July 14, 2021
The Centers for Medicare & Medicaid Services (CMS) released the 2022 proposed rule [PDF] 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.
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 develop and submit comprehensive comments on the proposed rule by early September. The final rule will apply to services provided in calendar year 2022.
CMS did not propose specific changes 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, but advocacy by ASHA and other stakeholders resulted in legislation that significantly mitigated 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 or CMS.
ASHA remains committed to continuing advocacy and collaboration with CMS, key decision makers—including members of Congress—and other provider groups to find short- and long-term policy solutions to stop the cuts. Please see ASHA’s resource page to learn more about the cuts and ASHA's ongoing advocacy efforts.
CMS uses an annual CF to calculate MPFS payment rates. For 2022, CMS estimates that 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 proposed rule notes that audiologists will see a cumulative 1% decrease in payments and SLPs a 2% decrease in 2022. However, it does not appear that CMS factored in the temporary 3.75% increase implemented to mitigate the cuts into the analysis. As a result, absent additional intervention by Congress or CMS, ASHA anticipates audiologists and SLPs will continue to face significant payment cuts beyond what CMS identified in the RIA, based on the changes to the CF.
ASHA will work with CMS and stakeholders to clarify how the E/M changes will affect 2022 payments, and will analyze the proposed adjustments to professional work, practice expense, and liability insurance values for individual procedure codes to determine how the CF will affect national payment rates for audiology and speech-language pathology services.
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.
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 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. However, CMS did not expand coverage of these CTB services for audiologists due to the limitations of the audiology diagnostic benefit.
CMS addresses 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 follows.
|989X1||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|
|989X4||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|
|989X5||each additional 20 minutes (list separately in addition to code for primary procedure)|
The RTM codes allow clinicians who cannot bill E/M services to report remote monitoring of health conditions as well as adherence and response to treatment during an episode of care. The codes describe time spent setting up a remote monitoring device as well as analyzing physiologic or non-physiologic data remotely collected through a device, patient self-reporting, and/or digital upload. Specific monitoring devices used must be approved by the U.S. Food and Drug Administration (FDA).
However, the proposed rule notes that these codes are considered general medicine codes under CMS’s definition, meaning that certain nonphysician providers, including audiologists and SLPs as well as physical and occupational therapists, cannot bill these codes under the MPFS as currently written. CMS is seeking comments on how better to structure the codes in order to allow nonphysician providers to use them. ASHA will provide comments and work directly with CMS and other stakeholders to find a favorable solution.
The codes listed above are temporary numbers. Final code numbers and additional coding guidance will be posted on ASHA’s coding web page after its official release in September.
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. However, CMS excluded providers who cannot report E/M services under the MPFS, including audiologists and SLPs. ASHA submitted comments [PDF] urging CMS to allow audiologists, SLPs, and other providers to report this important code. Despite ASHA’s request, CMS has opted not to expand use of G2252 in 2022. ASHA will continue to recommend that CMS include audiologists and SLPs as eligible providers of audio-only virtual check-ins.
Although CMS addresses telehealth services in the proposed rule, there are no telehealth changes for audiologists and SLPs in 2022. 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.
ASHA remains committed to securing Congressional authority for members to receive reimbursement for services provided via telehealth for an extended period beyone 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 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 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 nine 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 proposes to maintain eight of the measures in the audiology specialty measure set for the 2022 performance/2024 payment year. It is proposing to remove measure 154: Falls: Risk Assessment. This provides audiologists with the flexibility to select among eight options for reporting, as only a minimum of six measures need to be reported.
For SLPs, CMS proposes to maintain the five measures in the specialty measure set for the 2022 performance/2024 payment year. 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 proposed rule.
APMs, a key initiative within the QPP, incentivize 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. 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 proposed rule will be published in a future issue of The ASHA Leader. The current 2021 Medicare outpatient payment rates and related information for audiologists and SLPs are available on ASHA’s website.
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