UPDATED: 2023 MPFS Final Rule Summary for Audiologists

On November 1, 2022, the Centers for Medicare & Medicaid Services (CMS) published the Medicare Physician Fee Schedule (MPFS) Final Rule, indicating Medicare Part B payment and coding methodologies for 2023.

Below is a summary of the impact for audiologists effective January 1, 2023:

 

Physician/Non-Physician Provider (NPP) Order

There is a significant change for audiologists who provide audiologic services to Medicare Part B beneficiaries; these changes do not apply to Medicare Part C Advantage plans. The final rule states that:

“Audiologists may personally furnish diagnostic audiology tests for a patient once per patient per 12-month period without an order from the physician or nonphysician practitioner treating the patient. Such diagnostic audiology tests can be for non-acute hearing conditions but may not include audiology services that are related to disequilibrium, or hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids that are outlined at § 411.15(d). Audiology services furnished without an order from the treating physician or practitioner are billed using a modifier CMS designates for this purpose”

for the 12-month period. As a side note, it is essential to include in the patient’s record the reason for the test, which addresses medical necessity. By definition in Title XVII of the Social Security Act, section 1862 (a)(1)(a):

“Notwithstanding any other provision of this title no payment may be made under Part A or Part B for any expenses incurred for items and services, which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.”

For patients with acute and vestibular symptoms, an order is still required from a physician or a non-physician provider (NPP) enrolled in the Provider Enrollment Chain Ownership System (PECOS). NPPs are defined by CMS as those who can serve as the treating practitioner for purposes of ordering diagnostics tests — physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists, certified nurse-midwives, qualified psychologists, and social workers. Medicare will deny the claim if the ordering provider is not enrolled in PECOS and the patient cannot be billed for the procedure(s).

If the patient needs to return for any follow-up within this 12-month period, an order will be required. The CPT procedure code(s) should be filed as well, without the AB modifier. If the patient has an acute and/or vestibular-related issue regardless of the 12-month period, an order will be required. The procedure CPT codes will also be filed, without the AB modifier. Further, CMS has stated they plan to provide education and guidance for questions such as the use of the Advanced Beneficiary Notice (ABN) for audiologists.

Medically reasonable and necessary tests ordered by a physician or other practitioner and personally provided by audiologists will not be affected by the direct access policy, including the modifier and frequency limitation.

CMS cautions it may take until mid-2023 to enact the systems for the use of the new modifier, AB:

“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.”

When the claim is filed with this modifier, the ordering physician will not be placed on the claim. For those patients with acute or vestibular conditions, the ordering physician will continue to be placed on the claim.

CMS definition of acute hearing loss involves a sudden onset in one or both ears and is a perceived change in hearing by a beneficiary that is not consistent with the progressive loss of hearing over many years that is typical with aging process. A non-acute hearing loss is a more gradual hearing loss that one may experience with advancing age, known as presbycusis, with the National Institute on Deafness and Other Communication Disorders defines as “age-related hearing loss (presbycusis) is the loss of hearing that gradually occurs in most of us as we grow older.…Age-related hearing loss most often occurs in both ears, affecting them equally.”

The table below indicates the services that audiologists may furnish without a physician order that will be payable in the 12-month period beginning January 1, 2023, each to be filed with the AB modifier for that one date of service in the 12-month period without a physician order for each procedure performed. If a beneficiary returns at a later date without an order and within the same 12-month period, the procedure will not be payable.

 

TABLE 36: Codes for Tests that Audiologists can Bill with the AB Modifier for Nonacute Hearing Conditions without a Physician or NPP Order/Referral

See a downloadable image of the below table here.

 

Reimbursement

Part B providers, including audiologists, should expect to see an overall 4.4% reduction in allowed rates given the conversion rate for 2023 decreased $1.55 from the 2022 conversion rate of $34.61 to $33.06.

 

Telehealth and Audiology Services

There were no changes to current telehealth services from 2022 and will remain in effect until December 31, 2023, for CPT codes 92552, 92553, 92555, 92556, 92557, 92562, 92563, 92565, 92567, 92568, 92570, 92587, 92588, 92601, 92625, 92626, and 92627 as CMS has allowed some diagnostic testing to be performed via telehealth during the Public Health Emergency (PHE). After the PHE has been deemed expired, those services will no longer be recognized for payment by CMS for Part B beneficiaries when performed by an audiologist via telehealth.

 

Merit Incentive Payment System (MIPS)

The Merit Incentive Payment System (MIPS) allows for audiologists to be eligible and report within this payment system. While the majority of audiologists may report voluntarily under the low-volume threshold methodology, there are corporate entities employing audiologists where reporting may be required. To meet the low-volume threshold, a provider bills less than $90,000 to Medicare AND performs 200 or fewer procedures AND sees 200 or fewer beneficiaries. Check here to ensure your participation status for 2023.

An additional change for MIPS reporting will be for 2024 (but the payment year will be 2026 as there is a 2-year lag) audiologists will be required to report under the Promoting Interoperability category. Currently, audiologists must report only under the Cost and Improvement Activities categories. Further information will become available in the future from CMS as to the processes involved.

It is encouraged that audiologists report voluntarily in the Merit Incentive Payment System but note that there are several measures that can only be reported via a registry and not an individual claim. Healthmonix has the only dedicated audiology-specific registry at the time of this publication. The following measures are included in the 2023 audiology measure set:

• Measure 182: Functional Outcomes Assessment (can only be reported via electronic reporting, such as your office management system, and not on a claim)
• 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 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
• Measure 431: Preventive Care and Screening: Unhealthy Alcohol Use: Screening and Brief Counseling
• Measure 487: Screening for Social Drivers of Health