Additional Details on 2023 Medicare Proposed Rule, Including Payment Cuts, Access to Audiology Services, Coding Updates

The Centers for Medicare & Medicaid Services (CMS) has released the 2023 Medicare Physician Fee Schedule (MPFS) proposed rule, which establishes policies and payment rates for Part B (outpatient) audiology and speech-language pathology services. Significant policies addressed in this rule include—but are not limited to—a new provision for access to audiology services; payment cuts for audiology, speech-language pathology, and other services; changes to coding for remote therapeutic monitoring; telehealth services; quality reporting; and alternative payment models.

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).

ASHA will submit comprehensive comments on the proposed rule by early September. The final rule will apply to services provided in calendar year 2023.

Additional details included below:

• Payment Rates
• New Provisions for Access to Audiology Services
• Coding Updates
• Medicare Telehealth
• Quality Payment Program (QPP)
• Medicare Targeted Manual Medical Review 

Payment Rates

CMS uses an annual conversion factor (CF) to calculate MPFS payment rates. For 2023, CMS estimates that the CF will be $33.08, representing a nearly 4.5% decrease from the $34.61 CF for 2022. The decrease in the CF is primarily due 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.

Although Congress has taken action to limit the worst of the cuts over the past two years, similar action to address the 2023 cuts is not assured in part because of the cost to the federal government. The ongoing cuts threatening Medicare providers can only be permanently addressed through fundamental long-term changes to the Medicare payment system. ASHA remains fully 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. Please see ASHA’s update page for additional background on the payment cuts and to learn more about ASHA’s ongoing advocacy efforts.

In addition to the almost 4.5% reduction to the CF, CMS’s regulatory impact analysis (RIA) estimates that audiologists will see a cumulative 0% change in payments and SLPs will see a 1% decrease based on policy changes proposed for 2023. However, cumulative payment 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 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.

New Provisions for Access to Audiology Services

CMS states in the proposed rule that it has the administrative authority to remove the physician or practitioner (e.g., physician assistant, nurse practitioner) order requirement for audiology hearing and balance assessment services under traditional Medicare and proposes to do so. While ASHA strongly supports the ability of a Medicare beneficiary to access audiology services without a physician or practitioner order, implementation of this particular provision is limited, problematic and, as proposed, could create significant administrative burdens for audiologists and access issues for Medicare beneficiaries.

The proposal would create the development of a new G-code, GAUDX, that could be used once every 12 calendar months per Medicare beneficiary for non-acute hearing assessment only. When used, GAUDX would be reported instead of 36 Current Procedural Terminology (CPT®) codes that represent audiology services (see Table 29 in the proposed rule). Once GAUDX is used in the 12-month period, audiologists would need to secure an order for services and use the CPT code that reflects the service.

CMS proposes a payment value for GAUDX based on two CPT codes typically used by audiologists that in many cases would undervalue the cost of providing non-acute hearing assessments to patients. ASHA will make specific recommendations to CMS regarding ways to more accurately reflect utilization of audiologic non-acute hearing assessment services that minimizes administrative burden, appropriately pays for these services, and maintains access to care for Medicare beneficiaries. These recommendations will align with the Medicare Audiologist Access and Services Act (H.R. 1587/S. 1731) that includes a provision to remove the unnecessary physician or practitioner order requirement. Despite the action from CMS, ASHA remains committed to advocating for full passage of the Medicare audiology services bill this year.

Coding

Remote Therapeutic Monitoring (RTM) Services

CMS is proposing two new G-codes for RTM services for use under the MPFS. Under the proposed rule, speech-language pathologists (SLPs) would be required to report these new G-codes instead of existing CPT codes for RTM treatment management services (CPT codes 98980 and 98981), as follows.

GRTM3 Remote therapeutic monitoring treatment assessment services, first 20 minutes furnished personally/directly by a nonphysician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the month

GRTM4 Remote therapeutic monitoring treatment assessment services, each additional 20 minutes furnished personally/directly by a nonphysician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the month

Other RTM codes related to the monitoring devices (CPT codes 98975, 98976, and 98977) would still be available for billing under the MPFS. CPT codes 98980 and 98981 would be marked for nonpayment under the MPFS but would still be available for use with non-Medicare payers.

Communication Technology-Based Services (CTBS) Codes

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. SLPs and certain other nonphysician providers may bill Medicare for CTBS codes for brief virtual check-ins, e-visits, and remote assessment of recorded images or videos. However, SLPs are not able to bill for an extended audio-only virtual check in (G2252), which can be critical to help providers stay connected with Medicare beneficiaries who may not have access to audio-visual technology. 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 2023. ASHA will continue to recommend that CMS include audiologists and SLPs as eligible providers of extended audio-only virtual check-ins.

Billing of CTBS Codes by Audiologists

CMS has not expanded coverage of any CTB services for audiologists due to the limitations of the audiology diagnostic benefit. ASHA continues to request access to these codes under the audiology benefit, both in writing and in meetings with CMS staff, but CMS is again not allowing audiologists to bill Medicare Part B for these important CTB services in 2023.

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 ultimately expires. However, it will include several CPT codes typically used by audiologists and SLPs through the end of 2023, as listed below (see also, Table 8 of the proposed rule). If the PHE ends prior to the end of 2023, these codes will only be reimbursed when provide by a physician or practitioner.

ASHA remains committed to advocating for permanent Medicare coverage of audiology and speech-language pathology services delivered via telehealth at pay parity with in-person services.

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. However, CMS proposes to require reporting on the Promoting Interoperability performance category beginning with the 2024 performance period. 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 treat 200 or more Medicare beneficiaries, provide 200 or more covered professional services, and 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 nine potentially applicable measures and SLPs have six potentially applicable measures. More information on MIPS for audiologists and SLPs is available on ASHA’s website.

CMS proposes to maintain seven of the eight measures in the audiology specialty measure set for the 2023 performance/2025 payment year and is removing measure 261, Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness. It also proposes to add two new measures. This provides audiologists with the flexibility to select among nine options for reporting, since only 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 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; would not be eligible for claims-based reporting if changes finalized)
• Measure 226: Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention
• 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 proposes to maintain the five measures in the specialty measure set for the 2023 performance/2025 payment year and adds one measure. This means that SLPs must report all six 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
• Screening for Social Drivers of Health (Added)

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.

Advanced Alternative Payment Models (APMs)

APMs, 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%. In other words, 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.

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 at the individual level rather than APM entity level in the future. 

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 ASHA’s website.

ASHA Resources

Additional details on the proposed rule will be published in a future issue of The ASHA Leader. The current 2022 Medicare outpatient payment rates and related information for audiologists and SLPs are available on ASHA’s website.

Questions?

Please contact reimbursement@asha.org.