2021 Medicare Part B Final Rule Includes Significant Payment Cuts, Coding Changes

The Centers for Medicare & Medicaid Services (CMS) released the 2021 Medicare Physician Fee Schedule (MPFS) final rule for outpatient services on December 1, 2020. Significant policies addressed in this rule include payment cuts for audiology, speech-language pathology, and many other services; new and revised codes for vestibular and auditory evoked potential testing; coverage of communication technology-based services; and telehealth services during and beyond the public health emergency (PHE). 

Payment Rates

CMS finalized significant rate reductions for audiologists, speech-language pathologists (SLPs), and over 30 other Medicare provider groups due to changes in payment for primary care services and adjustments to the annual conversion factor (CF). ASHA will publish final 2021 national payment rates for audiology and speech-language pathology services in ASHA’s full MPFS analysis, available later this week.

Rate Reductions to Audiology and Speech-Language Pathology Services

The final rule implements a 6% decrease in payment for audiology services and a 9% decrease for speech-language pathology services beginning in 2021. Other physician and nonphysician provider groups are also set to see reductions as high as 10%.

These significant rate reductions result from changes to office-based outpatient evaluation and management (E/M) procedure codes that provide payment increases for primary care services. By law, every year, CMS must ensure that rate changes for all procedure codes paid under the MPFS remain budget neutral. CMS implemented the 2021 reductions to offset the significant increase in value for the new E/M codes and to meet the Medicare program’s budget neutrality mandate.

ASHA is disappointed CMS finalized the payment cuts despite sustained advocacy and collaboration with CMS, key decision makers—including members of Congress—and a large coalition of physician and nonphysician provider groups to stop the cuts. Learn more about ASHA's ongoing advocacy efforts and how audiologists and SLPs can still take action to address the cuts by asking members of Congress to co-sponsor H.R. 8702, the Holding Providers Harmless From Medicare Cuts During COVID-19 Act of 2020.

Clinicians should be prepared for the cuts to go into effect on January 1 in the event Congress does not pass H.R. 8702 or another similar legislative fix before the end of the year.

Conversion Factor

CMS uses a CF to calculate the MPFS payment rates. For 2021, the CF will be $32.41, representing an approximate 10% decrease from the $36.09 CF for 2020. This is due in large part to the increases to the E/M codes necessitating a steep reduction in the CF to meet the budget neutrality mandate.

Payment Increases for Certain Speech-Language Pathology Evaluation Codes

CMS increased the values for four procedure codes related to evaluation of speech, language, fluency, and voice evaluations (92521-92524) by approximately 28%. However, due to the steep cuts in the 2021 CF, the actual payment for these Current Procedural Terminology (CPT® American Medical Association) codes will increase by approximately 10-15%. CMS’s goal is to maintain relativity in the fee schedule by ensuring that CPT codes that include assessment and management work similar to E/M codes reflect the positive changes in value that the E/M services will receive. ASHA supported this effort and provided CMS with recommendations for other evaluation codes that should also receive increased payments, such as clinical swallowing and speech-generating device evaluations. However, CMS chose not to expand the list of speech-language pathology services receiving an increase in 2021. Although these increases are necessary, they do little to lessen the overall negative impact of the payment cuts on SLPs as evaluations make up only a small portion of total payment for therapy services for most clinicians.

ASHA urged CMS to implement similar increases for audiology codes, given the important role of audiologic and vestibular testing in assessing and managing balance, hearing, and communication disorders. However, CMS did not accept ASHA’s recommendations because the audiology codes covered under the Medicare benefit represent diagnostic services, which CMS does not consider analogous to E/M services.

New Procedure Codes

CMS finalized values for several new CPT codes for vestibular evoked myogenic potentials (VEMP) and auditory evoked potentials (AEP) testing. ASHA worked with the American Academy of Audiology (AAA), American Academy of Neurology (AAN), and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) to develop the codes and submit recommended values to CMS.

Vestibular Evoked Myogenic Potentials (VEMP) Testing

Beginning in 2021, audiologists can report VEMP testing with two new CPT codes for ocular (oVEMP) and cervical (cVEMP) testing when performed alone, and a bundled CPT code for oVEMP and cVEMP testing performed together on the same day.

