Additional Details on 2023 Medicare Fee Schedule, Including Payment Cuts, Access to Audiology Services

The Centers for Medicare & Medicaid Services (CMS) has released the 2023 Medicare Physician Fee Schedule (MPFS) final rule, which establishes payment policies and rates for Part B (outpatient) audiology and speech-language pathology services. Significant policies addressed in this rule include:

• negative payment adjustments for all services paid under the MPFS, including audiology and speech-language pathology,
• coding updates,
• a new provision that provides limited access to audiology services without a physician order,
• telehealth services,
• quality reporting, and
• alternative payment models.

ASHA provided extensive comments [PDF] to CMS regarding these issues in response to the 2023 proposed rule released in July.

Medicare pays for outpatient clinic and office-based audiology and speech-language pathology services under 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).

The final rule applies to services provided in calendar year 2023.

Payment Rates

CMS uses an annual conversion factor (CF) to calculate MPFS payment rates. The 2023 CF is $33.06, representing a nearly 4.5% decrease from the $34.61 CF for 2022. The significant decrease in the CF is due in large part to the expiration of the 3% positive adjustment that Congress implemented to mitigate the payment cuts in 2022. Congress must act again to stop the cuts in 2023.

Medicare providers also face other Medicare cuts known as sequestration (2% reduction) and statutory "Pay-As-You-Go", or PAYGO, (4% reduction). This could result in a total cut of over 10% to overall Medicare payments when added to the CF reduction. Congress acted in 2021 and 2022 by passing legislation that significantly reduced some of the cuts and phased in the remaining cuts over the course of 2022.

For 2023, CMS estimates an overall 2% decrease in payment for audiology services and a 1% decrease for speech-language pathology services in addition to the adjustments outlined above. This means audiologists and SLPs are facing at least a 12% and 11% decrease in payments, respectively. Note: The direct cumulative impact of payment adjustments on individual clinicians or practices will vary depending on several factors, including locality specific rates and the procedure codes billed. 

Due to federal budget concerns, similar action to address the 2023 cuts is not assured. The ongoing cuts threatening Medicare providers can only be permanently addressed through fundamental long-term changes to the Medicare payment system. ASHA is committed to continuing advocacy and collaboration with members of Congress, CMS, key decision makers, and other provider groups to find short- and long-term policy solutions to stop the cuts and initiate Medicare payment reform. Bipartisan legislation, the Supporting Medicare Providers Act of 2022 (H.R. 8800), has been recently introduced by Representatives Ami Bera (D-CA) and Larry Buchson (R-IN) to mitigate cuts in 2023. ASHA strongly encourages audiologists and SLPs to contact their members of Congress and ask them to cosponsor H.R. 8800 and address the Medicare cuts before the end of the year. Please see ASHA’s update page for additional background information on Medicare payment cuts and to learn more about ASHA’s ongoing advocacy efforts.

ASHA will publish final 2023 national payment rates for audiology and speech-language pathology services in its full MPFS analysis.

New Provisions for Access to Audiology Services

In response to recommendations made by ASHA, CMS has finalized its policy to remove the physician or practitioner (e.g., physician assistant, nurse practitioner) order requirement for select hearing assessment services for nonacute hearing loss. Note: This provision applies to hearing assessment services already covered under the MPFS and only expands coverage of audiology services by removing the physician order required under limited circumstances.

Audiologists will use the CPT code for the service with an “AB” modifier to indicate the service was provided without an order. A Medicare beneficiary can receive hearing assessment services without a physician order only:

1. once every 12 calendar months on the same date of service,
2. for a select number of services, outlined below, and
3. when presenting with nonacute hearing loss.

Medicare defines nonacute hearing loss as “a more gradual hearing loss that one may experience with advancing age, known as presbycusis.” In addition, only 36 Current Procedural Terminology (CPT® American Medical Association) codes can be provided without a physician order.

