If you're an audiologist who provides services to Medicare Part B beneficiaries, you need to know about some provisions in the 2013 Medicare rules that will affect reimbursement, quality reporting, and billing for some procedures.
Here's how the Medicare Final Rule that starts Jan. 1 applies to audiologists.
CPT Code Changes
The final fee schedule includes several new CPT codes (Common Procedural Terminology, © American Medical Association) used by audiologists for electrophysiologic evaluations and intraoperative monitoring.
Seven nerve conduction study codes (95907–95913) that include motor, sensory, and mixed nerve conduction studies replace the H-reflex codes (95934 and 95936). Tests must be formed with separate electrodes for stimulating, recording, and grounding on only the nerves that apply to the specific diagnosis.
The continuous intraoperative neurophysiology codes, 95940, 95941, and G0453, represent monitoring, testing, and data interpretation during surgical procedures. The codes mandate continuous attendance by a professional qualified to interpret the testing and monitoring, and require immediate communication directly with the operating room. The codes include the ongoing monitoring time (distinct from the performance of baseline studies).
The two continuous intraoperative neurophysiology monitoring codes, 95940 (in the operating room) and 95941 (outside the operating room), replace the deleted 95920 (intraoperative neurophysiology testing, per hour). However, 95941 may not be used for Medicare beneficiaries, because it allows a provider to monitor several patients remotely at the same time. Because the Centers for Medicare and Medicaid Services (CMS) allows a provider to monitor only one patient at a time, it created G0453, which covers continuous remote (outside the operating room) monitoring for one patient. Both 95940 and G0453 are billed in units of 15 minutes.
Additional information on the new codes will appear in a future issue of the Leader and on ASHA's New and Revised CPT & HCPCS Codes For 2013 webpage.
Physician Quality Reporting System
The final rule emphasizes that audiologists must participate in the Physician Quality Reporting System (PQRS) in 2013 or be penalized 1.5% on all Medicare Part B claims in 2015. This outcome measure system has been an incentive program, with providers receiving a bonus for participating. In 2015, however, the incentive system changes to a penalty system, and providers who don't participate in 2013 will incur a 1.5% penalty on their 2015 claims.
The incentives and penalties apply to private and group practice audiologists who bill Medicare Part B using their individual National Provider Identifier (NPI) on the claim form. Institutional providers, such as audiologists employed in hospitals, are not included in the rule.
There are only two conditions audiologists must report: referrals to otologists for congenital or traumatic ear deformity and for dizziness. Audiology PQRS information in the final rule was inconsistent, with the text naming only two conditions and the accompanying tables listing four. CMS subsequently clarified that despite the information in the table, two measures are being deleted.
Correct participation is based on the diagnosis of the patient and the procedures completed, not if the referral for the listed conditions was performed or even necessary. For example, an audiologist performs a comprehensive audiology evaluation (CPT 92557) on a patient with benign paroxysmal positional vertigo (BPPV). Even if the patient is already under the care of an otologist or physician for BPPV, the audiologist must report G8857 (no referral, patient already under the care of a physician for acute or chronic dizziness). Each reportable condition has a similar code to report if referral is not necessary or made.
In 2013, audiologists must report on at least one condition consistently for the entire year to avoid the 2015 penalty. In future years, however, providers will need to report on both conditions for at least 50% of beneficiaries who have the diagnoses and procedure code that require reporting.
ASHA, in collaboration with other audiology organizations, has created various materials to help audiologists report correctly. Audiologists should become familiar with the procedure and diagnosis codes that require reporting, and include the G-codes on documentation and claim forms when appropriate.
Audiologists will see changes in 2013 reimbursement rates because of two factors: the conversion factor 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 diagnostic codes.
The value of each procedure 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 insurance (malpractice). 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 conversion factor to determine the corresponding fee.
In 2013, audiologists will be affected by the final year of a four-year phase-in of practice expense value changes, the result of updated practice cost surveys. These changes have decreased rates for many audiology codes, mostly because the costs of operating an audiology practice are substantially less than those of a medical practice.
However, in the last few years, ASHA has worked with other audiology and physician groups to have the American Medical Association transfer audiologists' time and effort out of the practice expense and into professional work. Professional work RVUs do not 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 components.
Work Values for Otoacoustic Emission Codes
Despite efforts by ASHA and the American Academy of Audiology, CMS has not corrected the professional work value assigned to two codes for evoked otoacoustic emissions evaluations, CPT 92587 (for three to six frequencies) and CPT 92588 (more than 12 frequencies). The two organizations protested the work value assigned to the codes in 2012, and presented evidence to a CMS panel that the RVUs did not accurately represent the work involved in the procedures ("ASHA Argues for Higher Valuation of OAE Codes," The ASHA Leader, May 15).
Although the panel recommended higher work values, CMS disagreed with the recommendation and has maintained its original decision to assign work RVUs of 0.35 for 92587 and 0.55 for 92588.
CMS has established a 2013 conversion factor of $25.0008, a figure that is 26.5% lower than the 2012 factor. Although this rate is mandatory because of a statutory formula known as the sustainable growth rate (SGR), Congress has enacted legislation to change the factor almost every year since the SGR was implemented. It is anticipated that Congress will once again act to prevent this reduction by the end of 2012.
ASHA will post new fees for audiology codes when congressional action is complete—or when it becomes clear that Congress will choose not to act. Check ASHA's Billing & Reimbursement website for updates.
Hospital Outpatient Prospective Payment System
Rates for key hospital-based outpatient audiology services under the Outpatient Prospective Payment System increase, on average, in 2013. The rates vary from a drop of 3.3% to an increase of 4.4% over 2012:
- The bundled vestibular evaluation (92540) has increased by 3.7%.
- The fee for cochlear implantation (69930) has increased by almost 5% to $30,300, a figure intended to cover the device and surgical costs, but yields a variable loss for many hospitals.
- The rate for an auditory osseointegrated implant has increased by 3.5%, up substantially from the initial proposed 3.8% decrease.