AUDIOLOGY ADVOCATE | “Limited” Direct Access in Medicare: More Work to Be Done!

By Susan Pilch

This article is a part of the May/June, Volume 35, Number 3, Audiology Today issue. 

A Novel Proposal

Each year, the Centers for Medicare and Medicaid Services (CMS) releases a proposed Medicare Physician Fee Schedule (MPFS) to update payment policies, payment rates, and other provisions for services in Medicare. After a requisite public comment period, these updates may be amended and are ultimately finalized to go into effect the following year. 

The proposed CY2023 MPFS was released in July 2022 and included a proposal to allow audiologists to provide certain nonvestibular and nonacute services without a physician order. This initial proposal was based on the creation of a new code—the GAUDX code—that would be used for this limited list of services (36 codes). Provider reimbursement would be based on a “blended” rate of the existing Current Procedural Terminology (CPT) codes values for these services.

Academy Response and Corresponding Changes

The Academy’s Practice Policy Advisory Committee (PPAC) set to work analyzing the proposal and drafting the Academy’s official written comments in response to the proposal. In addition to pushing back on the proposal’s narrative limiting the direct access to nonvestibular, nonacute services due to “safety” concerns, the Academy suggested that existing CPT codes with current fee schedule values be used in addition to a new modifier to identify services provided without a physician order. 

The Academy’s comments and discussions directly with CMS also highlighted the inherent difficulty in determining or defining “nonacute.” The final MPFS was issued on November 1, 2022, and reflected the Academy’s suggestion that existing CPT codes with current fee schedule values be used in conjunction with an AB modifier.