ADA 2022 Proposed Rule Comments

Author: Kim Cavitt, Au.D.

On September 10, 2021, ADA provided the following comments and recommendations in response to the Centers for Medicare & Medicaid Services (CMS) Notice of Proposed Rule Making (Proposed Rule) on the revisions to Medicare payment policies under the Physician Payment Schedule for calendar year (CY) 2022, published in the Federal Register (Vol. 86, No. 139 FR, pages 39104-39907) on July 23, 2021:

Continued Reductions in Reimbursement Threaten Access to Audiology Services
The 2022 Medicare Physician Fee Schedule (MPFS) Proposed Rule decreases the 2022 conversion factor (from $34.89 in 2021 to $33.58 in 2022). This reduction in the conversion factor will translate to at least an estimated 3.75% reduction in reimbursement for audiology and vestibular services. This continued, annual assault on Medicare reimbursement, exacerbated by budget neutrality requirements, is unsustainable and devastating for practices as they attempt to grapple with reduced clinic capacities and the increased costs of personal protection equipment (PPE), and other infection control measures associated with combating the COVID-19 pandemic and public health emergency (PHE). Reductions in reimbursement for audiology services negatively impacts access to hearing and balance services for seniors and threatens the sustainability of audiology clinics across the nation.
Eliminate Physician Order Requirement for Coverage of Audiology Services
Currently, Medicare coverage of audiology services provided by licensed audiologists is contingent on the services being first ordered by a physician or appropriate non-physician practitioner.  As audiologists are already responsible for medical necessity under Medicare Part B, the order requirement is redundant. It creates inefficiencies and red tape for ordering providers, considerable confusion for beneficiaries, unnecessary beneficiary and system costs and barriers to access, and delayed care.

ADA respectfully requests that CMS eliminate the physician order policy so that Medicare beneficiaries can avoid an extra office visit as a condition of coverage for the hearing and balance care that they need. CMS’ order requirement for coverage of audiology services is not statutorily required, nor is it a requirement for other public or private health insurers in the United States, including Medicare Part C, Medicaid, the Federal Health Benefit Plans (FEHP), or the U.S. Department of Veterans Affairs (VA).

According to an independent legal opinion (Medicare Coverage of Diagnostic Audiology Services, 2016), obtained by ADA, CMS has the authority to eliminate the physician order requirement for coverage of audiology services administratively. Congress attests to the Secretary’s authority in legislation passed in the U.S. House of Representatives in 2019, which states “The Secretary of Health and Human Services may promulgate regulations to allow qualified audiologists (as so defined) to furnish audiology services (as so defined) without a referral from a physician or practitioner…” (H.R. 3, 116th Congress)

A study conducted by the Moran Company in 2020 estimates that rescission of Medicare’s physician order requirement for coverage of audiology services would save CMS $108M and save beneficiaries $34M in out-of-pocket costs over 10 years (Moran Co., 2020).  This savings could be applied to offset proposed increases in coverage for primary care and telehealth services.
Recognize Certain Audiology Services as Category 3 Telehealth Procedures
CMS requested comments regarding certain audiology services being added to Category 3 Telehealth status to allow for additional time, after the PHE expires, for continued data collection on utilization and clinical viability. The ADA wholeheartedly supports transitioning all currently assigned Category 2 Telehealth procedures to Category 3 procedures through CY2022.
The ADA also respectfully requests that the following audiology and vestibular codes be considered for addition to the Telehealth Category 3 list:
92620: Evaluation of central auditory function, with report; initial 60 minutes.
92621: Evaluation of central auditory function, with report; each additional 15 minutes.
92540: Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal or peripheral stimulation, with recording, and oscillating tracking test, with recording.
92541: Spontaneous nystagmus test, including gaze and fixation nystagmus, with recording.
92542: Positional nystagmus test, minimum of 4 positions, with recording.
92544: Optokinetic nystagmus test, bidirectional, foveal or peripheral stimulation, with recording.
92545: Oscillating tracking test, with recording.
92546: Sinusoidal vertical axis rotational testing.
92547: Use of vertical electrodes.
92537: Caloric vestibular test with recording, bilateral; bithermal (i.e., one warm and one cool irrigation for each ear for a total of four irrigations).
92538: Caloric vestibular test with recording, bilateral; monothermal (i.e,. one irrigation in each ear for a total of two irrigations).
92548: Computerized dynamic posturography sensory organization test (CDP-SOT), 6 conditions (i.e., eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform and visual sway), including interpretation and report.
92549: Computerized dynamic posturography sensory organization test (CDP-SOT), 6 conditions (i.e., eyes open, eyes closed, visual sway, platform sway, eyes closed platform sway, platform and visual sway), including interpretation and report; with motor control test (MCT) and adaptation test (ADT).
92517: Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report, cervical (cVEMP).
92518: Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report, ocular (oVEMP).
92519: Vestibular evoked myogenic potential (VEMP) testing, with interpretation and report, cervical (cVEMP) and ocular (oVEMP).
92650: Auditory evoked potentials; screening of auditory potential with broadband stimuli, automated analysis.
92651: Auditory evoked potentials; for hearing status determination, broadband stimuli, with interpretation and report.
92652: Auditory evoked potentials; for threshold determination at multiple frequencies, with interpretation and report.
92653: Auditory evoked potentials; neurodiagnostic, with interpretation and report
Provide Parity for Audiology Codes Analogous to E&M Codes
The ADA strongly urges CMS to apply adjustments uniformly across analogous services and specialties, including assessments furnished by audiologists. Audiologists specialize in preventing, evaluating, diagnosing, managing, and treating audiologic and balance (vestibular) disorders, using standardized quantitative and qualitative measures, including quality of life (QoL) handicap inventories, observations, procedures, and audiologic and vestibular diagnostic testing with appropriately calibrated instrumentation.

