2020 Medicare Proposed Rules for Outpatient Services Released

July 31, 2019

The Centers for Medicare & Medicaid Services (CMS) has released the 2020 proposed rules for the Medicare Physician Fee Schedule [PDF] and the Hospital Outpatient Prospective Payment System [PDF] on July 29, 2019. A summary of key issues for audiologists and speech-language pathologists (SLPs) follows. ASHA is developing official comments to CMS on the proposed rules.

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.

Proposed Rate Changes

CMS uses a conversion factor (CF) to calculate the MPFS payment rates. For 2020, CMS estimates that the CF will be $36.09, representing a slight increase over the $36.04 CF for 2019. ASHA will analyze proposed adjustments to professional work, practice expense, and liability insurance values for individual procedure codes that could affect payment for audiology and speech-language pathology services.

New and Revised Codes

The MPFS proposed 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. CMS has also proposed a new set of Medicare G-codes related to online assessments for use by qualified nonphysician health care professionals.

Pre- and Post-Implant Auditory Function Evaluation Code

Starting in 2020, CPT code 92626 will be 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 has proposed to 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. A new code 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 instead proposed lower values for both 92548 (CDP-SOT) and the new code (CDP-SOT, MCT, and ADT). ASHA will submit comments and work directly with other stakeholders to request CMS to accept the original recommendations from the specialty societies.

Cognitive Function Intervention

CPT code 97127 (cognitive function intervention)—an untimed code—will be deleted and replaced with two new timed codes: a base code for the initial 15 minutes of cognitive function intervention and an add-on code for each additional 15-minutes. ASHA worked with the American Psychological Association (APA) to develop the new codes and submit value recommendations to CMS. CMS has proposed to accept ASHA’s recommendations and will implement the new codes in the 2020 MPFS. However, CMS did not directly address G0515—Medicare’s current 15-minute code for cognitive skills development—in the proposed rule. ASHA will request deletion of G0515 to ensure there is a single coding option for cognitive treatment across payers in 2020.

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

CMS has proposed three new Medicare G-codes that describe non-face-to-face, patient-initiated online assessments. The new codes will allow qualified nonphysician health care professionals to report and receive payment for digital communications that require a clinical decision. The G-codes describe a qualified nonphysician health care professional online assessment, for an established patient, for up to seven days, cumulative time during the seven days for time increments of 5-10 minutes, 11-20 minutes, and 21 or more minutes.

CMS did not provide additional guidance on reporting requirements or identify Medicare providers that will be eligible to report these codes. ASHA will comment in support of implementation of the e-visit codes and continue to work to ensure audiologists and SLPs are eligible to receive payment for e-visits under the MPFS. 

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 and Advanced Alternative Payment Models.

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 more than 200 Medicare beneficiaries, provide more than 200 covered professional services, and receive more than $90,000 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 six measures apply. In 2019, 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 proposes to add three additional measures to the audiology specialty measure set for the 2020 performance/2022 payment year. This would provide audiologists with the flexibility to select among 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

For SLPs, CMS proposes adding two new measures and eliminating 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. 

  • 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 proposed to eliminate 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)

APMs, a key initiative within the QPP, are Medicare approaches 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 Manual Medical Review

CMS notes in the proposed 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 ongoing treatment whenever their care is medically necessary with no arbitrary payment limitations. 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.

Proposed Payment Updates and APC Changes

CMS proposes to increase OPPS rates by 2.7%. 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 provide comment on areas that directly affect audiologists.

Proposed Requirements for Hospitals to Make Public a List of Their Standard Charge

CMS proposes to 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 proposes it could impose a civil monetary penalty (CMP) of $300 a day until such time 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. 

Background

Every July, CMS releases Medicare proposed rules for comment and must respond to public comment before publishing the final rules in November. ASHA monitors and analyzes all rules related to the provision of audiology and speech-language pathology services and provides the analysis and comment to CMS for consideration. Often, ASHA staff will meet directly with CMS officials to advocate on behalf of members and their clients.

Comments on the proposed rules are due September 27, 2019, and the final rule will be issued around November 1. The final rules will be applicable to services provided in 2020 (January 1–December 31).

ASHA Resources

Additional details on the proposed rule will be published in the October 1, 2019, issue of The ASHA Leader. The current 2019 Medicare outpatient payment rates and related information for audiologists and SLPs are available on ASHA’s Outpatient Medicare Physician Fee Schedule web page.

More information on CPT code changes and final code numbers will be available on ASHA’s coding web page when the AMA releases the 2020 CPT code set in September.

For more information, contact reimbursement@asha.org


ASHA Corporate Partners