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

August 4, 2020

The Centers for Medicare & Medicaid Services (CMS) released the 2021 proposed rule for the Medicare Physician Fee Schedule (MPFS) for outpatient services on August 3, 2020. Significant policies addressed in this rule include payment cuts for audiology, speech-language pathology, and other services; new and revised codes for vestibular and auditory evoked potential testing; and telehealth services during and beyond the public health emergency.

Payment Rates

CMS proposed significant rate reductions in 2021 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).

Rate Reductions to Audiology and Speech-Language Pathology Services

CMS projects a 7% 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 11%.

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 proposed 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 dismayed by the scale of the rate reductions, given that audiologists and SLPs cannot bill E/M services under the MPFS to help potentially offset the projected reductions in 2021. ASHA will continue advocacy and collaboration with CMS, key decision makers—including members of Congress—and other provider groups to stop the cuts. Learn more about ASHA's ongoing advocacy efforts and how audiologists and SLPs can take action to stop the cuts.

Conversion Factor

CMS uses a conversion factor (CF) to calculate the MPFS payment rates. For 2021, CMS estimates that the CF will be $32.26, representing a nearly 11% 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. ASHA will analyze the 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.

Payment Increases for Certain Speech-Language Pathology Evaluation Codes

CMS proposes increasing payments for four procedure codes related to evaluation of speech, language, fluency, and voice evaluations (92521-92524), as outlined below. 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 supports this effort and will provide CMS with recommendations for other evaluation codes that should also receive increased payments, such as clinical swallowing and speech-generating device evaluations. Although these increases are necessary, they will 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. 

CPT Short Descriptor 2020 National Payment Estimated 2021 National Payment
92521 Evaluation of speech fluency $115.85 $126.46
92522  Evaluation of speech production $94.55 $106.46
92523 Evaluation of speech and language $198.49 $216.46
92524 Evaluation of voice $92.39 $103.88

CMS did not propose similar increases for audiology codes because they represent diagnostic services, which CMS does not consider analogous to E/M services. However, ASHA will recommend that CMS implement increases for audiology services, given the important role of audiologic and vestibular testing in assessing and managing balance, hearing, and communication disorders. 

New Procedure Codes

The MPFS proposed rule addresses values for several new CPT (Current Procedural Terminology ® American Medical Association) 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 has proposed to accept the recommended values from ASHA, AAA, AAN, and AAO-HNS, and audiologists can expect to receive estimated payment for VEMP testing as listed below.  

CPT
temporary codes
Short Descriptor Estimated 2021 National Payment Proposed 2021 Relative Value Units (RVUs)
925X1 cervical VEMP $81.30 2.52
925X2 ocular VEMP $75.81 2.35
925X3 cervical and ocular VEMP $126.46 3.92

 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 has proposed to accept 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. 

CPT
temporary codes
Short Descriptor Estimated 2021 National Payment Proposed 2021 Relative Value Units (RVUs)
92X51 AEP, automated analysis $0.00 0.25
92X52 AEP, hearing status determination $85.49 2.65
92X53 AEP, threshold estimation $112.26 3.48
92X54 AEP, neurodiagnostic $82.91 2.57

ASHA will post more information on CPT code changes and final code numbers on ASHA’s coding web page when the AMA releases the 2021 CPT code set in September.

Medicare Telehealth Services

Although CMS addresses telehealth services in the proposed rule, there are no telehealth changes for audiologists and SLPs in 2021. CMS lacks the statutory authority to maintain the telehealth flexibilities allowed during the public health emergency (PHE), so audiologists and SLPs will no longer receive Medicare reimbursement for telehealth services at the conclusion of the current PHE.

ASHA remains committed to securing Congressional authority for members to receive reimbursement for services provided via telehealth and will continue advocating for a permanent legislative solution.

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. CMS proposes to permanently expand these services for SLPs and certain other nonphysician providers, beginning in 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. 

CMS did not expand coverage of these CTBS services for audiologists in 2021 nor during the PHE, due to the limitations of the audiology diagnostic benefit. ASHA will continue to recommend that CMS include audiologists as eligible providers of CTBS services, both during and beyond the PHE. 

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. While MIPS includes four performance categories, only two—quality and improvement activities—apply to audiologists and SLPs. Given programmatic exclusions, such as the low volume threshold, most audiologists and SLPs remain excluded from mandatory participation in MIPS for 2021. 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.

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. In 2021, audiologists have nine potentially applicable measures and SLPs have five potentially applicable measures. Members can find more information on MIPS for audiologists and SLPs on the ASHA website.

CMS proposes to maintain the measures in the audiology specialty measure set for the 2021 performance/2023 payment year. This provides 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 to maintain the five measures in the specialty measure set for the 2021 performance/2023 payment year. This means that SLPs must report all five measures whenever applicable.

  • Measure 130: Documentation of Current Medications in the Medical Record
  • Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
  • 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

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, 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 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.

APM quality reporting takes place at the facility/APM entity level as opposed to the individual clinician level. Members are tied to the performance of the overall APM as opposed to an individualized report.

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 medically necessary treatment with no arbitrary payment limitations. Members can find more information regarding the permanent repeal of the cap and the current targeted medical review process on the ASHA website.

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). 

According to law, CMS must release the MPFS proposed rule for comment in July, and must respond to public comments before publishing the final rule in November. Given the late release of this year’s rule, CMS intends to issue to final rule in early December for implementation on January 1, 2021. 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.

Comments on the proposed rule are due October 5, 2020. The final rule will apply to services provided in calendar year 2021. 

ASHA Resources

Additional details on the proposed rule will be published in the October 1, 2020, issue of The ASHA Leader. The current 2020 Medicare outpatient payment rates and related information for audiologists and SLPs are available on ASHA’s Outpatient Medicare Physician Fee Schedule web page

Questions?

For more information, contact reimbursement@asha.org.


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