Final Rule Changes to the 2016 Medicare Physician Fee Schedule

Final Rule Changes to the 2016 Medicare Physician Fee Schedule

November 09, 2015 Government Relations News

American Academy of Audiology Analysis

On October 30, 2015, the Centers for Medicare & Medicaid Services (CMS) issued the  Revisions to Payment Policies under the Physician Fee Schedule, Clinical Laboratory Fee Schedule and Other Revisions to Part B for CY 2016 final rule. The final rule addresses adjustments to the Medicare physician fee schedule (MPFS) and other Medicare Part B payment policies to reflect changes in medical practice and the relative value of services. The finalized changes will go into effect on January 1, 2016. The Academy has prepared a list of payment rates by CPT code for audiology procedures covered under the fee schedule: CY 2016 and CY 2015 for comparison, along with helpful fee calculation definitions. The Academy has also prepared an analysis of the final rule below and will continue to add to this analysis and update our membership as more information becomes available.

The rule addresses key issues from the proposed rule, including changes to the Physician Quality Reporting System (PQRS) and Physician Compare Web site, as well as information on non-physician provider participation in the Value-Based Modifier (VM) program. CMS has also released a Fee Schedule Fact Sheet and a PQRS Quality Fact Sheet.

CMS Estimates a Conversion Factor of $35.8279 for CY 2016

In April 2015, Congress passed the Medicare Access and CHIP Reauthorization Act (MACRA), which eliminated the flawed sustainable growth rate (SGR) formula. MACRA also established an update factor for calendar years 2015-2025. As such, we no longer need to wait for Congress to pass a temporary fix of the SGR in order to estimate the conversion factor. 

For CY 2016, CMS estimates the MPFS conversion factor to be $35.8279, which reflects a budget neutrality adjustment of -0.02%, a target recapture amount of -0.77%, and the 0.5 percent update factor specified under MACRA. Due to the budget neutrality and target recapture updates this is slightly below the 2015 conversion factor of $35.9335.

New Vestibular Caloric Codes (CPT Codes 92537 and 92538)

In late 2014, the Academy and the American-Speech-Language-Hearing Association (ASHA) worked in collaboration with the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the American Academy of Neurology (AAN) to survey two new Current Procedural Terminology (CPT) codes to describe vestibular caloric testing. These two new CPT codes, 92537 and 92538, will replace CPT code 92543 (Caloric vestibular test, each irrigation, with recording) beginning in 2016. A description of the new codes is as follows:

  • CPT code 92537, Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation in each ear for a total of four irrigations)
  • CPT code 92538, Caloric vestibular test with recording, bilateral; monothermal (i.e., one irrigation in each ear for a total of two irrigations)

The purpose of these surveys was to assess and revise the "professional work" value for each procedure. Professional work value includes factors such as mental effort and judgment, technical skill, and psychological stress. This is part of the valuation process established by the American Medical Association's Relative Value Update Committee (RUC).

Click here for more information and to view the new payments rates for these vestibular codes

Potentially Misvalued PFS Codes (CPT Codes 92557 and 92567)

In the Medicare Physician Fee Schedule (MPFS) Proposed Rule for 2016, CMS identified two audiology-related codes as potentially misvalued services that would need to be reviewed and resurveyed in 2016. These codes included CPT code 92557 (Comprehensive audiometry threshold evaluation and speech recognition) and CPT code 92567 (Tympanometry). These codes were identified by CMS through a high expenditure by specialty screen. In their proposed rule comments to CMS, the AMA RUC requested that these two codes be removed from high expenditure screen as they do not fit the screen criteria. CMS agreed with the AMA RUC's assertion and will not review CPT codes 92557 and 92567 under the potentially misvalued code initiative for 2016.

Request for Input on the Provisions Included in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)

As noted above, MACRA was enacted on April 16, 2015. The passage of this legislation effectively repealed the Medicare sustainable growth rate (SGR) update formula for payments under the MPFS, established the Merit-based Incentive Payments System (MIPS) under the MPFS, established incentive payments for participation in certain alternative payment models (APMs), and made other changes affecting Medicare payments to health care providers. These new programs will replace PQRS beginning in 2019. In the MPFS proposed rule for CY 2016, CMS sought public comments on areas for future rulemaking related to the creation of these new merit-based reporting initiatives.  As a result of these responses, CMS issued a Request for Information (RFI) on October 1, 2015 seeking additional public comment on more detailed questions related to both MIPS and APMs. The Academy has prepared and submitted related comments in response to the MPFS proposed rule and to the RFI for MIPS and APMs.