While the use of the code/modifier improves the accuracy of audiology claims data and payments, as well as eliminates coding confusion, ASHA finds the restrictions placed on accessing audiology services without a physician order to be arbitrary and lacking any clinical justification. ASHA is committed to working with CMS to refine this proposal to ensure timely access to care for Medicare beneficiaries that recognizes the education and scope of practice of audiologists. Restrictions preventing the billing of both hearing and balance assessment services as well as to once per beneficiary per 12-calendar months does not align with the clinical needs of patients. In addition, passage of the Medicare Audiologist Access and Services Act (H.R. 1587/S. 1731), would remove the physician referral requirement completely while appropriately expanding Medicare coverage to include both diagnostic and treatment services provided by audiologists. ASHA encourages audiologists to ask their members of Congress to support passage of the Medicare Audiologist Access and Services Act before the end of this year.

More details on how to bill and document for the approved hearing assessment services provided without an order is available on ASHA’s website. ASHA will also host a webinar to walk through the new policy on December 13 at 1:00 p.m. ET. This course is available as part of the ASHA Learning Pass subscription or as an a la carte purchase.

Remote Therapeutic Monitoring (RTM) Services

Initially, CMS proposed two new G-codes for RTM services for use under the MPFS. ASHA opposed the new G-codes because they would have created coding confusion and reduced payment for RTM treatment management services when provided by SLPs. After considering extensive ASHA and stakeholder comments, CMS will not implement the G-codes and will maintain payment for the existing Current Procedural Terminology (CPT®) codes (98980 and 98981) for RTM treatment management services. As a result, SLPs currently reporting CPT codes 98980 and 98981 will see no change to Medicare coding and billing requirements for RTM treatment management services in 2023.

In addition to maintaining the current codes for RTM treatment management services, CMS also added a new RTM device code to reflect the supplies for monitoring devices related to cognitive behavioral therapy (CBT), as follows.

98978:    Remote therapeutic monitoring (eg, therapy adherence, therapy response); device(s) supply with scheduled (eg, daily) recording(s) and/or programmed alert(s) transmission to monitor cognitive behavioral therapy, each 30 days

CPT code 98978 was not assigned a specific value and will be contractor priced. SLPs should verify coverage and billing for this new code with their local Medicare administrative contractor and other non-Medicare payers.

Note: Audiologists may not bill Medicare for RTM services and should check with non-Medicare payers directly regarding coverage and billing.

Medicare Telehealth Services

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 and the 151-day extension expires. However, the final rule includes ongoing coverage of several CPT codes used by audiologists and SLPs through the end of 2023, as listed below (see also, Table 12 of the final rule). This means that these codes will continue to be payable through 2023 when provided by a physician or practitioner, or by an SLP providing services incident-to such a provider, even if the PHE and extension expire earlier.

ASHA is committed to advocating for permanent Congressional authority for audiologists and SLPs to be telehealth providers under Medicare.

Implementation of Telehealth Provisions for 151 Days After the End of the PHE

The Consolidated Appropriations Act extended certain Medicare telehealth flexibilities adopted during the PHE for 151 days after the federal COVID-19 PHE expires. In the final rule, CMS confirms that during the 151-day extension, it will continue the same flexibilities, which will help minimize provider and Medicare contractor burden and ensure continued beneficiary access to telehealth services across geographic areas; in a broad range of settings (including the patient’s home); and from a wide array of providers, including audiologists and SLPs.

Of note, CMS will still require providers to include modifier “95” on claims for Part B telehealth services furnished on or before the 151st day after the federal PHE expires, in alignment with policies related to the current telehealth flexibilities. CMS will also continue to allow Part B providers to use the place of service (POS) code that best reflects where the services would have normally been furnished in person. For example, a clinician in a private practice providing telehealth services into a patient’s home could report POS 11 (office) because that’s where they would have provided in-person services.

See ASHA’s website for additional details about Medicare’s telehealth coverage during and after 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. 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 2023. To qualify as a mandatory MIPS reporter, an audiologist or SLP must 1) treat 200 or more Medicare beneficiaries, 2) provide 200 or more covered professional services, and 3) receive $90,000 or more in allowed reimbursement from Medicare.

