Medicare is finalizing a 2.83 percent cut for MPFS services in CY 2025. Medicare payments currently do not keep up with the rising costs of inflation and running a practice. An additional cut for 2025 will further harm already overburdened practices. 

CY 2025 MPFS Key Takeaways for Audiology:   

Payments Decline

The Academy will continue to urge Congress to reverse the 2.83 percent cut to Medicare physician reimbursement announced in the 2025 fee schedule. This cut is based on a proposed 2025 conversion factor (CF) of $32.3465 from the current CY 2024 conversion factor of $33.2875. This is the fifth year in a row that the conversion factor is facing a cut. 

View the CY 2025 vs CY 2024 audiology services payment table

The CF update is primarily based on three factors:

• A statutory 0 percent update scheduled for the Physician Fee Schedule (PFS) in CY 2025
• A 0.02 percent positive budget neutrality adjustment
• The expiration of funding patches passed by Congress through the Consolidated Appropriations Act of 2023 and the Consolidated Appropriations Act of 2024, which partially mitigated cuts to the CF for CY 2023 and CY 2024 resource-based relative value scale and anesthesia CFs.

We support a bipartisan bill recently introduced in Congress, the Medicare Patient Access and Practice Stabilization Act of 2024, which aims to eliminate the 2.8 percent conversion factor cut and provide an approximate +1.80 percent update. We urge Congress to include this bill in an end-of-year legislative package during the post-election lame duck session.

CMS Proposes to End COVID-19 Era Telehealth Flexibilities

CMS plans to end COVID-19 telehealth flexibilities after CY 2024, reinstating pre-COVID limits on geography, service sites, and practitioner types unless Congress acts. CMS will retain virtual supervision for auxiliary personnel and temporarily extend it for teaching physicians overseeing residents. Congress is debating a potential two-year extension, and our societies are actively advocating for continued telehealth access. 

Services Addressing Health-Related Social Needs (Community Health Integration Services, Social Determinants of Health Risk Assessment, and Principal Illness Navigation Services)  

Inthe CY 2025 PFS proposed rule, CMS issued a broad request for information on the new Community Health Integration (CHI) services, Principal Illness Navigation (PIN) services, and Social Determinants of Health (SDOH) Risk Assessment, seeking input on policy refinements for future rulemaking. They requested insights on other factors, including auxiliary personnel types (e.g., Academy-supported roles like audiologists and audiology assistants) and additional certification or training requirements not fully addressed in current coding and payment structures. CMS received extensive comments, which may inform future rule making.

Quality Issues

There are no changes in the Quality Payment Program (QPP) eligibility criteria. Eligible clinicians must:

• Bill more than $90,000 for Medicare Part B covered professional services
• See more than 200 Medicare Part B patients
• Provide more than 200 covered professional services to Medicare Part B patients

To determine if you are an eligible clinician, see the QPP Participation Status Tool. For additional information on QPP and Audiology Quality Measures view the overview.

CY 2025 Hospital-Based Outpatient Department (HOPD)/ASC Rule   

Hospital and ASC Payments Increase

For CY 2025, CMS is increasing payment rates under the Hospital Outpatient Prospective Payment System (OPPS) and the Ambulatory Surgical Center (ASC) Payment Systems by 2.9 percent. This increase is based on a hospital market basket percentage increase of 3.4 percent reduced by a productivity adjustment of 0.5 percentage point. In continuation of an existing policy, hospitals and ASCs that fail to meet their respective quality reporting program requirements are subject to a 2.0 percent reduction in the conversion factor for CY 2025.

View the CY 2025 OPPS rule overview.

Quality

A number of proposals have been made to update and refine facility quality reporting programs. The Academy is continuing to review and determine the feasibility and associated administrative burden of some proposals.

Below are key MPFS resources:

• Final Rule Text
• CMS Press Release
• CMS Fact Sheet
• CMS QPP Resource Library

Below are key HOPD resources:

• Final Rule Text
• CMS Press Release
• CMS Fact Sheet

The post CMS Finalizes a 2.83 Percent Cut to Payments in 2025 appeared first on American Academy of Audiology.

For details on payments and other resources offered by CMS, click here.

Communications with your Medicare administrative contractor (MAC) will be key. Please be sure to reference the current MAC link provided in the CMS information link above.

To request additional flexibilities from CMS, use this form. 

Please note: This information will be updated as events warrant.  As of this writing, Hurricane Milton has not made landfall in the United States.

The post Medicare Resources for Providers and Suppliers in FEMA-Designated Disaster Zones appeared first on American Academy of Audiology.

The Academy supports reducing administrative burdens for practices that deliver evidence-based care, as it improves patient access. However, the Academy remains skeptical the program will significantly reduce the administrative burden associated with UHC prior authorization requirements, especially because practices that receive gold card status will still need to participate in UHC’s advance notification process. UHC states it may “require medical records as part of the monitoring and continuing evaluation of practices that have qualified for Gold Card status.”

The Academy will provide updates as program details emerge, and will work to ensure your voices are heard and needs addressed.

The post UHC Preparing to Launch Prior Authorization Gold Card Program appeared first on American Academy of Audiology.

The Affordable Care Act (ACA) included reporting requirements for Medicare overpayments. The statute requires the reporting, return, and reason for the overpayment by 60 days from when the overpayment is identified. The statute further defines “identified” to be that someone “has, or should have through the exercise of reasonable diligence, determined that the person has received an overpayment and quantified the amount.” The 2022 proposed changes from CMS would remove the “reasonable diligence” and amend this definition to specify that the provider “knowingly receives or retains an overpayment,” using the definition of “knowingly” from the False Claims Act (FCA).

