PQRS Measures for Audiology

PQRS

The Physician's Quality Reporting System (PQRS) is a program designed to improve the quality of care to Medicare beneficiaries.  We have audiology-specific PQRS information, and our website is www.audiologyquality.org.  If you bill traditional Medicare Part B, you need to be reporting PQRS in 2015 or you will have a 2% pay reduction in 2017.  It does not apply to Medicare Advantage, hospital or skilled nursing. 

I encourage those of you who work in hospital settings or group practices to contact your practice administrators and determine what your PQRS responsibilities are.  A lot of people did not ask in 2013 and are being penalized now as a result.  Those of you who work in smaller entities and bill Medicare Part B, you need to be reporting PQRS.  Eventually, we will not get paid without reporting quality.

PQRS Measures for Audiology

The reporting for 2015 is identical to the 2014 reporting, in order to avoid the penalty, but there are no more incentives now.  We have three measures to report in 2015: Measure 261 (referral for otologic evaluation for patients with acute or chronic dizziness), Measure 130 (documentation and verification of current medications in the medical record), and Measure 134 (screening for clinical depression in a follow-up plan of care).

Reporting that you did not do something, that you did not document current medications, that you did not refer for dizziness, or that you did not perform a depression screen, is just as if you did not report it at all.  We must report a positive action, such as a referral, documentation or screening, for the reporting to count and to assist in avoiding the penalty.  You cannot report that you did not do something. 

The depression measure is still optional as long as you are reporting the medication measure.  If you report the medication measure, then you do not need to report the depression measure.  You have to report dizziness; that is a measure in our wheelhouse.  It has to be a positive action that you documented medications or that you referred that patient.

Referral for Acute or Chronic Dizziness

Any time you perform any of these procedure codes below and have a diagnosis of dizziness or BPPV, you must report this measure. CPT Codes include: 92540, 92541, 92542, 92543, 92544, 92545, 92546, 92547, 92548, 92550, 92557, 92567, 92568, 92570, 92575.  Patients that have any of these CPT codes, as well as the ICD-9 codes 780.4 or 386.11, fit into the measure’s denominator, or are eligible patients for a measure.

There are three ways you can report referral for dizziness:

G8856: Referral to a physician for otologic evaluation;

G8857: Patient is not eligible for the referral for otologic evaluation (e.g., patients who are already under the care of a physician for acute or chronic dizziness);

G8858: Referral to a physician for an otologic evaluation not performed, reason not specified.  This means that you did one of those procedures and you diagnosed dizziness, but you did not refer the patient.  It would be a negative reporting, and that is not going to count towards avoiding the penalty.

Documentation of Current Medications

Any time you perform the CPT procedures below, regardless of the diagnosis, you need to be documenting current medications.  These codes include: 92541, 92542, 92543, 92544, 92545, 92547, 92548, 92557, 92567, 92568, 92570, 92585, 92588, 92626. Patients that have any of these CPT codes with any ICD-9 code fit into the measure’s denominator (the eligible patients for a measure). 

The measures for reporting current medications are:

G8427: List of current medications (includes prescription, over the counter, herbals, vitamin/dietary supplements) documented by the provider, including drug name, dosage, frequency, and route;

G8430: Provider documentation that the patient is not eligible for medication assessment;

G8428: Current medications (includes prescription, over the counter, herbals, vitamin/dietary supplements) with drug name, dosage, frequency, and route partially or not documented by provider, reason not specified. 

For G8427, it is important for you to select that code when you have those drugs documented and you have the four conditions documented.  G8430 may be for an emergent situation.  Perhaps they have dementia and come unaccompanied or they are not native English speakers and they do not understand what you are asking them without a translator.  That means you would not be eligible.

If you have a senior citizen that does not take any medications, you would still use G8427, because you have documented that they do not take any medications.  

G8428 is not your positive reporting.  It means that you did not document the patient's current medications and their drug name, dosage, or frequency, and the route is partially or not documented.  A lot of audiologists in dispensing offices or those that do not perform vestibular or electrophysiologic testing ask why they need this.  

This is about being able to look at your whole patient diagnose her condition.  Do they have ototoxicity that is contributing to their hearing loss or dizziness? Can you look at your patient as a whole?  It is about patient care and having a clinical focus. 

Many patients now carry their list with them.  Do not forget when scheduling this patient to remind them to bring a list of current medications, and do not forget to ask about the list at intake.  

