paul pessis, aud
TRANSCRIPT
Paul Pessis, AuD
How many people are practicing in a(n):◦ hospital system◦ ENT office◦ private practice as an employee ◦ private practice as an owner◦ educational setting◦ university clinic or instructor◦ VA facility◦ manufacturer◦ CI clinic ◦ other
Regardless of your title within your facility, it must be recognized that the facility needs to function at a profit to remain viable…Desirables:
◦ Continuing educational opportunities (CE)◦ Maintaining and advancing technology and equipment◦ Salaries that are competitive and increasing◦ Benefits: medical insurance, profit sharing…◦ Expanding staff including front office and assistants, as well
as audiologists◦ Paying overhead: rent, utilities, office supplies, cleaning
service, IT/Computers, EMR, Business Operating System, billing, etc
◦ Patient care is our “love” and primary focus, but the impact of the above can’t be marginalized…we are all in this together!
Should the practice accept insurance? In-Network or Out-of-Network Financial policy needs to be signed and
enforced Confirm appointments ? Charge for missed appointments? Charge interest for overdue accounts?
◦ Who codes and how is it processed? Paper Clearinghouse
HIPAA mandates that the three code sets that can be used for billing and processing of claims are:
1. Current Procedural Terminology (CPT) – codes to describe our services
The entire descriptor must be honored to be billed Know the modifiers (ex., 52, 53, GY) If a bundled code exists, it needs to be used Every audiologist must have a National Provider Number (NPI) Medicare mandates that services not statutorily
prohibited MUST be billed with the audiologist’s NPI and no “incident-to” billing (CMS-855R)
No services can never be billed incident-to an audiologist's NPI
2. International Classification of Diseases (ICD-10) -Diagnoses codes published by the World Health Organization (WHO)
◦ The number of commonly used audiology diagnosis codes is not
overwhelming, BUT…
◦ Remember, what constitutes a proper diagnosis? Hint: three things
History Symptoms Findings
Essentially the entire inventory of ICD-10 codes may be a coding option
with the code(s) of choice being as specific as possible
H90.A11 Conductive hearing loss, unilateral, right ear with restrictedhearing on the contralateral side
H90.A12 Conductive hearing loss, unilateral, left ear with restrictedhearing on the contralateral side
H90.A21 Sensorineural hearing loss, unilateral, right ear, with restricted hearing on the contralateral side
H90.A22 Sensorineural hearing loss, unilateral, left ear, with restricted hearing on the contralateral side
H90.A31 Mixed conductive and sensorineural hearing loss, unilateral, right ear with restricted hearing on the contralateral side
H90.A32 Mixed conductive and sensorineural hearing, unilateral,left ear with restricted hearing on the contralateral side
H93.A Pulsatile tinnitus H93.A1 Pulsatile tinnitus, right ear H93.A2 Pulsatile tinnitus, left ear H93.A3 Pulsatile tinnitus, bilateral H93.A9 Pulsatile tinnitus, unspecified ear
H91.21 Sudden idiopathic hearing loss, right ear H83.3X3 Noise effects on inner ear, bilateral H93.11 Tinnitus, right ear H93.231 Hyperacusis, right ear H83.02 Labyrinthitis, left ear H91.03 Ototoxic hearing loss, bilateral
Third party payers want specificity which needs to be supported with detailed chart documentation
Standardized coding system primarily used by hospitals and the
Veteran’s Administration, as well as, private practitioners or
facilities billing for product and/or for capturing
procedures associated with dispensing product
Published and revised annually
Examples include:L8614 - Cochlear Implant device/systemV5008 - Hearing ScreeningV5014 – Repair/Modification of hearing aidV5242 – Hearing Aid, analog, monaural, CICV5252 – Hearing Aid, programmable analog, binaural, ITEV5261 – Hearing Aid, digital, binaural, BTEV5275 – Ear Impression, each
Hearing services are listed as V5000-V5999
Must remember that insurance is a contract between the insurance carrier and the patient!
