2023 Proposed Rule – Medicare Physician Fee Schedule

Conversion Factor

The proposed 2023 Medicare conversion factor is $33.0775, reduced from the 2022 final conversion factor of $34.6062.

CY 2023 MPFS Estimated Impact on Total Allowed Charges by Specialty

CMS estimates the impact on audiology to be 0 percent.

Audiology Services and Waiver of Physician Order

CMS proposes to remove the physician order requirement under certain circumstances for certain audiology services furnished personally by an audiologist for non-acute hearing conditions. These non-acute hearing conditions would not include balance assessments that are used for patients with disequilibrium because CMS believes the physician/NPP needs first to evaluate the patient clinically due to the many serious medical conditions the beneficiary might have, and ensure the patient is cleared medically before setting them on track to receive vestibular function tests, possibly from an audiologist.

CMS proposes to permit the services described by the codes listed below to be furnished under the proposed exception without the order of the treating physician or non-physician practitioner (NPP).

Proposed Codes for Tests that Audiologists Can Provide Without a Physician or NPP Order/Referral

CMS proposes to create HCPCS code GAUDX – Audiology service(s) furnished personally by an audiologist without a physician/NPP order for non-acute hearing assessment but not audiology services that are related 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 to describe these audiology services furnished personally by an audiologist without the order of the treating physician or other practitioner.

Under this proposal, an audiologist would be able to bill code GAUDX once every 12 months for a beneficiary. The GAUDX code would include and be used to bill for any number of audiology services furnished in that particular encounter with the beneficiary. Since the proposed GAUDX code is generic, the tests provided could include those that are split into PC/TC and those that are not.

As with all services, the actual tests provided and their results would need to be documented in the medical record, for purposes of medical review.

CMS proposes that no more than one unit of code GAUDX could be billed – that means “1” is inserted in the “days or units” block 24G on the CMS 1500 professional claim form.

CMS is concerned that beneficiaries may receive services billed as code GAUDX from more than one audiologist in the 12-month period and/or be mistaken or misled into thinking that code GAUDX represents a screening/preventive service which Medicare does not cover. To avoid the potential for inappropriate use of HCPCS code GAUDX, CMS plans to establish system edits to ensure that GAUDX is only paid once every 12 months, per each beneficiary.

Under this proposal, the beneficiary would have to wait a full 12 months before receiving additional diagnostic tests from an audiologist without a physician/NPP order. The beneficiary would remain free to seek care from a treating physician (or /NPP) if needed, and that care could potentially include a referral with an order for further diagnostic testing furnished by an audiologist.

To value HCPCS code GAUDX, CMS proposes to use the combined values of CPT codes 92557 (Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)) and 92567 (Tympanometry (impedance testing)), which CMS believes would represent a typical service provided by audiologists. CMS chose CPT Codes 92557 and 92567 as typical because they make up 72 percent of all billings for audiologists; and, when all physician and practitioner specialties are considered, including audiologists, code 92557 is billed with code 92567 over 60 percent of the time and code 92567 is billed with code 92557 over 83 percent of the time in the same clinical encounter, according to Medicare claims data.

CMS proposes a total work RVU of 0.8 for GAUDX, calculated by combining the 0.60 work RVU for CPT code 92557 and 0.20 work RVU for CPT code 92567. CMS proposes to establish the PE value for GAUDX by combining the unduplicated PE of CPT codes 92557 and 92567.

Specifically, CMS proposes to include the following direct practice expense (PE) inputs for supply items: two SD046 (Ear tip, tympanometry probe), two SJ053 (Swab pad, alcohol), one SM0251 (Specula tips, otoscope), one (SK059) sheet of recording paper, and two SD047 (Ear tip insert with sound tube); and the following direct PE inputs for equipment: EQ054 (Audiometric soundproof booth (exam and control room)) for 20 minutes, EQ053 (Audiometer, clinical, diagnostic) for 20 minutes, and EQ244 (Tympanometer with printer) for 4 minutes.

CMS proposes to apply the same provisions for code GAUDX as those set for 92557 and 92567 (for example, PC/TC indicator, bilateral indicator, physician supervision indicator, etc.), as they now appear in the PFS Relative Value file found at https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFSRelative-Value-Files.

CMS seeks comment on how and where these audiology services would be provided without the order of a treating physician or practitioner. CMS also requests comment from interested parties about what settings might represent the typical places of service and which institutional providers might bill for HCPCS code GAUDX.

Extension of Covered Telehealth Services

Some audiology testing services are currently temporarily available on the Medicare Telehealth Services List for the duration of the Public Health Emergency (PHE). These are CPT codes 92550 (Tympanometry and reflex threshold measurements), 92552 (Pure tone audiometry (threshold); air only), 92553 (Pure tone audiometry (threshold); air and bone), 92555 (Speech audiometry threshold;), 92556 (Speech audiometry threshold; with speech recognition), 92557 (Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)), 92563 (Tone decay test), 92565 (Stenger test, pure tone), 92567 (Tympanometry (impedance testing)), 92568 (Acoustic reflex testing, threshold), 92570 (Acoustic immittance testing, includes tympanometry (impedance testing), acoustic reflex threshold testing, and acoustic reflex decay testing), 92587 (Distortion product evoked otoacoustic emissions; limited evaluation (to confirm the presence or absence of hearing disorder, 3-6 frequencies) or transient evoked otoacoustic emissions, with interpretation and report), 92588 (Distortion product evoked otoacoustic emissions; comprehensive diagnostic evaluation (quantitative analysis of outer hair cell function by cochlear mapping, minimum of 12 frequencies), with interpretation and report), 92601 (Diagnostic analysis of cochlear implant, patient younger than 7 years of age; with programming), 92625 (Assessment of tinnitus (includes pitch, loudness matching, and masking)), 92626 (Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour), 92627 (Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); each additional 15 minutes (List separately in addition to code for primary procedure)).

CMS indicates it has received information that, during the PHE, some practitioners have developed the capacity to perform these services using remote technology including specialized equipment inside an audiometric soundproof booth. CMS suggests that in circumstances in which such equipment is available at the originating site, these services can be furnished in a way in which all of the elements of the services are met and that there is likely to be a clinical benefit when these services are furnished via telehealth. CMS proposes to add these services to the Medicare Telehealth Services List on a Category 3 basis, which would allow these services to be available via telehealth through the end of CY 2023.

Quality Payment Program (QPP) and Merit-Based Incentive Payment System

CMS proposes to add two new measures to the audiology measures set under the MIPS program:

*Screening for Social Drivers of Health: Percent of beneficiaries 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety.

* Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling: Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 12 months AND who received brief counseling if identified as an unhealthy alcohol user.

CMS proposes to remove measure 261 from the audiology measures set:

*Acute or Chronic Dizziness: Percentage of patients aged birth and older referred to a physician (preferably a physician specially trained in disorders of the ear) for an otologic evaluation subsequent to an audiologic evaluation after presenting with acute or chronic dizziness.

The Academy will fully analyze the details of this proposed rule and respond to CMS by the September comment deadline.

For more information, please see the following CMS resources:

PFS press release

Proposed rule on the Federal Register

PFS fact sheet

QPP fact sheet