2020 Medicare Final Rules for Outpatient Services Released

November 4, 2019

The Centers for Medicare & Medicaid Services (CMS) released the 2020 final rules for the Medicare Physician Fee Schedule [PDF] and the Hospital Outpatient Prospective Payment System [PDF] on November 1, 2019. Key issues of interest to audiologists and speech-language pathologists (SLPs)—including coding changes, payment updates, and quality reporting requirements—are summarized below. Full analysis of the finalized rules and national 2020 payment rates will be published on ASHA’s website.

Medicare Physician Fee Schedule (MPFS)

Audiology and speech-language pathology services under Medicare Part B (outpatient) have payment rates established by the MPFS. Most speech-language pathology services provided in hospital outpatient settings are also based on the MPFS.

Finalized Rate Changes

CMS uses a conversion factor (CF) to calculate the MPFS payment rates. The 2020 CF is $36.09, representing a slight increase over the $36.04 CF for 2019. ASHA will analyze adjustments to professional work, practice expense, and liability insurance values for individual procedure and publish national payment rates for audiology and speech-language pathology.

New and Revised Codes

The MPFS final rule addresses values for several new and revised CPT (Current Procedural Terminology ® American Medical Association) codes for pre- and post-implant evaluation of auditory function, computerized dynamic posturography, and cognitive function intervention.

Pre- and Post-Implant Auditory Function Evaluation Codes

Starting in 2020, CPT code 92626 is revised to describe an evaluation of auditory function for surgically implanted device(s) candidacy or post-operative status of a surgically implanted device(s); first hour. CPT code 92627—an add-on code—may be reported in conjunction with 92626 for each additional 15 minutes of the evaluation.

Although the code descriptions have changed to clearly describe their intended use, CMS will maintain the current values for CPT codes 92626 and 92627. ASHA worked with the American Academy of Audiology (AAA) to recommend these values to CMS, preventing potential reduction to payments for this evaluation.

Computerized Dynamic Posturography Testing

Beginning in 2020, CPT code 92548 will be used to report computerized dynamic posturography sensory organization test (CDP-SOT), 6 conditions (i.e., eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform and visual sway), including interpretation and report. New code 92549 will also be available to report when the motor control test (MCT) and adaptation test (ADT) is completed in conjunction with the sensory organization test (SOT).

ASHA and AAA worked with the American Academy of Neurology (AAN) and the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) to revise coding for CDP testing and submit recommended values to CMS. However, CMS did not accept the recommendations and has implemented lower values for both 92548 (CDP-SOT) and 92549 (CDP-SOT, MCT, and ADT). Additionally, there will be substantial reductions to practice expense values, which reflect the direct cost of providing CDP testing. ASHA and AAA actively advocated CMS to phase-in the reductions over a 3-year span to mitigate the impact to audiologists; however, CMS chose not to implement the phase-in. As a result, audiologists should be prepared to see reductions of approximately 50% and 35% to payments for 92548 and 92549 respectively, beginning in 2020. 

Cognitive Function Intervention

CPT code 97127 (cognitive function intervention)—an untimed code—is deleted and replaced with two new timed codes: a base code for the initial 15 minutes of cognitive function intervention (97129) and an add-on code for each additional 15 minutes (97130). ASHA worked with the American Psychological Association (APA) to develop the new codes and submit value recommendations to CMS. CMS accepted ASHA’s recommendations and will implement the new codes in the 2020 MPFS. However, due to reductions to practice expense values, which reflect the direct cost of providing each service, SLPs should be prepared to see payment reductions of approximately 30% for cognitive therapy beginning in 2020.

CMS also confirmed that G0515—Medicare’s current 15-minute code for cognitive skills development—will be deleted, effective January 1. This ensures there is a single coding option for cognitive treatment across payers in 2020.

Online Assessment by Qualified Nonphysician Health Care Professional (E-Visit)

CMS had proposed three new Medicare G-codes that describe non-face-to-face, patient-initiated online assessments for use by qualified nonphysician health care professionals but did not provide additional guidance regarding reporting requirements or eligible providers. ASHA commented in support of implementation of the e-visit codes and urged CMS to allow audiologists and SLPs to report and receive payment for e-visits under the MPFS. However, CMS did not accept the recommendation and clarified in the final rule that these codes are outside the Medicare benefit category for most nonphysician specialty groups—including audiologists and SLPs— and cannot be reported for Part B beneficiaries.

The Quality Payment Program (QPP)

The QPP is a combination program that is transitioning Medicare payments away from the volume-based fee-for-service system to a value-based system of quality and outcomes. The program includes the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

The Merit-Based Incentive Payment System (MIPS)

MIPS is 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, given programmatic exclusions, such as the low volume threshold, most audiologists and SLPs will continue to be excluded from MIPS in 2020. To be considered a mandatory reporter, the audiologist or SLP must treat 200 or more Medicare beneficiaries, provide 200 or more covered professional services, and receive $90,000 or more in reimbursement from Medicare. Based on ASHA’s analysis of 2016 Medicare data, less than 1% of ASHA members will be subject to MIPS in 2020. 

