Otolaryngology Coding Alert

Conversion factor goes down $1.55, some PHE flexibilities continue.

Absent congressional action, all physician practices will face Medicare payment cuts this year. But on the bright side, enhancements in health equity and expanded access to first-rate comprehensive healthcare for all are on the horizon.

Context: On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) unveiled the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) final rule. It’s chock full of billing revisions and payment provisions, which include updates to key issues like evaluation and management (E/M) services, telehealth, dental coverage, and behavioral health.

Read on to learn about five policies that will likely impact your Medicare reimbursement.

Updates to Other E/M Services Approved

To better align with previous guideline changes made to office/outpatient E/M service codes in the CY 2021 MPFS final rule, CMS is pushing forward with AMA CPT^® Editorial Panel-approved revisions to coding and guidelines for “other E/M visits” — hospital inpatient, hospital observation, emergency department (ED), nursing facility, home or residence services, and cognitive impairment assessment — effective Jan. 1, 2023.

In a nutshell, CMS is finalizing its proposal to accept the changes for these E/M visits, which include adopting new code descriptors/definitions and utilizing the same interpretive guideline revisions for levels of medical decision making (MDM) CPT^® adopted in 2021 for office/outpatient E/M services. This means nixing history and exam and instead using time or MDM to determine code level for the majority of the code sets. These updates will bring Medicare in line with the CPT^® revisions for the services.

Coverage of Temporary Telehealth Codes Extended

CMS is keeping a number of the temporary telehealth codes in place as Category III codes due to the ongoing COVID-19 public health emergency (PHE) through at least 2023. While coverage of certain other services listed under the temporary column in the Telehealth Services List will expire 151 days following the conclusion of the PHE for COVID-19, which was renewed for another 90 days on Oct. 13.

Providers will continue to bill with the place of service code that would have been reported had the service been furnished in person and append modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) to the claim to identify them as services rendered via telehealth for Medicare Part B beneficiaries. This applies through the later of the end of the year in which the PHE ends or CY 2023, per the final rule.

“Keep in mind that each third-party payer has their own telehealth rules and may require different treatment of the place of service and require different modifiers. Claims must adhere to each third-party payer’s requirements as there is no one policy implemented across the board,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare in Tinton Falls, New Jersey.

Access to Select Audiology Services Expanded

CMS is finalizing the controversial policy that allows direct access to an audiologist without an order from a physician for non-acute hearing conditions unrelated to disequilibrium, hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids.

The final rule still limits the direct access to any of the 36 audiology services to once every 12 months. To report these tests performed by an audiologist you will use modifier AB (Audiology service furnished personally by an audiologist without a physician/npp order for non-acute hearing assessment unrelated to disequilibrium, or hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids; service may be performed once every 12 months, per beneficiary) — instead of a new HCPCS Level II G code, as proposed — with one or more of the 36 CPT^® codes for dates of service on and after Jan. 1, 2023.

Note: The 2023 final rule modifies the proposed rule that would have created a blended payment with a single new HCPCS Level II G code intended to replace the 36 individual CPT^® codes when services are provided by an audiologist without a physician order.

The American Academy of Audiology weighed in saying, “The CMS provision for limited direct access is a step forward but still imposes unnecessary restrictions.” This echoes the sentiments of the Speech-Language-Hearing Association (ASHA), “While the use of the code/modifier improves the accuracy of audiology claims data and payments, as well as eliminates coding confusion, ASHA finds the restrictions placed on accessing audiology services without a physician order to be arbitrary and lacking any clinical justification.”