Additional Details on the 2024 Medicare Final Rule, Including New Codes and Quality Measures, Payment Cuts, and Telehealth Coverage

UPDATED December 19, 2023: Based on recent clarification from Medicare staff, audiologists and SLPs must begin reporting on promoting interoperability measures under the Merit-Based Incentive Payment System on January 1, 2024, instead of 2025. Given the small number of ASHA members subject to MIPS and additional exemptions specific to this category, ASHA does not anticipate this change will have implications for most members.

Original News on November 10, 2023: The Centers for Medicare & Medicaid Services (CMS) has released the 2024 Medicare Physician Fee Schedule (MPFS) final rule, which establishes payment policies and rates for Part B (outpatient) audiology and speech-language pathology services. Significant policies finalized in this rule include—but are not limited to—new codes for auditory osseointegrated device (AOD) programming and caregiver training; payment cuts for audiology, speech-language pathology, and other services; audiology access; telehealth services; quality reporting; and alternative payment models.

Medicare pays for outpatient clinic and office-based audiology and speech-language pathology services under the MPFS. Medicare also pays for most speech-language pathology services provided in hospital outpatient settings based on the MPFS. However, audiology outpatient hospital services are paid under the hospital outpatient prospective payment system (OPPS).

ASHA submitted comprehensive comments [PDF] on the proposed rule to support or improve policies applicable to audiologists and speech-language pathologists (SLPs). The final rule applies to services provided in the 2024 calendar year.

The following information highlights key provisions impacting audiologists and SLPs. Many of the provisions contained in the rule reflect updates or policy improvements that ASHA advocated for. However, Congressional action is still needed to address the looming issue of across-the-board payment cuts under the MPFS.

• Payment Rates
• Coding Updates
• Access to Audiology Services and “AB” Modifier
• Telehealth
• Quality Payment Program
• Social Determinants of Health
• Targeted Manual Medical Review
• Resources and Contacts

Payment Rates

Conversion Factor

CMS uses an annual conversion factor (CF) to calculate MPFS payment rates. For 2024, the CF will be $32.7442, representing a 3.37% decrease from the $33.89 CF for 2023. The decrease in the CF is mostly due to the expiration of the temporary 2.5% positive adjustment that Congress implemented to mitigate significant payment cuts in 2023 and Medicare’s requirement to maintain a budget neutral program. However, it’s important to note that the CF includes a 1.25% increase required by Congress to help mitigate the 2024 payment cuts.

Medicare providers face other Medicare cuts known as sequestration (2% reduction) and statutory "Pay-As-You-Go", or PAYGO (4% reduction). This could result in a total cut of almost 10% to overall Medicare payments when added to the CF reduction. Congress has acted each year by passing legislation that reduced or eliminated some of these additional cuts and will need to do so again for 2024 payments.

Due to federal budget concerns and competing Congressional priorities, similar action to address the 2024 cuts is not assured. Audiologists and SLPs should prepare for the possibility that the payment cuts will go into effect on January 1, 2024.

Next steps for ASHA: We have strongly advocated against the Medicare Part B payment cuts since they were first set to occur in 2021, leading to Congressional intervention to soften the blow of the cuts each year, including the mitigation that is already in place for 2024. However, Medicare providers will continue to face payment instability unless Congress acts to reform the Medicare payment system. ASHA remains fully committed to continuing advocacy and collaboration with members of Congress, CMS, key decision makers, and other providers to find short- and long-term solutions to address Medicare payment issues, including supporting H.R. 2474, the Strengthening Medicare for Patients and Providers Act.

In addition to the potential cuts discussed above, CMS’s regulatory impact analysis (RIA) estimates that audiologists could see up to a 2% decrease and SLPs could experience up to a 3% decrease based on policy changes implemented for 2024. However, cumulative payment changes experienced by individual clinicians or practices will vary because actual payment depends on several factors, including locality-specific rates and the specific procedure codes billed. ASHA will publish final 2024 national payment rates for audiology and speech-language pathology services in its full MPFS analysis.

What you can do: ASHA members can take action by urging their members of Congress to improve fiscal stability for Medicare providers by supporting H.R. 2474, which would provide an annual inflationary payment update based on the Medicare Economic Index (MEI).

Coding Updates

CMS has added five new Current Procedural Terminology (CPT®) codes related to auditory osseointegrated device programming (2 codes) and caregiver training (3 codes) as covered services under the 2024 MPFS.

