Additional Details on the 2024 Medicare Proposed Rule, Including New Codes and Quality Measures, Payment Cuts, and Telehealth Coverage

The Centers for Medicare & Medicaid Services (CMS) has released the 2024 Medicare Physician Fee Schedule (MPFS) proposed rule, which establishes payment policies and rates for Part B (outpatient) audiology and speech-language pathology services. Significant policies addressed in this rule include—but are not limited to—new codes for auditory osseointegrated device (AOD) programming and caregiver training; payment cuts for audiology, speech-language pathology, and other services; 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 the 2024 calendar year.

The following information highlights key provisions impacting audiologists and speech-language pathologists (SLPs). Many of the proposals contained in the rule reflect policy improvements that ASHA advocated for.

• Payment Rates
• Coding Updates
• Access to Audiology Services and AB Modifier
• Telehealth
• Quality Payment Program
• Social Determinants of Health
• Targeted Manual Medical Review
• Resources and Contacts

Payment Rates

Conversion Factor

CMS uses an annual conversion factor (CF) to calculate MPFS payment rates. For 2024, CMS estimates that the CF will be $32.7476, representing a 3.36% decrease from the $33.89 CF for 2023. The proposed decrease in the CF is due in large part to the expiration of the temporary 2.5% positive adjustment that Congress implemented to mitigate significant payment cuts in 2023 and Medicare’s requirement to maintain a budget neutral program. However, it’s important to note that the proposed CF includes a 1.25% increase required by Congress to help mitigate the 2024 payment cuts.

Next steps for ASHA: ASHA has strongly advocated against the Medicare Part B payment cuts since they were first set to occur in 2021, leading to Congressional intervention to soften the blow of the cuts each year, including the mitigation that is in place for 2024. However, Medicare providers will continue to face payment instability unless Congress acts to reform the Medicare payment system. ASHA remains fully committed to continuing advocacy and collaboration with members of Congress, CMS, key decision makers, and other providers to find short and long-term solutions to address Medicare payment issues, including supporting H.R. 2474, the Strengthening Medicare for Patients and Providers Act.

In addition to the reduction to the CF, CMS’s regulatory impact analysis (RIA) estimates that audiologists and SLPs will see a cumulative 2% decrease based on policy changes proposed for 2024. 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.

What you can do: ASHA members can take action by urging their members of Congress to improve fiscal stability for Medicare providers by supporting H.R. 2474, which would provide an annual inflationary payment update based on the Medicare Economic Index (MEI).

Coding Updates

CMS proposes to add five new Current Procedural Terminology (CPT®) codes related to auditory osseointegrated device programming (2 codes) and caregiver training (3 codes) as covered services under the 2024 MPFS.

More information on the new codes, including final code numbers, will be posted on ASHA’s coding webpage when the AMA releases the 2024 CPT code set this September.

Auditory Osseointegrated Device (AOD) Services

Effective January 1, 2024, audiologists will see two new timed codes describing the first hour and each subsequent 15 minutes of time for the analysis, programming, and verification of an auditory osseointegrated sound processor. These codes can also be used for subsequent reprogramming of the AOD. CMS also proposes to add both codes to the list of services that can be billed with an “AB” modifier when performed by an audiologist without a physician referral for a nonacute hearing condition.

Caregiver Training

Beginning in 2024, SLPs can report caregiver training services (CTS) without the patient present, when provided under an established, individualized, and patient-centered plan of care. This proposed rule marks the first time CMS will allow therapists, including SLPs, to bill and receive MPFS payment for services without the patient present. CMS acknowledges the importance and efficacy of reasonable and necessary caregiver training to influence successful health outcomes for patients.

Billing for caregiver training is based on the individual patient whose caregiver(s) require training to help with the treatment plan and facilitate functional performance. Billing is not based on the number of caregivers in the training session.

• Training for the caregivers of one patient is billed with two timed codes for the initial 30 minutes (9X015) and each additional 15 minutes (9X016). Clinicians will bill caregiver training for an individual patient once per session, regardless of the number of caregivers involved in the training.
• Group training for caregivers of more than one patient is billed with one untimed code, 9X017, per patient represented in the group. Clinicians will bill group caregiver training once per patient, not once per caregiver.

Caregiver definition

CMS broadly defines a caregiver as “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.” For the purposes of the CTS policy, CMS proposes to further define a caregiver as a person who is assisting a patient with a short or long-term illness or condition that is not necessarily chronic or disabling in order to manage activities of daily living at home or to navigate the patient’s transitions between care settings. CTS may not be billed for training medical professionals or support personnel who are employed to provide care to the patient.

To bill for caregiver training without the patient present, CMS indicates that caregivers must be trained by the patient’s treating clinician to assist with aspects of the patient’s care that are directly related to an established plan of care to address a diagnosed illness or injury.

Reasonable and necessary CTS

CMS considers CTS to be reasonable and necessary when services are “integral to the patient’s overall treatment and furnished after the treatment plan (or therapy plan of care) is established.” They indicate that a plan of care should account for those clinical circumstances when the treating clinician determines that caregiver involvement is necessary to assist in carrying out a treatment plan to support successful outcomes for the patient. According to CMS, examples of patient conditions that may warrant CTS include, but are not limited to “stroke, traumatic brain injury (TBI), dementia, autism spectrum disorders, individuals with other intellectual or cognitive disabilities, physical mobility limitations, or necessary use of assisted devices or mobility aids.”

CMS also notes the patient should agree to caregiver involvement and proposes that clinicians must document the patient’s or their representative’s consent for the caregiver(s) to receive training without the patient present.

Next steps for ASHA: ASHA will provide comments to clarify CMS guidelines, such as documentation of patient consent, and to ensure that CMS’s CTS policies reflect current clinical practice while appropriately considering patient and caregiver needs.