Insurance must never influence decision-making AND must never restrict the practitioner from performing one’s scope of practice
The bottom line, bill the patient for services or product not covered by what is sometimes random third party payer policy
Which one(s) of the following is not mandated by
HIPAA as a code set to be used by
practitioners?:
◦ A) CPT
◦ B) ICD-10
◦ C) HCPCS
◦ D) EOB
should be entirely paid for by the government ensuring “health care for all” with comprehensive non-restrictive benefits
eligibility for Medicare benefits should be changed from age 65 to 72
for Medicare patients should not require monthly premiums and should provide full drug coverage
is not necessarily for everyone… it is survival of the fittest
1985 (pre Medicare Physician
Fee Schedule: MPFS) $85.00
2009 MPFS $49.47
2021 MPFS 36.43
30% of Medicare budget is paid on behalf of beneficiaries in the final year of life with close to 40% of budget spent on patients who die within two months
10% of Medicare beneficiaries account for 70% of program spending
Accountable Care Act insurance exchanges:◦ 40% of beneficiaries can’t afford the premiums◦ Insurance covers for 30 days after premium is delinquent,
then the provider essentially provides free services◦ Many have a $10,000 deductible – is this really
insurance?
The Medicare monthly premium for 2021 is$148.50 up from $144.60 for 2020
◦ There is additional monthly assessment based on the earnings of a beneficiary known as Income-Related Monthly Adjustment Amount (IRMAA) – based on income from 2 years prior
◦ $203 deductible up $5.00 from 2020 About 70% of Medicare beneficiaries have their
premiums deducted automatically from their Social Security benefits (significant for those on fixed incomes)
Reimbursement for diagnostic testing is hardly impressive
Physicians are selling or have sold their practices and are becoming employee-owned by hospital entities
More concierge physicians◦ New referral source?
Need to analyze services/products ◦ Must know the profit margin of providing a service or dispensing a
product◦ Implications of eliminating a service or product must be
considered
HHS Secretary Azar (before resigning) extended the COVID-19 Public Health Emergency (PHE) declaration effective Jan. 21, 2021 for an additional 90 days. This means that all of the telehealth and other waivers and flexibilities that have been implemented during the PHE will remain in effect until at least April 21, 2021
The Consolidated Appropriations Act that was signed into law on Dec. 27, 2020, included provisions that offset most of the 10.2% budget neutrality adjustment that had been slated to take effect for Medicare-covered services provided as of Jan. 1, 2021. CMS has now confirmed that that there will be no delay in claims processing for 2021 services; that is, claims will be paid on time at the correct 2021 rates that reflect this legislation
On December 27, the Consolidated Appropriations Act, 2021 modified the 2021 Medicare Physician Fee Schedule (MPFS) instituting a 3.75% increase in MPFS payments for CY 2021
Suspended the 2% payment adjustment (sequestration) through March 31, 2021
Reinstated the 1.0 floor on the work Geographic Practice Cost Index through CY 2023
Delayed implementation of the inherent complexity add-on code for evaluation and management services (G2211) until CY 2024
CMS has recalculated the MPFS payment rates and conversion factor to reflect these changes. The revised MPFS conversion factor for CY 2021 is 34.8931. The revised payment rates are available in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage
The raise of the 2121 proposed conversion factor (34.89), delay of implementation of G2211 (prolonged E/M service) and the suspensionof sequestration (2%) for at least 3 months results in Audiology receiving a 3% increase instead of a 6% decrease in the MPFS (a 9% savings!)
Remember, the MPFS is the template for nearly every third party payer resulting in this positive change impacting reimbursement essentially for all payers
Due to the Consolidated Appropriations Act, 2021, reimbursement for audiology codes will:
A) decrease for 2021 from 2020B) increase for 2021 from 2020C) have no change for 2021 compared to 2020D) not be known until after President Biden has
completed his first 90 days in office and Congress can vote
Next, let’s look at the implication of business decisions – Audiology is a business!