Audiologic and vestibular testing leads to the diagnosis of audiologic and/or balance disorders. The audiologist’s assessment includes performance and interpretation of test results identifying the probable cause of impairment and functional ability within hearing, balance, and other related systems.

Audiologists often identify the underlying disorder and diagnosis. Audiologists serve on care teams and the results of audiologic and vestibular assessments play a critical role in physician and other qualified health care professional management of Medicare beneficiaries with audiologic and vestibular disorders. 

Given an audiologist’s role in improving communication and mitigating falls risk, the ADA respectfully requests that CMS review audiology and vestibular services and adjust work Relative Value Units (RVUs) for analogous evaluation codes primarily reported by audiologists, to ensure relativity within the MPFS. 

We offer the following examples of audiology evaluations that include work analogous to office/outpatient E/M services:

CPT Code  CPT Descriptor  ADA Description 
92540  Basic vestibular evaluation, includes spontaneous nystagmus test with eccentric gaze fixation nystagmus, with recording, positional nystagmus test, minimum of 4 positions, with recording, optokinetic nystagmus test, bidirectional foveal and peripheral stimulation, with recording, and oscillating tracking test, with recording  Obtain comprehensive audiologic, vestibular, and medical case history.  Assesses vestibular function using a comprehensive battery of tests to aid in the differential diagnosis of balance disorders and distinguish between aural, peripheral, and central pathologies. Informs a plan of care to manage and/or treat a balance disorder and prevent falls. 
92557  Comprehensive audiometry threshold evaluation and speech recognition (92553 and 92556 combined)  Obtain comprehensive audiologic, vestibular, and medical case history.  Assesses behavioral responses from the patient using pure tone air and bone conduction, and speech threshold and recognition to aid in the differential diagnosis of hearing loss and audiologic disorders and determine the need for additional testing. Informs a plan of care to prevent, manage, and/or treat a hearing disorder. 
92620 Evaluation of central auditory processing, with report; initial 60 minutes
 
Obtain comprehensive audiologic, vestibular, and medical case history.  Assesses central auditory function through specialized audiologic testing to aid in the differential diagnosis of hearing and communication disorders. Informs a plan of care to manage and/or treat resulting central auditory disorders.  
92625 Tinnitus assessment (includes pitch, loudness, matching, and masking) Obtain comprehensive audiologic, vestibular, and medical case history.  Assesses behavioral responses from the patient to aid in the differential diagnosis of bothersome tinnitus and associated audiologic disorders and determine the need for additional testing. Informs a plan of care to manage and/or treat the tinnitus and any possible accompanying hearing loss and/or vestibular complaints.
92626  Evaluation of auditory function for surgically implanted device(s) candidacy or postoperative status of a surgically implanted device(s); first hour  Obtain comprehensive audiologic, vestibular, and medical case history.  Assesses auditory function through behavioral and audiologic testing for medically necessity of and suitability for a surgically implanted hearing device, as well as post-surgical implant performance and outcomes. Informs the final surgical decision and post-surgical plan of care to improve functional hearing and communication abilities. 
     