For those of you who are in a hospital or medical environment, all you need to do is pull up their list of medications that was last listed in the EMR, go over them with the patient, and document that they have been updated.  

The same goes with the list the patient gives to you.  Go over it with the patient, sign and date it to document that it has been confirmed.  I like having a space on the patient intake form for people to list their current medications and ask about frequency, route, drug name, and dosage.  

Clinical Depression Screening

Remember that this code is optional.  It only now applies in 2015 to the tinnitus assessment, regardless of the diagnosis.  The CPT code included is 92625.  No ICD-9 codes are specified, so all are included.  Patients that this CPT code are eligible patients for this measure.

You will report on Measure 134 when it is allowed by your state licensure law and when deemed within your scope of practice in your state by written contact with your state licensure board.  

Second, if this is within your scope of practice, you should be appropriately trained and competent to perform the depression screening using a standardized tool and you must be comfortable creating a plan of care based upon the result of that screening.  

Third, that when that plan of care is created and implemented, it is fully documented in the medical record. 

The codes for screening for clinical depression are:

G8431: Positive screen for clinical depression using an age appropriate standardized tool and a follow-up plan documented;

G8510: Negative screen for clinical depression using an age appropriate standardized tool and a follow-up plan documented;

G8433: Screening for clinical depression using an age appropriate standardized tool not documented, patient not eligible/appropriate;

G8432: No documentation of clinical depression screening using an age appropriate standardized tool;

G8511: Positive screen for clinical depression using an age appropriate standardized tool documented, follow-up plan not documented, reason not specified.

The last two codes, again, are not positive outcomes.  Either you did not screen or you have a positive screen but you did not create a follow-up plan of care.  I would avoid any negative outcomes, because they will not help you avoid the penalties, and they are not good outcomes for the patient.

Submitting PQRS

You can submit PQRS via the CMS 1500 (837 format) or its electronic equivalent.  You can learn more and see sample forms at www.audiologyquality.org.  The diagnosis codes are placed in box 21.  CPT codes are placed in the CPT HCPCS column of 24D and the G PQRS codes are placed below the procedure codes in box 24D.

Avoiding the Penalty

To avoid the penalty, you need a report at least on 50% of eligible patients.  In a nutshell, you report dizziness on at least 50% of your Medicare claims, which you diagnosed as dizziness or BPPV.  You need to report on documentation of current medications at least 50% of the time.  

I would not recommend trying to play the numbers.  The documentation of current medications is 50% of each provider’s medical claims if you do a hearing test, calorics, tympanograms, and auditory brainstem response (ABR), comprehensive otoacoustic emissions (OAEs), and/or cochlear implant testing.  You need to be documenting current medications.

The incentive programs have ended and all that is left are penalties.  

The appeal period has ended for those who received a penalty in 2013.  We will find out what 2014 penalties are in December 2015, but my goal is to deal in the here and now and help you avoid penalties moving forward.

Penalty Letters

If you received the penalty letter, all of your Medicare claims for 2015 will be reduced by 1.5%.  That is a combination of your NPI and your tax identification.  It would not follow you to another employer.  If in 2013 you did not meet your one measure and you still work for the same employer, you will be penalized.  If you work for different employer, you will not be penalized. 

If you are nonparticipating provider and you received a penalty letter, you need to reduce the amount you collect in your limiting charge.  Your Medicare Area Contractor website has all the fee schedules available; those will tell you what your new limiting charge will be if you received the penalty and are nonparticipating.  

You can look at your PQRS participation status on QualityNet to see if you are reporting or not.  Many people felt like they had been putting things on their super bill or in their EMR, but it did not get transferred to their claims.  This will allow you to check on your PQRS reporting status for the current year.

Looking Ahead to 2016

In 2016, we will likely be adding the cost-cutting measures of smoking cessation.  What that means is that you need ask your patients if they smoke, and if they say yes, you give them a brochure that tells them to not smoke.  It can be that simple. 

Falls risk assessment and plan of care is a very complicated measure.  In short, we will be asking patients if they have fallen more than twice and if those falls resulted in the need for medical attention.  This is another area where we will refer people and create a plan of care when a patient has had two or more falls requiring medical attention.