Develop the mission of the “why” statement for the practice/facility
◦ we listen, we educate, we treat, we care Put the right people on the bus:◦ Audiologists – how many? How do you know?◦ Front office – how many? How do you know?◦ Billing and Collections: Staff size? Outsource?
How often is the fee schedule “revisited”?◦ Medicare Physician Fee Schedule (MPFS)◦ Review the Explanation of Benefits (EOB)
How many audiograms necessary per month for…? What are the fees? How are they determined? Is there a standard of care for a diagnostic
evaluation (Hint: “”medical necessity”) for the facility?
What are the insurance plans paying for diagnostics?◦ Can you balance bill? Probably NO!
Hearing Aids◦ Profit margin?◦ Professional fees able to be billed (bundling/unbundling)?◦ If so, what is the fee structure?◦ How many need to be dispensed per month?
Hearing Aid Supplies: What is the profit margin?
◦ Batteries, TV assistive devices, etc. What is the hourly billable rate?◦ For the owner?◦ Employees?
Can you afford “free”?◦ What is the cost of “free”?◦ How does this impact the image of the facility?
You dispense hearing aids to 4 prior patients a month totally 8 hearing aids
To acknowledge patient loyalty, you provide a $500 discount for each patient
Let’s look at the financial impact:◦ 4 patients x $500 = $2000◦ 12 months = $2000 x 12 = $24000◦ 2 audiologists on staff = $48000 ◦ If 8 patients a month for each of 2 audiologists, the
annual loss to the facility is $96000
92700 – unlisted otorhinolaryngologic service or procedure
Used for any procedure that doesn’t have an existing code
Requires a written report of justification (literature substantiated) Track reimbursement? Is it cost-effective?
Insurance is a third party contract between
the insurance company and the patient
IT IS NOT A Healthcare Provider CONTRACT!
It is okay to bill the patient
As shown repeatedly, know what is the bottom line for breaking-even
Decide scope of practice influenced by itsreimbursement, but sometimes there are other factors to keep the procedure in the mix
Determine a hearing aid delivery model(s)◦ Separating product and professional services
Are the insurance contracts profitable◦ The diagnostic reimbursement may be acceptable, but
not the hearing aid benefit or vice versa What can you do to differentiate your practice from the
competition?
AMA committee authorized by the Board of Trustees to revise, update, or modify CPT codes, descriptions, rules, and guidelines
Responsible for maintaining the CPT Code set
Meets three times per year 17 Members on the Panel CPT Advisory Committee: representatives
appointed from national medical specialty societies and CPT HCPAC organizations
Panel composition:◦ 11 physicians nominated by the National
Medical Specialty Societies◦ 1 from the BCBS Association◦ 1 from the America’s Health Insurance Plans◦ 1 from the American Hospital Association◦ 1 from the CMS◦ 2 from the CPT HCPAC
Health Care Professional Advisory Committee Members of the CPT and RUC Advisory
Committees who represent non-physician providers
Responsibilities include:◦ Resource to the CPT Editorial Panel and RUC◦ Provide documentation on medical appropriateness of
codes ◦ Present revisions to the code set◦ Present valuations of surveyed codes◦ Educate society members
Members of the CPT and RUC Advisory Committees who represent non-physician providers
Audiologists
Chiropractors
Nurses
Occupational Therapists
Optometrists
Physical Therapists
Physician Assistants
Podiatrists
Psychologists
Registered Dieticians
Social Workers
SLPs
Societies interested in the code are identified
Code structure and development
Membership survey
Panel presentation
Goes to the RUC for valuation
RVS Update Committee
AMA Committee created in 1991 as
an ADVISORY Committee for CMS
◦ CMS does not have to accept the
recommendation(s)…no rubber-stamping!