CMS accepted the recommended values from ASHA, AAA, AAN, and AAO-HNS as listed below.

Auditory Evoked Potentials (AEP) Testing

Current AEP testing codes 92585 (comprehensive) and 92586 (limited) will be deleted and replaced with four new, more descriptive CPT codes to reflect the spectrum of AEP testing. The new AEP codes describe: 1) automated screening of auditory potential with broadband stimuli; 2) testing for hearing status determination with broadband stimuli; 3) testing for threshold estimation at multiple frequencies; and 4) testing to evaluate neural conduction.

CMS accepted the recommended values from ASHA, AAA, AAN, and AAO-HNS as outlined below. Note that CMS does not cover screenings, but published the total relative value units (RVUs) for use by Medicaid programs and commercial insurers.

ASHA’s coding web page provides additional information on the CPT code changes. ASHA will publish final payment rates and detailed RVUs in ASHA’s full MPFS analysis.

Medicare Telehealth Services

CMS will add five CPT codes commonly reported by SLPs to the telehealth services list on a temporary basis for the duration of 2021, even if the PHE ends before then. None of the audiology services authorized during the PHE will be covered in 2021, after the end of the PHE. Because CMS lacks the statutory authority to maintain the telehealth flexibilities allowed during the PHE, at the conclusion of the current PHE, audiologists and SLPs will no longer receive Medicare reimbursement for telehealth services unless Congress enacts legislation changing the underlying law. Therefore, CMS will only reimburse for these select speech-language pathology services when provided by a physician or practitioner (e.g., physician assistant) or when provided incident to a physician. SLPs may provide these telehealth services incident to a physician only when under the physician’s direct supervision. Through the end of 2021, the direct supervision requirements can be met either by the physical presence of the physician in the same office as the SLP or virtually through the use of audio/video real-time communications technology.

The speech-language pathology codes added for 2021 (when provided by a physician or practitioner) are:

• 92507: Treatment of speech, language, voice, communication, and/or auditory processing disorder; individual
• 92521: Evaluation of speech fluency (eg, stuttering, cluttering)
• 92522: Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria)
• 92523: Evaluation of speech sound production (eg, articulation, phonological process, apraxia, dysarthria); with evaluation of language comprehension and expression (eg, receptive and expressive language)
• 92524: Behavioral and qualitative analysis of voice and resonance

 ASHA will continue advocating with CMS and Congress to secure reimbursement for additional audiology and speech-language pathology telehealth services during the PHE and beyond. ASHA’s website provides more information on audiology and speech-language pathology telehealth services for the duration of the PHE.

ASHA is also working with Congress to pass legislation to include audiologists and SLPs on the list of providers eligible for Medicare reimbursement for telehealth services by supporting H.R. 8755, the Expanded Telehealth Access Act.

Communication Technology-Based Services (CTBS)

In its interim final rules related to the PHE, CMS temporarily allowed SLPs to report CTBS codes for virtual check-ins, e-visits, and remote assessment of recorded images or videos. The final rule permanently expands these services for SLPs and certain other nonphysician providers, beginning in 2021. ASHA’s coding webpage provides additional detail regarding new and updated CTBS codes for 2021.

Although not technically considered Medicare telehealth services, and while they do not represent full evaluation and treatment services, these codes broaden the scope of speech-language pathology services available to Medicare beneficiaries and will allow SLPs to receive payment for brief, patient-initiated communications or check-ins when medically necessary.

ASHA urged CMS to include audiologists as eligible providers of CTB services, both during and beyond the PHE. However, CMS did not expand coverage of CTBS codes for audiologists in 2021 nor during the PHE, due to the limitations of the audiology diagnostic benefit.

