2019 Medicare Final Rule: Some Enrolled Audiologists and SLPs Subject to MIPS

November 2, 2018

Reversing its earlier position, the Centers for Medicare & Medicaid Services (CMS) announced in the 2019 Medicare Physician Fee Schedule (MPFS) final rule [PDF] that they have elected to include audiologists and speech-language pathologists (SLPs) as eligible professionals in the Merit-Based Incentive Payment System (MIPS) for 2019. If an audiologist or SLP meets the criteria for a MIPS eligible clinician (EC), they will need to report data associated with quality measures and improvement activities in 2019 that can be used to adjust their payments in 2021. ASHA anticipates that only a very small percentage of members will be impacted in 2019 due to participation exclusions.

MIPS provisions and other items of interest to ASHA members are described in more detail below. Additional information detailing the rule will be available on ASHA’s website. Throughout the remainder of 2018, ASHA will be providing resources and guidance for its members on MIPS participation. 

Quality Payment Program

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 established the Quality Payment Program (QPP). The QPP is comprised of two tracks, MIPS and Advanced Alternative Payment Models (AAPMs). Medicare modifies payment for outpatient services as a result of QPP participation.

Merit-Based Incentive Payment System (MIPS)

Under MIPS, there are four performance categories including quality, promoting interoperability (EHR meaningful use program), resource use (cost), and clinical practice improvement activities. Clinicians will be subject to MIPS unless they meet one or more of the exclusion criteria. While there are four performance categories, ASHA members and other non-physician providers (e.g., occupational and physical therapists) will only be subject to the quality and improvement activities categories for 2019.

Since CMS included setting exclusions and low-volume thresholds, a large majority of ASHA members will be excluded for 2019. MIPS only applies to clinicians in outpatient non-facility settings. In addition, clinicians must meet ALL of the following criteria to be required to participate:

  • bill $90,000 or more to the Medicare program; and
  • treat 200 or more distinct Medicare beneficiaries; and
  • provide 200 or more distinct procedures.

Clinicians meeting one or two of the criteria may opt-in to the program to compete for payment adjustments while others—who do not meet any of the criteria—may voluntarily report to gain experience. Required participants who choose not to report will be subject to the maximum payment reduction for the year of -7%.

Advanced Alternative Payment Models (AAPM)

AAPMs are Medicare approaches that incentivize quality and value. AAPMs take a variety of forms, including accountable care organizations, patient-centered medical homes, bundled payments, and episodes of care. Audiologists and SLPs have been able to participate in the AAPM option since 2017. Those who successfully participate in 2019 will be eligible to receive a 5% lump-sum incentive payment on their Part B services in 2021. An example of an AAPM is the Medicare Shared Savings Program ACO-Track 2.

Functional Limitation Reporting

Effective January 1, 2019, CMS will no longer require the claims-based reporting and documentation of the functional limitation G-codes and associated severity modifiers. It will retain these codes until 2020 to provide time for clinicians and others to update their systems (e.g., EHRs) and avoid denials if these G-codes and severity modifiers are inadvertently included on claims. 

Repeal of the Therapy Caps

The Bipartisan Budget Act of 2018 repealed the Medicare outpatient therapy caps. Congress maintained the KX modifier (formerly the therapy cap threshold) and medical review thresholds. Providers must continue to use the KX modifier on all claims above the modifier threshold. There is a $2,040 threshold for physical therapy and speech-language pathology services combined and a separate $2,040 threshold for occupational therapy services in 2019. 

The law retains the targeted medical review (MR) process at $3,000 for 2019. CMS contractors only review a small percentage of claims above that threshold.

Payment Rates

CMS uses a conversion factor (CF) to calculate the MPFS reimbursement rates. The 2019 CF is $36.0391. This represents a slight increase from the 2018 CF of $35.9996. Audiologists and SLPs should see minimal changes to overall payment for Medicare services.

CMS also finalized ASHA’s recommendations to maintain the current professional work values for Current Procedural Terminology (CPT®) codes related to standardized testing of aphasia (CPT 96105) and cognition (CPT 96125). 

No additional changes related to the value of audiology related services were included for 2019.

ASHA will publish final national rates and relative values for individual CPT codes in the full analyses of the 2019 MPFS for audiologists and SLPs.

Questions?

Contact Sarah Warren, MA, ASHA’s director for health care policy for Medicare, at swarren@asha.org


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