It has been in existence since 1992
31 member multi-specialty committee composed of physicians and one non-physician member who represents the interests of the Health Care Professional Advisory Committee (HCPAC)
Meet 3x/yr to consider specialty society code value proposals and make relative value recommendations to CMS
The RUC is guided by the Resource Based Relative Value Scale (RBRVS) which produces a Relative Value Unit (RVU) for every CPT code
Resource-Based Relative Value Scale Before 1992, Medicare paid for physician
services based on fee-for-service In 1992, CMS began basing payment on
an RBRVS Payments for services are based on
resource costs needed to provide them◦ Physician work (being cognitive)◦ Practice expense ◦ Professional liability insurance
Three components to the valuation:◦ Professional Work Time to perform service, technical skill, physical and mental
effort, stress/risk to patient◦ Practice Expense Cost of the professional, space, operations, utilities, equipment,
etc.◦ Professional Liability Insurance (PLI) In 2000, CMS implemented a resource based PLI
Payments calculated by multiplying the RVU by a conversion factor (changes annually)
Geographic adjustment by locality
Practice Expense, 44%
Physician Work, 52%
Professional Liability
Insurance, 4%
An RVU is not compromised of which of the following:
A) CognitionB) Malpractice CostsC) MarketingD) The professional’s salary
for performing the procedure
Mandated in the Social Security Act To comply with budget neutrality, changes
to the MPFS cannot increase or decrease expenditures by more than $20 million annually
An increase in value requires a corresponding decrease in another
The size of the pie stays the same; the pieces either become bigger or smaller
The conversion factor is adjusted accordingly
CPT Editorial Panel
Level of Interest
Survey
Specialty RVS Committee
Medicare PaymentSchedule
The RUC
CMS
CMS reviews RUC recommendations and makes the final decision regarding values, then posts their recommendations in the Federal Register (~July or August) for comment (due ~ October)
Professional Societies respond again to CMS Final CMS determination results in the Medicare
Physician Fee Schedule (MPFS) which is posted ~December and becomes the new payment structure effective the following January 1
All discussions subject to strict confidentiality
Members of the RUC Advisory Committees who represent non-physician providers• Audiologists
• Chiropractors
• Nurses
• Occupational Therapists
• Optometrists
• Physical Therapists
• Physician Assistants
• Psychologists
• Registered Dietitians
• Social Workers
• SLPs
Vestibular Evoked Myogenic Potential (VEMP) Testing
Codes: 92517, 92518, and 92519
Auditory Evoked Potentials (AEPs)
Codes: 92650, 92651, 92652, and 92653
New Parentheticals: 92584 (Electro-cochleography
Deleted Codes: 92585, 92586
Special Otorhinolaryngologic Services/Vestibular
Function Tests, With Recording (eg, ENG)
92517 Vestibular evoked myogenic potential (VEMP)
testing, with interpretation and report; cervical (cVEMP)
50
Special Otorhinolaryngologic Services/Vestibular Function Tests, With Recording
92518 Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; ocular (oVEMP)
51
Special Otorhinolaryngologic Services/Vestibular Function Tests, With Recording
92519 Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report; cervical (cVEMP) and ocular (oVEMP)
RUC Recommendations 2021:VEMP Testing
52
CPT Code Current Work RVU
RUC Recommended
Work RVU
Proposed CMS Work
RVU
92517 N/A 0.80 0.8092518 N/A 0.80 0.8092519 N/A 1.20 1.20
53
Special Otorhinolaryngologic Services/Audiologic Function Tests
92585 Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system; comprehensive
54
Special Otorhinolaryngologic Services/Audiologic Function Tests
92586 limited
55
Special Otorhinolaryngologic Services/Audiologic
Function Tests92650 Auditory evoked potentials; screening of
auditory potential with broadband stimuli, automated analysis
92651 for hearing status determination, broadband stimuli, with interpretation and report
