August 31, 2012 Marilyn Tavenner Acting Administrator and Chief Operating Officer Centers for Medicare and Medicaid Services Department of Health and Human Services Attention: CMS-1590-P P.O. Box 8013 Baltimore, MD 21244-1850 Re: CMS 1590-P: Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2013 Dear Dr. Tavenner: The American Academy of Audiology is the world's largest professional organization of, by, and for audiologists, representing over 11,000 members. The American Academy of Audiology (the Academy ) promotes quality hearing and balance care by advancing the profession of audiology through leadership, advocacy, education, public awareness, and support of research. Below are the Academy s comments regarding the Centers for Medicare and Medicaid Services (CMS) Proposed Rule 1590-P published in the Federal Register on July 30, 2012. We commend the Agency on its commitment to improving the quality of care for Medicare beneficiaries and appreciate the opportunity to comment on the areas enumerated below. I. FEE SCHEDULE AND SUSTAINABLE GROWTH RATE (SGR) While many professions are expected to see minimal or no change in payment based on the 2013 Medicare Physician Fee Schedule proposal, audiology will experience an overall reduction in payment of 5%. Audiology has been affected by a major decrease in reimbursement each year for the last five consecutive years. It is becoming unsustainable for audiology practices to provide hearing and balance services to Medicare beneficiaries. If audiologists cannot afford to provide a reasonable and medically necessary level of care to Medicare beneficiaries, access to care will be limited. The Academy views this as an untenable situation that is compounded by the ongoing expected increase of enrolled Medicare beneficiaries who will need high quality hearing and balance care as they age.
The Academy is also deeply concerned about the estimated 27% decrease in payment rates to Medicare services as a result of the flawed Sustainable Growth Rate (SGR) formula. While a long-term solution to the SGR formula has yet to be established by Congress, the 27% cuts scheduled for January 1, 2013 will make it impractical for all health care professionals to provide quality services to Medicare beneficiaries. We strongly urge the Agency to continue to work with Congress in establishing a permanent and viable solution to the SGR formula that will result in fair payment for services provided. II. PHYSICIAN QUALITY REPORTING SYSTEM (PQRS) Qualified professionals, including audiologists, who satisfactorily report on PQRS quality measures during 2013 and 2014 will be eligible to receive an incentive equal to 0.5 percent of the total estimated Medicare Part B allowed charges for all covered professional services furnished during the applicable reporting period. The Academy agrees with CMS that reporting on these quality measures not only helps Medicare track quality of care and outcomes for beneficiaries, but also promotes best practices within the profession of audiology. In 2010, audiologists were noted as being among the top-five specialties with the highest percentages of valid quality-data codes reported. The Academy, however, was disappointed to learn in the 2013 proposed rule that, of the 14 measures recommended for PQRS retirement, two are audiology measures owned by the Audiology Quality Consortium (AQC), an entity comprised of 10 audiology organizations, one of which is the Academy. CMS states that its decision is based on the recommendations of the National Quality Forum s (NQF) Measure Application Partnership (MAP) in its report titled, MAP Pre-Rulemaking Report: Input on Measures under Consideration by HHS for 2012 Rulemaking, however, CMS does not provide any additional explanation regarding the reasoning for this decision. The NQF report provides a listing of measures proposed for retirement, but does not provide a specific analysis with respect to the audiology measures proposed for retirement. The current four hearing and balance health-related reportable measures are: Measure #188: Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of the Ear; Measure #189: Referral for Otologic Evaluation for Patient with a History of Active Drainage From the Ear Within the Previous 90 Days; Measure #190: Referral for Otologic Evaluation for Patients with a History of Sudden or Rapidly Progressive Hearing Loss; and Measure #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness. The two measures CMS proposes for retirement in 2013 are Measure #189 and Measure #190. The Academy offers the following recommendations regarding the agency s treatment of audiology measures in the 2013 PQRS program. A. Measure #188: Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of the Ear CMS proposed to continue accepting Measure #188 in the 2013 PQRS, however, this measure relates to a relatively uncommon condition seen in audiology practices. Measure #188 refers to 2
congenital or traumatic ear-health issues; patients with congenital issues have often had a medical evaluation in childhood and traumatic issues (in childhood or as an adult) are typically medically managed at the time of the trauma. The technical specifications included in the Measure denominator, including the diagnosis codes selected, are not commonly treated conditions by audiologists. This will continue to be a difficult measure for quality reporting and measurement in the audiology community. The Academy recommends consideration of the retirement of Measure #188 in lieu of Measure #190. B. Measure #189: Referral for Otologic Evaluation for Patient with a History of Active Drainage From the Ear Within the Previous 90 Days The timeframe in the Measure #189 criteria for a patient presenting with a history of active drainage from the ear within the previous 90 days to be referred to a physician for evaluation seems extremely lengthy as the maximum timeframe of 90 days is not indicative of the clinical care typically provided by an audiologist. In fact, if a patient with active drainage from the ear presents to an audiologist, the referral for a medical evaluation occurs more quickly and the patient is typically treated within 7-14 days. The Academy