November 4, 2021
The Centers for Medicare & Medicaid Services (CMS) released the 2022 final rule for the Medicare Physician Fee Schedule (MPFS) for outpatient services. Significant policies addressed in this rule include—but are not limited to—payment cuts for audiology, speech-language pathology, and other services; new codes for remote therapeutic monitoring (RTM); audio-only virtual check-in services; telehealth services; quality reporting; and Alternative Payment Models. ASHA provided extensive comments [PDF] to CMS regarding these issues in response to the 2022 proposed rule released in July.
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 will address the OPPS final rule in a separate analysis.
CMS did not finalize specific actions to mitigate the payment cuts set to return in 2022 for audiologists, speech-language pathologists (SLPs), and over 30 other Medicare provider groups. These cuts would have gone into effect in 2021 due to changes in payment for outpatient office-based evaluation and management (E/M) services and adjustments to the annual conversion factor. Fortunately, advocacy by ASHA and other stakeholders resulted in legislation that significantly mitigated the cuts by 3.75%. However, the 3.75% adjustment is set to expire at the end of 2021, meaning that the cuts will resume in 2022 without additional action from Congress.
ASHA is working with allied stakeholders to convince Congress to address the cuts with a positive adjustment to 2022 Medicare payments. However, clinicians should be prepared for the cuts to go into effect on January 1 if Congress does not pass a legislative fix before the end of the year. Learn more about ASHA's ongoing advocacy efforts and how audiologists and SLPs can get involved to address the cuts.
CMS uses a CF to calculate the MPFS payment rates. For 2022, the CF will be $33.59, representing a nearly 4% decrease from the $34.89 CF for 2021, and a nearly 7% decrease from the 2020 CF. CMS’s regulatory impact analysis (RIA) of the final rule notes that audiologists will see a cumulative net zero change in payments and SLPs a 1% decrease in 2022. However, CMS did not factor in the temporary 3.75% increase implemented to mitigate the cuts into the analysis. As a result—without additional intervention by Congress or CMS—audiologists and SLPs will continue to face significant payment cuts beyond what CMS identified in the RIA due to the CF changes. It is important to note that cumulative reimbursement changes experienced by individual clinicians or practices will vary because actual payment depends on several factors, including locality-specific rates and the specific procedure codes billed.
ASHA will publish final 2022 national payment rates for audiology and speech-language pathology services in ASHA’s full MPFS analysis, available later this week.
CTBS codes represent brief communication services conducted over different types of technology to help avoid unnecessary office visits. These services, by definition, are virtual and do not replace services that would normally be performed in person. In 2021, CMS permanently expanded the use of CTBS codes for virtual check-ins, e-visits, and remote assessment of recorded images or videos for SLPs and certain other nonphysician providers. CMS did not expand coverage of these CTB services for audiologists due to the limitations of the audiology diagnostic benefit.
CMS finalized the following updates related to CTB services, including the use of audio-only virtual check-ins and new codes for remote therapeutic monitoring (RTM).
Effective January 1, 2022, clinicians will see a new family of codes for RTM services, including three codes of interest to audiologists and SLPs, as outlined in the table below. See ASHA’s audiology and speech-language pathology CPT code updates for more information on the new codes.
Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment
Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes
each additional 20 minutes (listed separately in addition to code for primary procedure)
The new RTM codes allow clinicians who cannot bill for E/M services to report remote monitoring of health conditions as well as adherence and response to treatment during an episode of care. In response to comments from ASHA and other stakeholders, CMS agreed that these services are important to beneficiaries and will allow therapists—including SLPs—and certain other nonphysician providers to bill the RTM codes, as written. When billing the new RTM codes to Medicare, SLPs should include the -GN modifier to indicate services provided under a speech-language pathology plan of care.
CMS did not indicate whether the RTM codes may be billed by audiologists. Absent specific guidance from CMS, ASHA concludes that audiologists may not report these services under the MPFS due to limitations of the audiology diagnostic benefit. ASHA will continue to work with CMS to identify opportunities to allow audiologists to bill for RTM services that fit within the Medicare benefit.
Clinicians should check with non-Medicare payers directly regarding coverage and coding of RTM services, as individual payer policies will vary.