For eligible participants, a payment incentive or penalty will be applied to 2022 Medicare payments for performance on the quality and improvement activities (IAs) performance categories in 2020. For the quality performance category, MIPS eligible clinicians—including audiologists and SLPs—must report a minimum of six measures when/if six measures apply. Currently, audiologists have six potentially applicable measures and SLPs have three potentially applicable measures. More information on MIPS for audiologists and SLPs can be found on the ASHA website

CMS added three measures to the audiology specialty measure set for the 2020 performance/2022 payment year. This would provide audiologists with the flexibility to select from nine options for reporting as only a minimum of six measures need to be reported.

  • Measure 130: Documentation of Current Medications in the Medical Record
  • Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
  • Measure 154: Falls: Risk Assessment
  • Measure 155: Falls: Plan of Care
  • Measure 181: Elder Maltreatment Screen and Follow-Up Plan (new for 2020 performance/2022 Payment Year)
  • Measure 182: Functional Outcome Assessment (new for 2020 performance/2022 Payment Year)
  • Measure 226: Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention
  • Measure 261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
  • Measure 318: Falls: Screening for Future Falls Risk (new for 2020 performance/2022 Payment Year)

For SLPs, CMS added two new measures and eliminated one measure from MIPS entirely, leaving SLPs with four measures in the specialty measure set for the 2020 performance/2022 payment year. This means that SLPs must report all four measures whenever applicable; since there are only four possible measures SLPs will not be penalized for reporting on fewer than six measures. 

  • Measure 130: Documentation of Current Medications in the Medical Record
  • Measure 181: Elder Maltreatment Screen and Follow-Up Plan (new for 2020 performance/2022 Payment Year)
  • Measure 182: Functional Outcome Assessment (new for 2020 performance/2022 Payment Year)
  • Measure 226: Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention

CMS eliminated Measure 131: Pain Assessment and Follow-Up for the 2020 performance/2022 payment year because of concerns regarding the association between pain assessment and the potential prescription of opioids.

Audiologists and SLPs must score a minimum of 40 points associated with IAs and attest to their completion via the CMS QPP website. A full list of IAs can be found in Appendix 2 of the propose rule. 

Advanced Alternative Payment Models (APMs)

A key initiative within the QPP, APMs are Medicare payment systems that incentivize quality and value. APMs take a variety of forms: accountable care organizations, patient-centered medical homes, bundled payments, and episodes of care. Audiologists and SLPs may participate in the Advanced APM option in 2020. Those who successfully participate will be eligible to receive a 5% lump-sum incentive payment on their Part B services in 2022. An example of an Advanced APM is the Medicare Shared Savings Program ACO-Track 2. Quality reporting metrics and other elements of APM participation are tied to the priorities of the APM entity rather than more “generic” MIPS reporting. 

Medicare Targeted Medical Review

The Bipartisan Budget Act of 2018 permanently repealed the hard caps on therapy services and permanently extended the targeted medical review (TMR) process first applied in 2015. Therefore, Medicare beneficiaries should continue to receive medically necessary treatment without arbitrary payment limitations. The law established two financial thresholds, a KX modifier threshold and a TMR threshold. The KX modifier is used on all claims exceeding $2,080, including those over the TMR threshold. The TMR threshold will remain at $3,000 until 2028 when it will be updated annually in the same manner as the KX modifier threshold. More information about the impact of the permanent repeal of the cap and the targeted medical review process can be found on the ASHA website.  

Hospital Outpatient Prospective Payment System (OPPS)

Medicare pays for outpatient hospital audiology services under the OPPS. However, most speech-language pathology services provided in hospital outpatient settings are paid under the MPFS.

Payment Updates and APC Changes

OPPS rates will increase by 2.6%. Additionally, changes to Ambulatory Payment Classifications (APCs) may result in adjusted payment rates for certain audiology services. ASHA will conduct a careful analysis of these changes and publish the final payment rates on ASHA’s website.

Requirements for Hospitals to Make Public a List of Their Standard Charges

CMS did not finalize any policies associated with this price transparency initiative and will issue a separate final rule at a later date. Under the proposal, CMS would require all hospitals (except for federally owned or operated hospitals) to publish charges (both gross charges and negotiated rates with insurers) on their websites to arm consumers with cost data to ensure they can make educated choices regarding where to receive services. If a hospital fails to do so, CMS will impose a civil monetary penalty (CMP) of $300 a day until the hospital comes into compliance with this policy. ASHA has supported price transparency in previous comments but will continue to work with CMS to ensure implementation imposes as little burden to providers and institutions as possible.

Site Neutral Payment for Services Provided in Outpatient Hospitals (OPPS) and Physician Offices (Fee Schedule)

Section 603 of the Bipartisan Budget Act of 2015 requires site neutral payments for services, including audiology services, regardless of whether they are provided by an outpatient hospital department or an independent physician’s office. This change in the law is in response to concerns that the higher OPPS rate was being paid when the service was provided in the outpatient hospital department despite similar costs experienced by independent physician offices. Therefore, for services to which the site neutral payment policy applies, a fee schedule rate will be paid instead of the higher OPPS rate. CMS phased in implementation of this policy over two years and 2020 is the final year of the transition. With the completion of this two-year transition, the reduced rate will be paid under the OPPS in 2020. 

ASHA Resources

Additional details on the final rule will be published in the January/February issue of The ASHA Leader. The final 2020 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? 

Contact reimbursement@asha.org


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