Physician Quality Reporting System (PQRS)

As amended by MACRA, PQRS will end in 2018 and the Merit-based Incentive Payment System (MIPS) will begin in 2019, incorporating aspects of PQRS. However, in the MPFS final rule CMS finalized its proposals for PQRS through CY 2018.

Consistent with the 2017 PQRS payment adjustment, individual eligible professionals (EPs) or group practices who fail to either satisfactorily report data to PQRS, or participate via the PQRS Group Practice Reporting Option (GPRO) in 2016 will be subject to a 2% negative payment adjustment in 2018.

Audiologists currently may report on three PQRS measures:

For 2016, audiologists will be eligible to report on three additional PQRS measures:

Measure #226:

This measure requires the audiologist to ask the patient if they use tobacco products on a regular basis, and with affirmative answers, offer brief (less than 3 minutes) of counseling on the adverse effects to health. It is required once a year for the comprehensive audiology evaluation, vestibular evaluation, or tinnitus evaluation.

Measure #154—Falls: Risk Assessment and Measure #155—Falls: Plan of Care:

These are two part measures reported in conjunction with a vestibular evaluation. For patients that have experienced more than two falls in 24 months or one fall with an injury, it requires a balance/gait assessment along with one of the following: medication assessment, home hazards assessment, vision assessment or postural blood pressure. For patients that have experienced more than two falls in 24 months or one fall with an injury, regardless of whether the risk assessment was provided, a plan of care must be documented.

The Audiology Quality Consortium (AQC) is currently working on guidance documents detailing these new measures. That information will be made available on the Academy's PQRS page as soon possible.

The AQC is comprised of ten independent audiology organizations that collaborate on PQRS measure development and member education.  In addition, the AQC is the measure owner of one current audiology measure in the PQRS program. Since it was founded in 2008, the AQC has worked diligently toward developing, establishing, and reviewing the PQRS measures for the profession of audiology. Still, audiologists are among a small number of provider types who are limited in the number of measures available for PQRS reporting. Due to the limited nature of current PQRS measures available for audiologists, the Academy has continued to urge CMS to maintain these measures. The Academy has also offered comment to CMS to ensure the profession of audiology is appropriately included as the Agency further defines the quality measures performance category of the MIPS.

Definition of satisfactory reporting/satisfactory participating

The Academy strongly supports the Agency's continued application of the Measure-Applicability Validation (MAV) process for audiologists and other eligible professionals with fewer than 9 PQRS measures. The MAV process offers protection to these providers from a PQRS payment penalty when current circumstances require they report on fewer than 9 measures. In the MPFS final rule, CMS states that eligible professionals who report on less than 9 measures would still be subject to the MAV process. The Academy, in conjunction with the AQC, will update the 2016 PQRS Step-by-Step Guide when the 2016 MAV is released. Visit the Academy's Web site for more information and regular updates regarding PQRS. For more information on the claims and registry MAV process, please visit the measures section of the PQRS Web site.

The Academy has requested that CMS consider a continuation of the MAV process or the application of a similar process for the MIPS where appropriate.

Physician Compare

The Academy has continued to advocate for its ongoing involvement in the development and refinement of the Physician Compare Website. We have requested that our representative experts continue to advise CMS as the Agency updates the Physician Compare Web site to ensure that audiologists are meaningfully represented and can be easily identified by other professionals and patients. In the MPFS final rule, CMS continues the phased approach to public reporting on Physician Compare. CMS will continue to make all 2016 individual EP and group practice PQRS measures available for public reporting

CMS also affirmed their commitment to continuing to improve the site and its functionality to ensure it is a useful resource for Medicare consumers. CMS stressed the importance of the Provider Enrollment Chain and Ownership System (PECOS) as a means of updating and ensuring accuracy of demographic data. CMS strongly encourages all providers and group practices listed on the Physician Compare site to regularly check their data and to make sure their PECOS records are up to date. CMS requests that individuals contact the Physician Compare support team if there are any issues.