Coding and Payment for Personal Protective Equipment (PPE)

In early September 2020, the AMA released new CPT code 99072 and requested that CMS approve 99072 for reporting the cost of additional PPE, cleaning supplies, and clinician or clinical staff time needed to safely provide in-person services during the PHE. Unfortunately, CMS stated in the final rule that it will not consider separate Medicare payment for 99072 because the cost of PPE is bundled into the payment for existing CPT codes. Instead, the final rule indicates that CMS would recognize the increased market-based pricing associated with certain PPE supply items, namely surgical masks, N95 masks, and face shields. The increased cost to purchase each item will be automatically calculated into the final payment for CPT codes, but only if they currently include these items in the practice expense component. However, the supplies that are currently included in the practice expense component of each CPT code are based on pre-pandemic practice patterns. As such, CMS’s action to increase the value of certain PPE supplies does not provide relief to audiologists or SLPs because the CPT codes they commonly report do not include those PPE supply items, such as surgical masks, in their practice expense component. ASHA will continue to advocate with CMS and other payers to seek additional support for PPE supplies now, when clinicians need them the most.

Quality Payment Program (QPP)

The QPP transitions Medicare payments away from a volume-based fee-for-service payment to a more value-based system of quality and outcomes-based reimbursement. The program includes the Merit-Based Incentive Payment System and Advanced Alternative Payment Models.

Merit-Based Incentive Payment System (MIPS)

MIPS represents one track of the QPP that focuses on quality improvement in fee-for-service Medicare. CMS added audiologists and SLPs to MIPS for the first time in 2019 and they will remain in the program in future years. However, most audiologists and SLPs remain excluded from mandatory participation in MIPS for 2021 due to the structure of the low volume threshold. To qualify as a mandatory reporter, an audiologist or SLP must treat 200 or more Medicare beneficiaries, provide 200 or more covered professional services, and receive $90,000 or more in allowed reimbursement from Medicare. Based on ASHA’s analysis of 2016 Medicare data, less than 1% of ASHA members will be subject to MIPS in 2021.

While MIPS includes four performance categories, only two—quality and improvement activities—apply to audiologists and SLPs. For eligible participants, CMS will apply a payment incentive or penalty to 2023 Medicare payments for performance on the quality and improvement activities (IAs) performance categories in 2021. For the quality performance category, MIPS eligible clinicians—including audiologists and SLPs—must report a minimum of six measures when six measures apply. ASHA will review the 2021 measure specifications to confirm the complete list of measures applicable to audiologists and SLPs and will update our guidance as soon as it is available. Audiologists and SLPs can find more information on MIPS on the ASHA website.

Audiologists and SLPs must score a minimum of 40 points associated with IAs and attest to their completion via the CMS QPP website. CMS made small modifications to the list of IAs as outlined in Appendix C of the final rule. The CMS website provides a full list of IAs for clinicians.

Advanced Alternative Payment Models (APMs)

APMs, a key initiative within the QPP, incentivize quality and value. APMs take a variety of forms: accountable care organizations, direct contracting, patient-centered medical homes, bundled payments, and episodes of care. Audiologists and SLPs may participate in the Advanced APM option in 2021. Those who successfully participate will receive a 5% lump-sum incentive payment on their Part B services in 2023. An example of an Advanced APM includes the Maryland Total Cost of Care.

Medicare Targeted Manual Medical Review

CMS notes in the final rule that the Bipartisan Budget Act of 2018 permanently repealed the hard caps on therapy services and permanently extended the targeted medical review process first applied in 2015. Therefore, Medicare beneficiaries can continue to receive medically necessary treatment with no arbitrary payment limitations. The use of the KX modifier is still required on claims above the modifier financial threshold. CMS will publish this amount for 2021 in future guidance. ASHA’s website provides additional information regarding the permanent repeal of the cap and the current targeted medical review process.

Background

Audiology and speech-language pathology services under Medicare Part B (outpatient) have payment rates established by the MPFS. Medicare also pays for most speech-language pathology services provided in hospital outpatient settings based on the MPFS. However, audiology outpatient hospital services are paid under the hospital outpatient prospective payment system (OPPS).

ASHA monitors and analyzes all rules related to the provision of audiology and speech-language pathology services and provides analysis and comments to CMS for consideration. ASHA staff also meet with CMS officials throughout the year to advocate on behalf of members and those they serve.

ASHA Resources

Additional details on the final rule will be published on ASHA’s Leader Live in December. The final 2021 Medicare outpatient payment rates and related information for audiologists and SLPs will also be published on ASHA’s Outpatient Medicare Physician Fee Schedule web page.

More information on CPT code changes are available on ASHA’s web pages for audiologists and SLPs.

Questions?

For more information, contact reimbursement@asha.org.