recognizes that the number of Medicare Part B patients who present with active drainage to the audiology practice is minimal. Therefore, while we maintain that referral for medical evaluation in these circumstances is essential to ensure appropriate treatment, the Academy concedes that if the retirement of two measures is necessary, this measure is suitable for retirement. C. Measure #190: Referral for Otologic Evaluation for Patients with a History of Sudden or Rapidly Progressive Hearing Loss Sudden and rapidly progressing hearing loss is one of the more common reasons for referral to a physician, and is a very serious and time-sensitive condition. Complementary care by the audiologist and physician secures a treatment plan that provides opportunity for a positive outcome, including possible reversal of the hearing loss. In fact, the technical specifications for Measure #190 are closely tailored to the most common diagnoses (ICD-9 codes) of patients who seek the services provided by an audiologist and will permit the greatest number of audiologists to participate in PQRS, as compared to the three remaining audiology measures. Further, this measure contributes to the larger quality of care objective for CMS, as well as for the audiology community, to enhance and increase care coordination among health care professionals. The Academy urges CMS to reconsider its proposal to retire Measure #190, and to continue to permit audiologists to report on Measure #190. D. Measure #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness Audiology Measure #261, acute or chronic dizziness, is also a common condition among Medicare beneficiaries who seek the care of an audiologist and this symptom is prevalent among the aging American population. In addition, audiologists who report this measure assure that patients who may be at risk of falling are provided with the appropriate referral for follow-up care. Further, as mentioned above, this measure contributes to the larger quality of care objective to enhance and increase care coordination among health care professionals. We commend CMS for retaining Measure #261 as part of the 2013 PQRS program. In addition to the audiology-specific measures outlined above, audiologists can choose to report on three additional measures: (1) Measure: #124: Health Information Technology: Adoption/Use 3
of Electronic Health Records; (2) Measure: #130: Documentation and Verification of Current Medications in the Medical Record; and (3) Measure: #134: Screening for Clinical Depression and Follow-Up Plan. We offer the following recommendation regarding Measure #134. E. Measure #134: Screening for Clinical Depression and Follow-Up Plan Measure #134 includes several CPT codes utilized by audiologists, which would require reporting screening or documentation of a screening for clinical depression. It is recognized that patients with hearing loss may exhibit symptoms of depression. However, audiologists are not reimbursed by Medicare through Evaluation and Management codes to provide a standardized screening tool and follow-up plan for screening clinical depression. Data collected by audiologists performing audiometric evaluations for hearing loss, as indicated by the CPT codes listed, would not specifically inform CMS of depression screenings being performed. The only CPT code included where audiologists may typically perform additional screening for depression is 92625, assessment of tinnitus because those who experience tinnitus often experience depression. The Academy recommends the deletion of the CPT codes 92557, 92567, 92568, 92590, and 92626 from Measure #134. In conclusion, the Academy strongly urges CMS not to retire Measures #190 for use in the 2013 PQRS program. In the Academy s view, Measures #190 and #261 are the strongest, most applicable quality measures for audiology and would allow audiologists to continue to report on the most common and medically necessary symptoms. Retaining Measure #189 would ensure that data is collected on Medicare beneficiaries who required medical evaluation, however, as previously stated, ear drainage does not present as frequently in audiology practices as compared to conditions such as sudden hearing loss (#190) or dizziness (#261). If CMS determines that it must retire two audiology measures in 2013, the Academy recommends Measure #188 (ear deformity) and Measure #189 (active drainage) be retired from the 2013 PQRS program for the reasons discussed above. PQRS Payment Adjustment CMS states that, beginning in 2015, the PQRS program would no longer be a voluntary incentive program. In fact, CMS proposes that a payment adjustment of -1.5% in 2015 will be applied to eligible professionals who fail to meet the satisfactory reporting criteria of reporting on at least one quality measure on 2013 claims. The Academy requests that CMS provide clear guidance in the final rule regarding the impact of the payment adjustment as applied to professionals, such as audiologists, with a very limited number of quality measures on which to report due in part to the CMS decision to retire half of our profession-specific measures. Additionally, the Academy urges CMS to provide additional basic PQRS educational materials for use by professional associations with eligible professionals who may not understand the impact of the payment adjustment for failure to report on quality measures. Current PQRS educational materials are extremely voluminous and cumbersome and not all professionals and/or practices are able to absorb these materials, especially in a short period of time. The Academy recommends that CMS consider the creation of Fact Sheets, MedLearn Matters articles, continued Special Open Door Forums and other specialized educational seminars to explain the finalized PQRS policies and educate as many professionals as possible of policy changes in 2013 and beyond. * * * * * 4
Thank you for your consideration of the Academy s comment letter. If there are any questions about our recommendations, please contact Sharmila Sandhu, Esq., Director of Regulatory Affairs at 202.544.9337 or via email at ssandhu@audiology.org. Sincerely, Deb Carlson, PhD President, American Academy of Audiology 5