Centers for Medicare and Medicaid Services (CMS) CY2023 Physician Fee Schedule Update

Kim Cavitt, Au.D.

Physician Order Requirement Changes, effective January 1, 2023 (www.cms.gov/files/document/cy2023-physician-fee-schedule-final-rule-cms-1770f.pdf)

As of January 1, 2023, audiologists will be able to provide Medicare Part B beneficiaries with a nonacute hearing assessment every 12 months without a physician order. However, these assessments must be unrelated to:

• Disequilibrium or hearing aids
• Examinations for the purpose of prescribing, fitting, or changing hearing aids

This applies to traditional Medicare (Part B) beneficiaries only. Medicare Advantage plans, generally, do n

Medicare Advantage plans, generally, do not require a physician order (unless specified in your agreement).

Vestibular Services (92517-92519 and 92537-92549) will always require a physician order for traditional Medicare coverage. (See Table A).

When the chief complaint is non-acute hearing assessment and unrelated to disequilibrium or hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids AND the audiologist is providing one or more of the 36 procedures listed in Table A, the audiologist can assess this patient once per calendar year without a physician order.

Audiology practices, especially at the outset, will need to be wary of the use of acute diagnoses such as sudden idiopathic hearing loss, acute otitis media, or vestibular diagnoses (dizziness, labyrinthis, neuronitis) on claims without a physician order. The Academy of Doctors of Audiology (ADA) recommends obtaining a physician order when receiving a referral from a physician or NPP, specifically an otolaryngologist (even if you are employed by the same business entity), for assessment of an acute otologic or vestibular conditions. In these situations, it is better to err on the side of caution and obtain a physician order, even if you are employed by the same business entity.

SCHEDULING

Triage will be invaluable at scheduling to determine the appropriate need for a physician order. A practice will need to screen individuals for the warning signs of ear disease and any complaint, symptom, or condition that is recent (within the past 90 days), or which involves disequilibrium (dizziness, vertigo, imbalance). Acute and disequilibrium concerns should be referred to a physician or NPP prior to testing, to secure a physician order.

Table A: The list of 36 audiologic procedures that can be provided by audiologists for non-acute conditions without a physician or non-physician practitioner (NPP; nurse practitioner, physician assistant, for example) order once every 12 months.

BILLING

When a physician order is not required and not obtained, no ordering physician will be listed on the claim. Instead, the AB modifier (Audiology service furnished personally by an audiologist without a physician/NPP order for non-acute hearing assessment unrelated to disequilibrium, or hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids; service may be performed once every 12 months, per beneficiary) must be added to every procedure code performed on that date of service.

Generally, the services billed on a traditional Medicare claim, will either all be physician ordered (where the name and national provider identifier of the ordering physician or non-physician practitioner is listed on the claim) or not ordered (non-acute hearing assessment and unrelated to disequilibrium or hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids where the AB modifier is added to every item and service listed on the claim). Failure to document an ordering physician AND failure to add an AB modifier to every service on a claim (that was provided without an order) will result in a claims denial. One exception may be when billing for some services to obtain the required Medicare denial. In this case, the GY modifier (item or service statutorily excluded or does not meet the definition of a Medicare benefit) would be added to those items and services which are non-covered by Medicare.

CMS will provide additional communication to determine if a patient has been seen in the past 12 months and therefore, a practice would be required to obtain a physician and/or NPP order to inform the patient that the testing would not be medically necessary.

It is recommended that practices either utilize an Advanced Beneficiary Notice, prior to assessment, or secure a physician referral if their practice has 1) no record of the use of the AB code (and associated testing) by their or another practice within the past 12 months, 2) does not have a physician order, AND 3) are planning, as a result of the lack of a physician order, to utilize the AB modifier. Triage at the time of scheduling cannot be understated. ADA also encourages audiologists to reach out to their Electronic Health Record/ Electronic Medical Record (EHR/EMR) vendors to determine what internal verification processes might exist.

Practices will need to obtain a physician order for ANY medically necessary procedure on the audiology code list (www.cms.gov/audiology-services) and/or that is listed in Table A once the beneficiary has undergone audiologic testing and utilized the AB modifier, for any service, within the past 12 months.

GENERAL REMINDERS

Please note that just because the outcome is a hearing aid, does not mean that Medicare does not cover audiologic testing. Per CMS Update to Audiology Policies, “It is appropriate to pay for audiological services for patients who have sensorineural hearing loss and who wear hearing aids if the reason for the test is anything other than evaluation of the hearing aid. For example, there may be a perceived change in hearing or tinnitus that makes testing appropriate and covered1. Such testing might rule out other reasons for the symptoms (auditory nerve lesions, middle ear infections) and result in subsequent evaluation of the hearing aid (not covered) or aural rehabilitation by a speech-language pathologist (covered). 5717.5 When a test reveals information that is not known to the physician prior to the test, that information cannot be used to deny payment. For example, a test ordered due to a reported change in hearing may not be denied when the results reveal there is no change in hearing, but the audiologist also finds a hearing aid malfunction. However, if no hearing change is reported but the physician is aware that the patient’s hearing aid is broken, a test cannot be ordered solely for the purpose of fitting a new hearing aid.

Medicare covers testing that is medically reasonable and necessary. Per CMS Medicare Benefit Policy Manual, Chapter 15, section 80.3 (C)2:

“Coverage and, therefore, payment for audiological diagnostic tests is determined by the reason the tests were performed, rather than by the diagnosis or the patient’s condition.”