For eligible participants, CMS will apply a payment incentive or penalty to 2025 Medicare payments for performance on the quality and improvement activities (IAs) performance categories in 2023. For the quality performance category, MIPS eligible clinicians—including audiologists and SLPs—must report a minimum of six measures when six measures apply. In 2023, audiologists have 10 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 will maintain the eight measures in the audiology specialty measure set and add two new measures for the 2023 performance/2025 payment year. This provides audiologists with the flexibility to select six measures from the 10 options for reporting.

• Measure 130: Documentation of Current Medications in the Medical Record
• Measure 134: Preventive Care and Screening: Screening for Depression and Follow-Up Plan
• Measure 155: Falls: Plan of Care
• Measure 181: Elder Maltreatment Screen and Follow-Up Plan
• Measure 182: Functional Outcome Assessment (updated to reflect function in terms of hearing; not be eligible for claims-based reporting)
• 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
• Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling (Added)
• Screening for Social Drivers of Health (Added)

For SLPs, CMS will maintain the five measures in the specialty measure set for the 2023 performance/2025 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
• Measure 182: Functional Outcome Assessment (updated to reflect function in terms of swallowing; would not be eligible for claims-based reporting if changes finalized)
• 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 final rule.

Advanced Alternative Payment Models (APMs)

APMs, the second track and a key initiative within the QPP, incentivize quality and value. Audiologists and SLPs may participate in the Advanced APM option in 2023. Those who successfully participate will receive a 5% lump-sum incentive payment on their Part B services in 2025. For performance year 2023, the Medicare-Only payment threshold is 75% and the patient count threshold is 50%. Therefore, at least 75% of your Medicare Part B payments or at least 50% 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 50% for the payment amount method or 35% under the patient count method.

Note: 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 is requesting feedback on the idea of calculating threshold scores and making qualified provider determinations exclusively at the individual, rather than APM entity level, in the future.

Additional changes have been made for 2023 with the aim to jumpstart enrollment in accountable care organizations (ACOs) and make them more accurate and equitable.

To address the need for upfront capital to succeed in accountable care, shared savings payments (referred to as advance investment payments) will be available to low revenue ACOs inexperienced with performance-based risk Medicare ACO initiatives, those that are new to the Shared Savings Program, and those that serve underserved populations.

To ease the transitions from fee-for-service to value-based care, CMS will allow ACOs inexperienced with the performance-based risk model to participate in a one-sided shared savings model for 5-7 years. This means that ACOs can be rewarded for providing high-quality, cost-effective care without financial risk for the first 5-7 years.

Other changes include:

• retooling the benchmarking system to encourage long-term participation in the program,
• modifying the risk adjustment methodology to more accurately account for medically complex and high-cost patients, and
• providing a health equity adjustment of up to 10 bonus points to an ACO’s quality performance category score will be available for certain participants.

For performance year 2023, ACOs will be required to report either the 10 measures under the CMS Web Interface:

• Quality ID# 001 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
• Quality ID # 134 Preventive Care and Screening: Screening for Depression and Follow-Up Plan
• Quality ID # 370 Depression Remission at Twelve Months
• Quality ID # 318 Falls: Screening for Future Fall Risk
• Quality ID # 438 Statin Therapy for the Prevention and Treatment of Cardiovascular Disease
• Quality ID # 110 Preventive Care and Screening: Influenza Immunization
• Quality ID # 112 Breast Cancer Screening
• Quality ID # 113 Colorectal Cancer Screening
• Quality ID # 226 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention
• Quality ID # 236 Controlling High Blood Pressure

or the three electronic clinical quality measures (eCQMs) /MIPS CQMs:

• CMS eCQM ID: CMS122v11 Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
• CMS eCQM ID: CMS2v12 Depression Screening and Follow-Up
• CMS eCQM ID: CMS165v11 Controlling High Blood Pressure

and administer the Consumer Assessment of Healthcare Providers & Systems (CAHPS) for MIPS survey.

Medicare Targeted Manual Medical Review

CMS notes in the final 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.

ASHA Resources

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 2023 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.

Questions?

Contact reimbursement@asha.org.