Remote Therapeutic Monitoring (RTM)

SLPs have been able to provide and bill for RTM services under the MPFS since 2023. However, CMS waived certain billing requirements to allow broader patient access to care during the federal public health emergency (PHE). In this proposed rule, CMS clarifies that billing requirements for RTM services have changed with the end of the PHE. For example, the RTM codes may only be billed when monitoring requires data collection for at least 16 days in a 30-day period. In addition, CMS notes that only one clinician may report the remote monitoring codes in a 30-day period and that RTM services may not be billed in conjunction with remote physiologic monitoring (RPM) codes.

Access to Audiology Services and “AB” Modifier

In 2023, CMS implemented a policy that allows audiologists to provide nonacute hearing assessment services―under limited circumstances―without a physician order. No substantive changes were made to this policy with the exception of adding two CPT codes to the list of services that can be billed without an order using the “AB” modifier―926X1 and 926X2―bringing the total number of services that can be provided under the limitations of the policy to 38 CPT codes. More details regarding this policy can be found on the ASHA website.

Next steps for ASHA: ASHA continues to monitor the implementation of this policy and to advocate for improvements. In addition, ASHA supports legislation that would improve the Medicare audiology benefit to include removal of the physician order requirement, coverage of both assessment and treatment services, and reclassifying audiologists as “practitioners” which would allow them to bill for telehealth services on a permanent basis.

What you can do: Contact your member of Congress today and encourage them to cosponsor the Medicare Audiology Access Improvement Act (S. 2377)

Telehealth

CMS implements the requirements of the Consolidated Appropriations Act of 2023 (CAA) by extending telehealth coverage of audiology and speech-language pathology services paid under the fee schedule through December 31, 2024. All CPT codes covered under the federal PHE will remain covered through the end of next year.

Next steps for ASHA: ASHA remains committed to securing permanent authority for audiologists and SLPs to receive reimbursement for services provided via telehealth at parity with payment for in-person services.

What you can do: Visit ASHA’s Take Action site to urge your members of Congress to advocate for permanent telehealth coverage under Medicare by supporting the Expanded Telehealth Access Act (H.R. 3875).

Telehealth Billing Change

Although CMS plans to extend telehealth coverage through 2024 by continuing most PHE-era policies, CMS confirms that, effective January 1, 2024, clinicians will no longer bill telehealth claims with modifier “95” when the originating site is the patient’s home. Instead, clinicians will include place of service (POS) “10” when providing telehealth services in the patient’s home or POS “02” when the patient is at a location other than their home, such as a satellite office or other facility.

In addition, CMS acknowledges that most clinicians providing telehealth services also maintain an in-person practice, so their expenses to provide telehealth services do not change significantly. As a result, CMS proposes to continue paying for telehealth services in the patient’s home when billed with POS “10” at the higher nonfacility rate. All other claims billed with POS “02” will be paid at the lower facility rate.

Telehealth in Institutional Settings

CMS also seeks feedback on coverage of outpatient physical and occupational therapy and speech-language pathology services provided by institutional providers, including hospital outpatient departments, skilled nursing facilities, and home health agencies. CMS notes in the proposed rule it will continue to allow institutional providers to bill for telehealth services as they did under the PHE through December 31, 2024, as they analyze the feedback they receive.

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 (MIPS) and Advanced Alternative Payment Models (APMs). Details on key updates to MIPS measures are outlined below. Additional details on qualifying for incentive payments through APMs will be posted on ASHA’s website at a later date.

Merit-Based Incentive Payment System (MIPS)

CMS proposes to add several new measures to the MIPS specialty measure sets for audiologists and SLPs in 2024. A robust measure set is important because there is a requirement to report a minimum of 6 quality measures when a clinician is a mandatory MIPS reporter. These additions ensure audiologists and SLPs have more than 6 measures in their respective specialty measure sets, giving these professionals the flexibility to select measures that are most reflective of their clinical practice.

If the proposal is finalized, the audiology specialty measure set for the 2024 performance/2026 payment year will include two new measures:

• Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive
• Connection to Community Service Provider: Percent of patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety; and had contact with a Community Service Provider (CSP) for at least 1 of their HRSNs within 60 days after screening.

Clinicians continue to be excluded from mandatory MIPS participation if they have allowed charges for covered professional services less than or equal to $90,000, furnish covered professional services to 200 or fewer Medicare Part B-enrolled individuals, or furnish 200 or fewer covered professional services to Medicare Part B-enrolled individuals. As a result, ASHA estimates that less than 1% of its members are subject to MIPS.

Social Determinants of Health (SDOH)

CMS proposes several policy changes to better align with the Department of Health and Human Services’ (HHS) SDOH Action Plan. Although the proposals don’t include audiologists or SLPs at this time, CMS’s actions highlight the growing importance of SDOH considerations in payment systems. ASHA encourages clinicians to learn more about SDOHs and how they impact patient care.

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. However, clinicians must append modifier “KX” when medically necessary services reach a monetary threshold, which changes annually. For 2024, CMS proposes a “KX” modifier threshold of $2,330 for physical therapy and speech-language pathology services combined. This represents a $100 increase from the 2023 threshold amount of $2,230. Find more information regarding the permanent repeal of the cap and the current targeted medical review process on ASHA’s website.

ASHA Resources

The current 2023 Medicare outpatient payment rates and related information for audiologists and SLPs are available on ASHA’s website.

Take action! Visit ASHA’s Take Action page to contact your representatives regarding the Medicare Audiology Access Improvement Act (S. 2377), Expanded Telehealth Access Act (H.R. 3875), and Strengthening Medicare for Patients and Providers Act (H.R. 2474).

Questions?

Please contact reimbursement@asha.org.