Medicare Fee Schedule

The Medicare fee schedules for 2015 are valid until the end of March.  Audiologists have already seen a reduction in reimbursement from their 2014 rates for the vestibular code family, because those codes were surveyed and revalued when billed individually; the bundle was unaffected.  Pay attention to your national associations to see what will happen to the Medicare fees schedule as the year starts to go on.

Medicare Advantage

Except for Medicare Advantage HMO's, most Medicare Advantage plans do not require a physician order this year.  I strongly advise you to consult each plan to determine their specific requirements.  

What does exist in Medicare Advantage is that ABNs are not applicable and are inappropriate for Medicare Advantage.  They have their own process called pre-service organization determination.  

You may need pre-service organization determination from a payer prior to performing a service or dispensing an item.  What they require to be predetermined can vary.  For some payers, anything that is not covered, such as a hearing aid, could require pre-service organization determination if you are an in-network provider for that Medicare Advantage plan.  

You need to consult each payer for their guidance on pre-service organization determination for 92700, L9900, V5298 and V5299, as this varies by state insurance laws and individual payers.

Medicare Data

When my colleagues and I were trying to find audiologists to participate in our PQRS testing, we had to start Googling people, because we needed to know if there was more than one audiologist in a facility.  

Now that Medicare has had their data dump, there is a lot of information available about you on the Internet and how many claims you submitted and for how much and how you compared to the national average.  That data is going to become more prolific.  

I strongly encourage you Google yourselves.  Many of you will find that your Medicare claims data is available online to consumers, and the degree of disclosure depends on how much they want to data mine.  

You can find some of this data through the SMC.  There is also the Medicare website, Physician Compare, which will ultimately house detailed PQRS information about how much you report and the quality of your practice.  As time goes on, more and more data is going to be housed there for public viewing and dissemination.

Conclusion

While there is much changing this year for audiology and the way we file claims and bill for reimbursement, it is not an insurmountable task.  We need to pay attention and proactively inform ourselves of the changes that will directly affect our clinics. 

The professional organizations will be a good source of information as these rules evolve.

Questions and Answers

Can you use the code for unrestricted hearing if there is a high frequency hearing loss which does not affect the patient's speech perception?

How would you describe that in your documentation?  If you would describe it as a hearing loss in the other ear, even though it is not aidable, I would not use the unrestricted code.  If you are not going to describe it or document it as a hearing loss, then you could use unrestricted hearing.

A training I took by an audiology professional association on ICD-10 said to use the rule-out codes, which you said not to use.  Which is correct?

I would be happy to send you guidance for Medicare that tells you not use rule-out diagnosis codes.  All I can say is what I know.  I will tell you that my colleagues at the professional associations do not talk about rule-out codes, and they stopped talking about rule-out codes about nine years ago.  Was it a recent presentation that you saw?  

Remember that things change the world of coding reimbursement every year.  That is why we provide resources and regular updates for audiologists. 

Is a physician referral required for an audiologist to remove ear wax?

No.  Removal of earwax is statutorily excluded from coverage if provided by an audiologist.  Because there is not coverage involved, the physician order is not required.  As long as it is within your scope of practice as an audiologist in your state to remove cerumen, you do not need a physician order, and you can bill the patient privately for cerumen removal.

What would our situation be if we have not filed for Medicare up to now?  

Most of our patients are private pay or their insurance pays a portion of our services.

Audiologists cannot opt out of Medicare.  We are mandatory claims submitters.  When you are seeing people who are Medicare eligible, you have three choices.  

You can be enrolled in Medicare as a participating provider, you can be enrolled in Medicare as a nonparticipating provider, or you can give all your testing free to every patient you see, regardless of age.  

There is not a fourth option where we can opt out and enter into private contracts and have patients pay privately for testing.  Medicare beneficiaries have the right to access their benefits. 

When a patient sees the physician and audiologist on the same day and the physician records current meds or updates the meds, does the audiologist also need to document this also in the note?

Yes.  Remember on the Medicare claim, the audiologist is the rendering provider.  We should not be billing incident to.  Because of that, you need to write in the audiologist documentation that you have reviewed and confirmed current medications.

Do hospital-based audiologists who bill audiological services to Medicare Part B have to participate in PQRS?

Maybe, and that is why I indicated that those working in a hospital or large medical group need to reach out to the administrators and compliance officers to see what the reporting requirements are.  Is your facility in a group reporting option?  If so, what kind of group reporting option?  Some require an audiologist to report; some do not.