CMS is also finalizing a proposal to add Board Certification to the Physician Care Web site, specifically the American Board of Optometry (ABO) and American Osteopathic Association (AOA) certifications. In our proposed rule comments, the Academy supported inclusion of Board Certification, and recommended to the Agency, that as they begin to add specific Board Certification to the site, that they consider professions like of audiology, who have multiple, voluntary certification options. The Academy encouraged CMS to develop a tool for Medicare beneficiaries and other health care consumers to view a comparison of the multiple certifications on the site. CMS acknowledged these comments in the final rule.

Value-Based Payment Modifier (VM)

CMS will not apply the VM to audiologists for the CY 2018 payment period. In terms of non-physician providers, the VM will only apply to physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs) and certified registered nurse anesthetists (CRNAs) for the CY 2018 payment adjustment period. After 2018, the VM will become integrated into the quality measure performance category of the MIPS. To prepare for this transition, the Academy requested that CMS work to provide sufficient education and training for audiologists and other non-physician practitioners on the VM and other components of this category to ensure timely and appropriate application and reporting.

Changes to "Incident to" Billing Policies and Regulations

CMS continues to take steps to ensure that qualified individuals provide incident to services to Medicare beneficiaries in a manner consistent with Medicare statute and regulations, as well as applicable state laws. The Academy shares CMS's position that billing practitioners should take a personal interest in, and responsibility for, furnishing services for which they are billing as an incident to their own professional services.
For 2016, CMS is working to amend existing regulations to specify that only the physician (or other practitioner) that supervises the auxiliary personnel that provide incident to services may bill Medicare Part B for those incident to services. CMS seeks to offer further clarification on their policy by amending the regulatory text to say that the physician (or other practitioner) directly supervising the auxiliary personnel need not be the same physician (or other practitioner) that is treating the patient more broadly. CMS is also modifying the definition of the term "auxiliary personnel", who are permitted to provide incident to services, to exclude individuals who have been excluded from the Medicare program or have had their Medicare enrollment revoked. The Academy believes that these policy changes will further promote appropriate incident to billing practices among health care providers.

Proposed Elimination of Refinement Panel Review Process

Currently, specialty societies survey codes and present their findings before the RUC to support valuation for these codes. The RUC then makes a recommendation to CMS regarding this valuation. CMS does not have to accept the RUC recommendations, and oftentimes will conduct an internal review and assign a different, typically lower, value for the codes. If there is disagreement over the CMS assigned value, and a specialty determines they have new clinical information or other support to justify a different value for their codes, they may request a multispecialty refinement panel to review. The refinement panel is comprised of a multispecialty group of providers and representatives from each of the participating societies, as well as Medicare contractor medical directors. These experts review and discuss the work involved in the procedure(s) and then independently value the work of the procedure. CMS will consider the refinement panel's recommendation, but is not required to revise the value.

In the 2016 MPFS proposed rule, CMS proposed to permanently eliminate the refinement panel process beginning in 2016. CMS justified this decision by asserting that because they will be publishing the proposed payment rates for all interim codes in the MPFS proposed rule for the subsequent year, specialties will have more opportunities for review and comment on the valuation of codes, and as such, a refinement panel would no longer be necessary. CMS believes this process lends itself to improved transparency and increased opportunities for public feedback on the interim values for codes.

The Academy, and many other specialties including the AMA, questioned CMS' decision to eliminate the refinement panel process, as it provides added and necessary transparency to the valuation process. Though CMS has its own process for assessing and determining valuation, that process is not clear to many specialties or individual providers. Due to the feedback received in response to the MPFS proposed rule, CMS has decided not to permanently eliminate the refinement panel at this time. They will retain the ability to convene the refinement panel when it adds value to the existing notice and comment rulemaking process. CMS will eventually phase out the refinement panel process in favor of the new process. CMS has also stated that they will work towards greater transparency and accountability by describing in the rulemaking how they develop the proposed values for individual codes.

Additional Information

The Academy will continue to update this analysis as more information becomes available. We will also include any updates in the Audiology Today Weekly E-newsletter. The Academy will also be hosting its next eAudiology Coding and Reimbursement Web Series presentation on November 17, 2015. This presentation will address Medicare Payment Changes and Updates to Quality Reporting: What to Expect for 2016


The Academy will continue to monitor CMS Medicare Part B policies, provide commentary, and meet with CMS at Agency headquarters as necessary to advocate for the profession of audiology.

Also of Interest