Allow Audiologists to Supervise Procedures with TC/PC Split
The 2021 MPFS proposed rule allowed for non-physician practitioners (NPP), such as Nurse Practitioners, clinical nurse specialists, Physician Assistants, and certified nurse-midwives to supervise the performance of diagnostic tests performed by technicians. The ADA again requests that licensed audiologists be added to this list, allowing the audiologist to directly supervise a technician performing procedures in the audiology code set that have a technical/professional component (TC/PC) split (i.e., 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, 92547, 92548, 92549, 92587, and 92588).  Currently, non-physician practitioners, many who have limited clinical knowledge or expertise in the performance or interpretation of audiologic or vestibular procedures, supervise the performance of these procedures; therefore, audiologists, who independently perform and interpret these procedures daily, should also be allowed to supervise the actions of technicians completing these procedures and have these services covered.
Add Audiologists as Covered Recipients Under Open Payments Provisions
Audiologists prescribe, order, and/or dispense durable medical equipment (DME), specifically hearing aids, cochlear implants, and osseointegrated devices, to Medicare Part C, Medicaid, FEHP, and VA beneficiaries. Including audiologists as covered recipients, subject to Open Payments reporting, would ensure greater transparency regarding financial relationships between audiologists and manufacturers, provide information on the nature and extent of these relationships, help to identify relationships that can both lead to the development of beneficial new technologies but also produce wasteful or fraudulent healthcare spending, help prevent inappropriate influence on research, education, and clinical decision making, specifically kickbacks, and level the playing field for providers across the clinical spectrum.
Enhance and Mandate Hearing Screenings and Falls Risk Assessments at IPPE and AWV
Untreated hearing loss and balance difficulties have been found to significantly increase healthcare costs and utilization (Reed et al, 2019, Kovacs, et al, 2019) and significantly affect quality of life (Li-Korotky, 2012). The ADA requests that hearing screenings and falls risk assessments be enhanced and mandated in the Initial Preventative Physical Examination (IPPE) and Annual Wellness Visit (AWV).  Like substance abuse screenings, otoscopy, cerumen management, acoustic hearing screenings, and falls risk assessments should be required procedures in every IPPE and AWV visit.

Add MIPS Measures to the Audiology Specialty Set
As it pertains to the Merit Based Incentive Payment System, the ADA requests that the following measures be added to the Audiology Specialty Set:
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling (Quality ID #431 (NQF 2152))
Assigned to procedures: 92517, 92518, 92519, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, 92547, 92548, 92549, 92550, 92552, 92553, 92555, 92556, 92557, 92550, 92567, 92570, 92584, 92587. 92588, 92650, 92651, 92652, 92653, 92620, 92621,92625, 92626, and 92627.
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (Quality ID #317)
Assigned to procedures: 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, and 92625.
Closing the Referral Loop: (Quality ID #374)
Assigned to procedures: 69200, 69209, 69210, 92517, 92518, 92519, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92546, 92547, 92548, 92549, 92550, 92552, 92553, 92555, 92556, 92557, 92550, 92567, 92570, 92584, 92587, 92588, 92650, 92651, 92652, 92653, 92620, 92621,92625, 92626, 92627, and 95992.
Clarify Planned 2022 Low-Volume Threshold Application
The ADA requests clarification about language in the 2022 Proposed Rule regarding application of the low-volume threshold to group practices.  In 2022, will the low volume threshold be applied to group data rather than merely individual data? This detail is extremely important to audiologists; currently many are excluded from required reporting because they (1) individually have allowed charges for covered professional services less than or equal to $90,000; (2) provide covered professional services to 200 or fewer Medicare Part B-enrolled individuals; and (3) provide 200 or fewer covered professional services to Medicare Part B-enrolled individuals.  A large percentage of these audiologists would be required to report (to avoid a penalty) if these same threshold requirements were applied to group or sub-group data. The clarification is essential for audiologists prior to the creation and implementation of the 2022 participation tool.    
References
Kovacs E, Wang X, Grill E. Economic burden of vertigo: a systematic review. Health Econ Rev. 2019;9(1):37. Published 2019 Dec 27. doi:10.1186/s13561-019-0258-2
Li-Korotky, H. Age-Related Hearing Loss: Quality of Care for Quality of Life, The Gerontologist, Volume 52, Issue 2, April 2012, Pages 265–271, https://doi.org/10.1093/geront/gnr159
Reed NS, Altan A, Deal JA, et al. Trends in Health Care Costs and Utilization Associated with Untreated Hearing Loss Over 10 Years. JAMA Otolaryngol Head Neck Surg. 2019;145(1):27-34. doi:10.1001/jamaoto.2018.2875
The Moran Company. HR 4056 - Medicare Audiologist Access and Services Act: Fiscal Implications. July 2020.
Medicare Coverage of Diagnostic Audiology Services. Kanner Sheree. Hogan Lovells. October 14, 2016 (previously submitted to CMS).
H.R. 3. Elijah E. Cummings Lower Drug Costs Now Act. 2016. Accessed on September 9, 2021 at the following link: https://www.congress.gov/bill/116th-congress/house-bill/3/text.
Dr. Kim Cavitt was a clinical audiologist and preceptor at The Ohio State University and Northwestern University for the first ten years of her career. Since 2001, Dr. Cavitt has operated her own Audiology consulting firm, Audiology Resources, Inc. She currently serves on the State of Illinois Speech Pathology and Audiology Licensure Board. She also serves on committees through AAA and ASHA and is an Adjunct Lecturer at Northwestern University.