Advocacy in action: ASHA worked with stakeholders―including the American Academy of Audiology, American Occupational Therapy Association, and American Physical Therapy Association―to develop and value the new procedure codes through the American Medical Association’s (AMA) code development process [PDF]. ASHA also advocated with CMS for appropriate valuation and coverage under the MPFS. As a result, CMS accepted the new codes for payment under the MPFS at the recommended values.

More information on the new codes, including final code numbers, is available on ASHA’s coding webpage.

Auditory Osseointegrated Device (AOD) Services

Effective January 1, 2024, audiologists will see two new timed codes describing the first hour and each subsequent 15 minutes of time for the analysis, programming, and verification of an auditory osseointegrated sound processor. These codes can also be used for subsequent reprogramming of the AOD. CMS is adding both codes to the list of services that can be billed with an “AB” modifier when performed by an audiologist without a physician referral for a nonacute hearing condition.

Caregiver Training

Beginning in 2024, SLPs can report caregiver training services (CTS) without the patient present, when provided under an established, individualized, and patient-centered plan of care. This marks the first time CMS will allow therapists, including SLPs, to bill and receive MPFS payment for services without the patient present. CMS acknowledges the importance and efficacy of reasonable and necessary caregiver training to influence successful health outcomes for patients.

Correct billing for caregiver training is based on the individual patient whose caregiver(s) require training to help with the treatment plan and facilitate functional performance. Billing is not based on the number of caregivers in the training session.

• Training for the caregivers of one patient is billed with two timed codes for the initial 30 minutes (97550) and each additional 15 minutes (97551). Clinicians will bill caregiver training for an individual patient once per session, regardless of the number of caregivers involved in the training.
• Group training for caregivers of more than one patient is billed with one untimed code (97552) per patient represented in the group. Clinicians will bill group caregiver training once per patient, not once per caregiver.

However, CMS has provided conflicting information in the final rule. Although CMS acknowledged that billing is based on the patient, the agency also stated in its coding guidance that billing should be based on the number of caregivers, rather than the number of patients represented. This interpretation is not consistent with the intent of the codes and will cause confusion among payers and providers as they implement the new codes in 2024.

Next Steps for ASHA: We will work with related stakeholders to request that CMS issue updated guidance with accurate coding and billing instructions and will provide updates on ASHA’s website.

Caregiver Definition

For the purposes of the CTS policy, CMS will use two definitions that the agency believes complement each other, as follows:

Family Caregiver: A family caregiver is "an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability, or functional limitation." This definition is from the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act (Pub. L. 115-119).

Caregiver: A caregiver is “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.” This version is based on the CMS Outreach and Education definition.

To bill for caregiver training without the patient present, CMS indicates that caregivers must be trained by the patient’s treating clinician to assist with aspects of the patient’s care that are directly related to an established plan of care to address a diagnosed illness or injury.

CTS should not be billed for training medical professionals or support personnel who are employed to provide health care services to the patient.

Reasonable and Necessary CTS

CMS considers CTS to be reasonable and necessary when services are “integral to the patient’s overall treatment and furnished after the treatment plan (or therapy plan of care) is established.” They indicate that a plan of care should account for those clinical circumstances when the treating clinician determines that caregiver involvement is necessary to assist in carrying out a treatment plan to support successful outcomes for the patient. According to CMS, examples of patient conditions that may warrant CTS include, but are not limited to, “stroke, traumatic brain injury (TBI), dementia, autism spectrum disorders, individuals with other intellectual or cognitive disabilities, physical mobility limitations, or necessary use of assisted devices or mobility aids.”

CMS also notes the patient should agree to caregiver involvement and will require clinicians to document the patient’s or their representative’s specific consent for the caregiver(s) to receive training without the patient present.

Remote Therapeutic Monitoring (RTM)

SLPs have been able to provide and bill for RTM services under the MPFS since 2023. However, CMS waived certain billing requirements to allow broader patient access to care during the federal public health emergency (PHE). In this final rule, CMS clarifies that billing requirements for RTM services have changed with the end of the PHE. For example, RTM codes may only be billed when monitoring requires data collection for at least 16 days in a 30-day period. In addition, CMS notes that only one clinician may report the remote monitoring codes in a 30-day period and that RTM services may not be billed in conjunction with remote physiologic monitoring (RPM) codes.