In 2021, CMS established a new HCPCS code, G2252, for audio-only virtual check-in services to help providers stay connected with Medicare beneficiaries who may not have access to audio-visual technology. Unfortunately, CMS excluded providers who cannot report E/M services under the MPFS, including audiologists and SLPs. ASHA submitted comments urging CMS to allow audiologists, SLPs, and other providers to report this important service.
Despite ASHA’s request, CMS has opted not to expand use of G2252 in 2022. CMS did acknowledge ASHA’s comments and indicated they will consider them in future rulemaking. ASHA will continue to urge CMS to allow audiologists and SLPs to bill for audio-only virtual check-in services. Clinicians should check with non-Medicare payers directly regarding coverage of audio-only virtual check-ins, as individual payer policies will vary.
In the final rule, CMS extends payment for select telehealth services provided by SLPs through December 31, 2023, including CPT codes 92507, 92521, 92522, 92523, and 92524 when provided incident to a physician. CMS lacks the statutory authority to maintain the telehealth flexibilities allowed during the federal public health emergency (PHE), so audiologists and SLPs will no longer receive Medicare reimbursement for telehealth services when the PHE ultimately expires. The current PHE has been extended through at least January 13, 2022.
ASHA remains committed to securing Congressional authority for members to receive reimbursement for services provided via telehealth for an extended period beyond the federal PHE and will continue advocating for a permanent legislative solution.
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.
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 2022. To qualify as a mandatory reporter, an audiologist or SLP must treat at least 200 Medicare beneficiaries, provide at least 200 covered professional services, and receive at least $90,000 in allowed reimbursement from Medicare. Based on ASHA’s analysis of Medicare data, less than 1% of ASHA members will be subject to MIPS in 2022.
For eligible participants, CMS will apply a payment incentive or penalty to 2024 Medicare payments for performance on the quality and improvement activities (IAs) performance categories in 2022. 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 eight potentially applicable measures and SLPs have five potentially applicable measures. More information on MIPS for audiologists and SLPs is available on ASHA’s website.
CMS maintains the eight measures in the audiology specialty measure set for the 2022 performance/2024 payment year. But CMS is removing the option to report Measure 182: Functional Outcomes Assessment via claims and will only allow electronic reporting (e.g., reporting via an electronic health record). Audiologists maintain the flexibility to select among seven options for claims-based reporting, as only a minimum of six measures must be reported.
For SLPs, CMS maintains the five measures in the specialty measure set for the 2022 performance/2024 payment year. However, it is removing the option to report Measure 182: Functional Outcomes Assessment via claims and will only allow electronic reporting (e.g., reporting via an electronic health record). This means that SLPs must report all five measures whenever applicable.
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 final rule.
APMs, a key initiative within the QPP, incentivize providers who shift towards quality and value. Audiologists and SLPs may participate in the Advanced APM option in 2022. Those who successfully participate will receive a 5% lump-sum incentive payment on their Part B services in 2024. Pursuant to the Consolidated Appropriations Act passed last year, CMS is freezing APM thresholds at the 2020 levels. For performance year 2022, the Medicare-Only payment threshold is 50% and the patient count threshold is 35%. In other words, at least 50% of your Medicare Part B payments or at least 35% of your Medicare patients must be seen through an Advanced APM entity. Under the All-Payer Combination Option, you must first meet certain threshold percentages under the Medicare Option, which is 25% for the payment amount method or 20% under the patient count method.
This payment and patient count threshold freeze will help more providers, like audiologists and SLPs, in Advanced APMs qualify for the 5% bonus. These thresholds are designed to measure whether the provider is actively taking steps to increase their participation in value-based care arrangements.
Determination of the Advanced APM 5% bonus takes place at the facility/APM entity level (Tax Identification Number or TIN) or at the individual eligible clinical level.
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. The use of the KX modifier is still required on claims above the modifier financial threshold, which is $2,150 in 2022 for physical therapy and speech-language pathology services combined. Claims and medical record documentation may be reviewed if reimbursement exceeds $3,000. Members can find more information regarding the permanent repeal of the cap and the current targeted medical review process on ASHA’s website.
Additional details on the final rule will be published in a future issue of The ASHA Leader and on ASHA’s Leader Live later this month. The final 2022 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.
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