The current CMS proposal retains the 2022 proposed changes and adds more changes open to public comment. In brief, the additional changes stipulate that the 60-day reporting and return requirement could be suspended if a provider is investigating if any related overpayments exist, or could arise from a similar case. If such an investigation is being conducted, the provider could report and return the overpayments within 60 days of identification of the completion of an investigation, or 180 days from the date the overpayment is identified, whichever is the earliest date. Some analyses of the proposed rule suggest that ambiguity may still remain about the timeline and if any repayments will be needed during investigations.

CMS is accepting comments on the calendar year 2025 MPFS proposed rule until September 9, 2024. As reported previously by the Academy, the MPFS includes cuts in payments to all providers including audiology (see audiology code payment tables).

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MPFS High-Level Takeaways 

• Payments decline: The proposed CY 2025 conversion factor (CF) is $32.3562, a decrease of approximately 2.80 percent from the final 2024 CF of $33.2875. The CF has continued to decrease over consecutive years, and only congressional action can mitigate this cut. The Academy continues to work closely with other health-care provider stakeholders to urge Congress to address these unsustainable reimbursement cuts.

• Continued coverage of telemedicine: In this proposed rulemaking, CMS chose not to make any current provisional telemedicine services permanent. However, CMS acknowledges that it has received numerous requests for a permanent designation for speech therapy and audiology services. CMS stated it will undertake a comprehensive review independent of this proposed rulemaking.

Quality Payment Program (QPP) Provisions

• CMS does not propose to add or remove any measures from the audiology specialty measures set.
• CMS does propose to add pediatric audiology codes for inclusion under the measure of addressing documentation of current medications in the medical record, in an effort to remove age restrictions currently associated with the measure.
• CMS proposes to maintain the 75 percent data completeness criteria through the 2028 performance period.

The Academy has prepared a chart of proposed 2025 MPFS payment values for audiology codes, available here.

The Academy will further review this comprehensive proposed rule for changes that would affect the provision of audiology services. We will post additional information as it becomes available. CMS is accepting comments on the proposed rule until September 9, 2024.

OPPS High-Level Takeaways

• CMS proposes updating OPPS payment rates for 2025 by 2.6 percent for hospitals that meet applicable quality reporting requirements 
• All but one audiology code would receive a positive payment update under OPPS in 2025 (see tables under resources listed below)

Resources

• Audiology MPFS Proposed CY 2025 Table Based on July 10, 2024 Proposed Rule Release
• CMS Fact Sheet: MPFS Proposed Rule for 2025   
• Audiology OPPS Proposed CY 2025 Tables Based on July 10, 2024 Proposed Rule Publication
• CMS Fact Sheet: OPPS Proposed Rule for CY 2025  
• Full Text of Proposed Rules

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The Academy encourages members to continue with routine monitoring of email folders (inbox, spam, etc.) for communication about the CPI survey. Any audiologist, not just Academy or American Speech-Language-Hearing Association (ASHA) members, with an NPI could be selected randomly and would receive an email directly from Mathematica with instructions. Please check with other audiologists and the management at your facility to encourage their participation if they received the communication via email or postal mail from Mathematica.

The CPI survey is the partner survey to the physician practice information (PPI) survey, and together they collect updated data on practice expenses across health care disciplines and specialties. The Academy and ASHA have contracted with Mathematica for the audiology portion.

See the original announcement from the Academy and ASHA for more details. We recognize that the survey is quite detailed and appreciate members’ willingness to contribute accurate data on practice costs.

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The significant changes to Utilization Guideline 005: Hearing Aids are in the following sections:

OBJECTIVE

1. Removes reference to adults
   
   • ORIGINAL LANGUAGE: This guideline only addresses air conduction hearing aid devices for adults.
   • UPDATED LANGUAGE: This guideline only addresses air conduction hearing aid devices.
     
2. Removes the phrase: “Consideration should be given on an individual basis for hearing loss of 40 decibels or less with a prescription from a licensed healthcare provider.

MEDICAL NECESSITY

1. Clarification was added regarding the FDA requirement for hearing aids:
   
   • ORIGINAL LANGUAGE: For medical necessity, hearing aids must be FDA-approved
   • UPDATED LANGUAGE: For medical necessity, hearing aids must be approved, listed/or registered with the FDA as a prescription device.

2. Clarification was added regarding the dispensing provider
   
   • ORIGINAL LANGUAGE: Dispensed by prescription from a licensed healthcare provider
   • UPDATED LANGUAGE:  Dispensed by prescription or signed written order from a licensed healthcare provider who is practicing within the scope of their license.

3. Degree of hearing loss amended:
   
   • ORIGINAL LANGUAGE: Moderate hearing loss of 40 dB or greater (based on pure tone average-tone conduction detection threshold
   • UPDATED LANGUAGE: The degree of hearing loss is confirmed by audiometry or other age-appropriate testing to be greater than 26 dB hearing loss

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The update included an additional 1.68 percent to the 2024 conversion factor that offset a portion of cuts that went into effect on January 1. The Centers for Medicare and Medicaid Services has now established the new conversion factor of $33.2875 for dates of service March 9 through December 31 and has updated its website accordingly.  

The post Updated Audiology Code Table Reflects New MPFS Conversion Factor appeared first on American Academy of Audiology.