Access to Audiology Services and “AB” Modifier

In 2023, CMS implemented a policy that allows audiologists to provide nonacute hearing assessment services―under limited circumstances―without a physician order. No substantive changes were made to this policy with the exception of adding two CPT codes to the list of services that can be billed without an order using the “AB” modifier―92622 and 92623―bringing the total number of services that can be provided under the limitations of the policy to 38 CPT codes. More details regarding this policy can be found on the ASHA website.

Next steps for ASHA: We continue to monitor the implementation of this policy and advocate for improvements. In addition, ASHA supports legislation that would improve the Medicare audiology benefit to include removal of the physician order requirement, coverage of both assessment and treatment services, and reclassifying audiologists as “practitioners” which would allow them to bill for telehealth services on a permanent basis.

What you can do: Contact your member of Congress today and encourage them to cosponsor the Medicare Audiology Access Improvement Act (S. 2377).

Telehealth

CMS has implemented the requirements of the Consolidated Appropriations Act of 2023 (CCA) by extending telehealth coverage of audiology and speech-language pathology services paid under the fee schedule through December 31, 2024. All CPT codes that were covered during the federal PHE will remain covered through the end of next year.

While there is technically a brief gap in guidance from CMS regarding telehealth coverage from October to the end of 2023, the agency highlighted in a frequently asked questions (FAQ) resource [PDF] that it would exercise enforcement discretion through the end of 2023 to allow the necessary regulations to be finalized for 2024. This FAQ applies enforcement discretion to all outpatient providers, including those in institutional settings like outpatient hospital departments. This means that providers in outpatient settings can continue to provide telehealth services to Medicare beneficiaries without interruption through the end of 2024. See Providing Audiology and Speech-Language Pathology Telehealth Services Under Medicare for more information.

Next steps for ASHA: We remain committed to securing permanent authority for audiologists and SLPs to receive reimbursement for services provided via telehealth at parity with payment for in-person services.

What you can do: Visit ASHA’s Take Action site to urge your members of Congress to advocate for permanent telehealth coverage under Medicare by supporting the Expanded Telehealth Access Act (H.R. 3875).

Telehealth Billing Change

Although CMS plans to extend telehealth coverage through 2024 by continuing most PHE-era policies, including for institutional settings, the agency has finalized some changes to how telehealth services are billed on a claim beginning in 2024, as follows.

• Hospitals will use modifier “95” in addition to a hospital place of service (POS) code for outpatient telehealth services, aligning with current policy for other types of institutional providers.
• Therapy providers, including SLPs, will continue to use modifier “95” to indicate telehealth services and will not use one of the POS codes for telehealth services, regardless of settings. SLPs should continue to report the POS code that best reflects where services would have been provided in person.
• Audiologists will no longer use modifier “95” and will instead use POS “10” when providing telehealth services in the patient’s home or POS “02” when the patient is at a location other than their home, such as a satellite office or other facility.

In addition, CMS acknowledges that most clinicians providing telehealth services also maintain an in-person practice, so their expenses to provide telehealth services do not change significantly. As a result, CMS will continue paying for telehealth services in the patient’s home when billed with POS “10” at the higher nonfacility rate. All other claims billed with POS “02” will be paid at the lower facility rate.

Quality Payment Program (QPP)

The QPP transitions Medicare payments away from a volume-based fee-for-service payment to a more value-based system of quality and outcomes-based reimbursement. The program includes the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

Alternative Payment Models (APMs)

Only a small percentage of audiologists and SLPs participate in the APM track. These clinicians typically work for larger health systems and have the support of finance and administration departments to manage the complexity of such models.

This rule establishes digital measurements of quality called the Medicare Clinical Quality Measures (CQMs) for Accountable Care Organizations (ACOs) that are participating in the Medicare Shared Savings Program under the APM Performance Pathway as a new type of data collection. However, in addition to this new option to report quality data using Medicare CQMs, ACOs will continue to have the option to report quality data using the CMS Web Interface measures, electronic clinical quality measures (eCQMs), and/or MIPS CQMs collection types through 2024. In 2025, the CMS Web Interface measures will no longer be available and ACOs will have to report quality data using the eCQMs, MIPS CQMs, and/or Medicare CQMs.

The data completeness thresholds for Medicare CQMs are at least 75% for the 2024, 2025, and 2026 performance periods/2026, 2027, and 2028 MIPS payment years, respectively.