Under any Medicare payment system, payment for audiological diagnostic tests is not allowed by virtue of their exclusion from coverage in section 1862(a)(7) of the Social Security Act when:

• The type and severity of the current hearing, tinnitus or balance status needed to determine the appropriate medical or surgical treatment is known to the physician before the test; or
• The test was ordered for the specific purpose of fitting or modifying a hearing aid.

Payment of audiological diagnostic tests is allowed for other reasons and is not limited, for example, by:

• Any information resulting from the test, for example:
  • Confirmation of a prior diagnosis;
  • Post-evaluation diagnoses; or
  • Treatment provided after diagnosis, including hearing aids, or
• The type of evaluation or treatment the physician anticipates before the diagnostic test; or
• Timing of reevaluation. Reevaluation is appropriate at a schedule dictated by the ordering physician when the information provided by the diagnostic test is required, for example, to determine changes in hearing, to evaluate the appropriate medical or surgical treatment or to evaluate the results of treatment. For example, reevaluation may be appropriate, even when the evaluation was recent, in cases where the hearing loss, balance, or tinnitus may be progressive or fluctuating, the patient or caregiver complains of new symptoms, or treatment (such as medication or surgery) may have changed the patient’s audiological condition with or without awareness by the patient.

Examples of appropriate reasons for ordering audiological diagnostic tests that could be covered include, but are not limited to:

• Evaluation of suspected change in hearing, tinnitus, or balance;
• Evaluation of the cause of disorders of hearing, tinnitus, or balance;
• Determination of the effect of medication, surgery, or other treatment;
• Reevaluation to follow-up changes in hearing, tinnitus, or balance that may be caused by established diagnoses that place the patient at probable risk for a change in status including, but not limited to: otosclerosis, atelectatic tympanic membrane, tympanosclerosis, cholesteatoma, resolving middle ear infection, Meniére’s disease, sudden idiopathic sensorineural hearing loss, autoimmune inner ear disease, acoustic neuroma, demyelinating diseases, ototoxicity secondary to medications, or genetic vascular and viral conditions;
• Failure of a screening test (although the screening test is not covered);
• Diagnostic analysis of cochlear or brainstem implant and programming; and
• Audiology diagnostic tests before and periodically after implantation of auditory prosthetic devices”.

Please note that, if an audiologist has never assessed the beneficiary, they do not know the “cause of disorders of hearing, tinnitus, or balance” or whether or not they are a hearing aid candidate. As a result, this testing is not precluded from legitimate Medicare coverage if medical necessity is documented in the medical record.

TAKE HOME MESSAGE

Audiology has a significant opportunity here to illustrate the safety, efficacy, and savings of direct access. Do not ruin this for the entire profession by failing to refer for otologic and/ or medical evaluations, when medically necessary, and/or by failing to appropriately document referrals in the medical record and in the audiologic reports to primary care and attending physicians and health care providers. Documentation will be vital for medical necessity and medical review.

This will be a large learning curve for audiologists, their staffs, EHR/EMR vendors, clearinghouses, and Medicare Administrative Contractors (MACs). Education and patience will be important, especially in the first quarter of 2023. Per CMS, in the Final Rule:

“Aligning our final policy to use modifier AB…necessitates multiple changes to our claims processing systems, which will take some time to operationalize, possibly until midyear 2023. Until such time, audiologists may use the AB modifier that is available for dates of service on and after January 1, 2023, to provide services/tests to beneficiaries who have directly accessed their services. Audiologists who furnish these services without an order are expected to follow our policy and safeguards built into the AB modifier, as above and in the code descriptor below. As we noted above, we plan to communicate to audiologists via provider education and other guidance, including the Audiology Services webpage page at https://www.cms.gov/audiology-services”.

The Academy of Doctors of Audiology (ADA) will continue to communicate with its members as new information becomes available. ADA will be hosting their annual coding and reimbursement update on December 9, 2022 at 12PM EST. Please watch your email for more information.

Medicare Conversion Factor and Pricing Formula

The 2023 Medicare conversion factor will decrease by $1.55, from $34.61 in CY2022 to $33.06 in CY2022. That will result in an approximately 4.4% reduction in Medicare allowable rates for 2023. In coming weeks, you will be able to view your 2023 Medicare fee schedule at https://www.cms.gov/ medicare/physician-fee-schedule/search/overview.

Telehealth

Medicare has again granted a temporary extension of coverage of audiology services, delivered via evidence-based telehealth, until December 31, 2023.

The services listed in Table B are covered if provided by a licensed audiologist.

Table B: Audiology Telehealth Codes

Merit Based Incentive Payment System (MIPS)

Audiologists are eligible providers within the MIPS system. Audiologists can determine their reporting requirements/ options for voluntary reporting at https://qpp.cms.gov/. At this juncture, most audiologists do not meet the low volume threshold for required reporting, without penalty.

The Audiology Measure Set for 2023 includes:

• Documentation of Current Medications in the Medical Record
• Preventive Care and Screening: Screening for Depression and Follow-Up Plan
• Falls: Plan of Care
• Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
• Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention
• Elder Maltreatment Screen and Follow-Up Plan
• Already a requirement of many state audiology licensure acts.
• Functional Outcome Assessment
• Falls: Screening for Future Falls Risk
• Screening for Social Drivers of Health
• Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

This communication is the intellectual property of the Academy of Doctors of Audiology (ADA) and was created solely for the use of ADA and its members. Any replication, dissemination, or republication of this communication without the express consent of ADA is strictly prohibited. ■

Dr. Kim Cavitt was a clinical audiologist and preceptor at The Ohio State University and Northwestern University for the first ten years of her career. Since 2001, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc. She currently serves on the State of Illinois Speech Pathology and Audiology Licensure Board. She also serves on committees through AAA and ASHA and is an Adjunct Lecturer at Northwestern University.