and beneficiaries.
- Vertical electrode recording code. The vertical electrode recording rate (CPT +92547, an add-on procedure that is paired with a second procedure in billing) will reflect the actual time to perform the procedure. The fee will be $5.31, which can be billed multiple times as an add-on procedure in 2005, versus $45.18 in 2004 for the entire test battery. The American Medical Association (AMA) will instruct providers and coders that the procedure can be billed as an add-on. In 2004 the AMA instructed coders to bill +92547 only once per visit. That instruction should be changed in early 2005 as a result of ASHA collaboration with the AMA.
The separate fee schedules for SLPs and audiologists with analysis (members only) are available in the Reimbursement section of the ASHA Web site. For more information contact Neela Swanson by e-mail at firstname.lastname@example.org, or by phone at 800-498-2071, ext.4387.