56
Special Otorhinolaryngologic Services/Audiologic Function Tests
92652 Auditory evoked potentials; for threshold estimation at multiple frequencies, with interpretation and report
►(Do not report 92652 in conjunction with
92651)◄92653 Auditory evoked potentials; neurodiagnostic,
with interpretation and report
57
Special Otorhinolaryngologic Services Audiologic Function Tests92584 Electrocochleography
(92585 has been deleted. To report, see 92652, 92653)(92586 has been deleted. To report, see 92650, 92651)
RUC Recommendations 2021: AEPs
58
CPT Code Current Work RVU
RUC Recommended
Work RVU
Proposed CMS Work
RVU
92584 0.00 1.00 1.0092650* N/A 0.25 0.2592651 N/A 1.00 1.0092652 N/A 1.50 1.5092653 N/A 1.05 1.05
*CMS accepted RUC recommended work RVU of 0.25 for code 92650; however, this code is a Medicare non-covered service
Hearing aids are most typically sold as a “bundled”
package
◦ The cost of goods is not differentiated from the cost for
performing professional services
Insurance companies don’t necessarily prohibit
the audiologist from billing for professional
services
Many plans “assume they are paying for the cost of goods”
If the insurance plan doesn’t prohibit billing for hearing aid related services, it would be cost effective to bill all procedures related to the selection, fitting, dispensing, and maintaining of hearing aid performance
Imperative to know the specifics of the insurance plan
◦ Diagnostic testing for securing a diagnosis◦ Cerumen management◦ Speech-in-Noise testing◦ Hearing aid evaluation◦ Earmold impression taking◦ Verification of hearing aid performance◦ Electroacoustic evaluation◦ Cleaning of the hearing aids ◦ Tubing replacement◦ Replacement of battery doors, earhooks, microphone covers ◦ Earmolds◦ Office visit(s)◦ Aural rehabilitation
92557 (basic audiometry) 92567, 68, 69 (bundled options
when indicated) 92579 (VRA) 92582 (Play Audiometry) 92583 (Picture
Audiometry) 92587 (OAE’s) if indicated 92590 (HAE) monaural
92591 (HAE) binaural
92592 Hearing Aid Check
(monaural)
92593 (binaural)
92594 Electroacoustic eval
(monaural)
92595 (binaural)
92596 (Ear protector attenuation
testing)
To describe technology (examples):
◦ V5242 – Hearing Aid, analog, monaural, CIC
◦ V5252 – Hearing Aid, programmable analog,
binaural, ITE
◦ V5261 – Hearing Aid, digital, binaural, BTE
To describe dispensing fees (examples):
◦ V5240 Dispensing fee BICROS
◦ V5200 Dispensing fee, CROS
◦ V5110 Dispensing fee, bilateral
◦ V5241 Dispensing fee, monaural
◦ V5090 Dispensing fee, unspecified hearing aid
To describe assistive technology (examples):
◦ V5274 Assistive listening device, not specific
Miscellaneous Codes (examples):
◦ V5275 Ear impressions, each
◦ V5020 Real ear measures
◦ V5299 Hearing service, miscellaneous
Bundle without exception Unbundle without exception Bundle services for two years (or while under
warranty), but bill for all professional services The options are endless Unbundling provides value to services and to product Have a policy for products purchased on the internet Patients may present with non-programmed hearing aids
provided by the insurance plan…what is policy? A patient asks to be “fit” with hearing aids from a friend or
relative… what is policy?
FACTS: There are procedures performed that either
don’t have a procedure code and/or a device code
There are some codes that the insurance payer deems “not within our provider category” and, therefore, deny payment even though the procedure is within the audiologist’s scope of practice
Action: For services not covered, or for those without a
CPT code, bill the patient Provide an invoice to the patient for each visit◦ List any services that are provided especially those given
away for “free” (ex., during the bundled period) and give a dollar amount
Ex., you cleaned the hearing aid for free, use V5299 on the invoice with a charge amount, then an adjustment showing a credit for that amount but this… allows the patient to see the value of the “giveaway”