In an effort to streamline the administration of both programs and reduce administrative burden, standards for data completeness, benchmarking, and scoring of ACOs for the Medicare CQM collection type will align with MIPS benchmarking and scoring policies.

The Shared Savings Program’s health equity adjustment will also be applied to an ACO’s MIPS Quality performance category score when calculating shared savings payments, which advances equity by supporting ACOs that deliver high quality care while also serving a high proportion of underserved individuals.

To increase the number of patients in ACOs and improve access for underserved and high-complexity populations, multiple modifications were made to risk adjustment models, negative regional adjustments, and advanced investment payment policies.

Merit-Based Incentive Payment System (MIPS)

CMS added several new measures to the MIPS specialty measure sets for audiologists and SLPs in 2024. A robust measure set is important because there is a requirement to report a minimum of six quality measures when a clinician is a mandatory MIPS reporter. These additions ensure audiologists and SLPs have more than six measures in their respective specialty measure sets, giving them the flexibility to select measures that are most reflective of their clinical practice.

The audiology specialty measure set for the 2024 performance/2026 payment year will include two new measures:

• Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented: Percentage of patient visits for patients aged 18 years and older seen during the measurement period who were screened for high blood pressure AND a recommended follow-up plan is documented, as indicated, if blood pressure is elevated or hypertensive
• Connection to Community Service Provider: Percent of patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety; and had contact with a Community Service Provider (CSP) for at least one of their HRSNs within 60 days after screening.

Advocacy in action: As a direct result of ASHA’s advocacy [PDF], the speech-language pathology specialty measure set for 2024 will include three new measures for the 2024 performance/2026 payment year:

• Assessment of Cognitive Impairment or Dysfunction for Patients with Parkinson’s Disease: Percentage of all patients with a diagnosis of Parkinson’s Disease (PD) who were assessed for cognitive impairment or dysfunction once during the measurement period
• Screening for Social Drivers of Health: Percent of patients 18 years and older screened for food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety
• Connection to Community Service Provider: Percent of patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety; and had contact with a Community Service Provider (CSP) for at least one of their HRSNs within 60 days after screening.

Clinicians continue to be excluded from mandatory MIPS participation if they have allowed charges for covered professional services less than or equal to $90,000, furnish covered professional services to 200 or fewer Medicare Part B-enrolled individuals, or furnish 200 or fewer covered professional services to Medicare Part B-enrolled individuals. As a result, ASHA estimates that less than 1% of its members are subject to MIPS.

In addition, CMS will apply the promoting interoperability performance category to audiologists and SLPs beginning in 2025. Given the small number of audiologists and SLPs subject to MIPS and additional exemptions specific to this category, ASHA does not anticipate this change will have significant implications for most members.

For additional information, CMS provides extensive resources on MIPS on its website.

Social Determinants of Health (SDOH)

CMS finalized several policy changes to better align with the Department of Health and Human Services’ (HHS) SDOH Action Plan. Although the policies don’t include audiologists or SLPs at this time, CMS’s actions highlight the growing importance of SDOH considerations in payment systems. ASHA encourages clinicians to learn more about SDOHs and how they impact patient care.

Medicare Targeted Manual Medical Review

CMS notes in the final rule that the Bipartisan Budget Act of 2018 permanently repealed the hard caps on therapy services and permanently extended the targeted medical review process first applied in 2015. Therefore, Medicare beneficiaries can continue to receive medically necessary treatment with no arbitrary payment limitations. However, clinicians must append modifier “KX” when medically necessary services reach a monetary threshold, which changes annually. For 2024, the “KX” modifier threshold will be $2,330 for physical therapy and speech-language pathology services combined. This represents a $100 increase from the 2023 threshold amount of $2,230. Find more information on the permanent repeal of the cap and the current targeted medical review process on ASHA’s website.

ASHA Resources

The full analysis of 2024 Medicare outpatient payment rates and related information for audiologists and SLPs will be available on ASHA’s website next week.

Take action! Visit ASHA’s Take Action page to contact your representatives about the Medicare Audiology Access Improvement Act (S. 2377), Expanded Telehealth Access Act (H.R. 3875), and Strengthening Medicare for Patients and Providers Act (H.R. 2474).

Questions?

Please contact ASHA’s health care and education policy team at reimbursement@asha.org.