Medicare Updates

Medicare Updates


*UPDATE* CMS Announces Delays in RAC Reviews of the New Hospital Inpatient "2 Midnight" Rule (2/13/2014)
Based on comments received from stakeholders and the Academy, CMS has announced a delay in RAC post-payment audit of the most new "2 Midnight" requirement for a patient to be treated as a hospital inpatient under Medicare payment rules.  Implemented in the final rule last August, CMS had stated they would be conducting file reviews and providing feedback to hospitals on how their inpatient status assignments were measuring up in light of the new “2 midnight” rule during the months of March 31 to September 30, 2014. CMS has now clarified that Medicare contractors will still be allowed to review and deny payment of claims during this "Probe and Educate" period, but that RACs will not be reviewing hospital files at this time. Visit the CMS website for further details.

CMS Issues New Hospital Inpatient Admission Requirements for 2014 (1/10/2014)
Recently, CMS released the 2014 Inpatient Prospective Payment System final rule which clarifies that a beneficiary is an inpatient of a hospital if formally admitted via an order by a physician or other qualified practitioner.  The rule, commonly referred to as the "2 Midnight Rule" establishes new principles of which members should be aware, including:
  • Admission must be "certified" by a physician with an order a required component of that certification.  The order must be written, cited in the medical chart, signed by a physician or other qualified practitioner and must be completed either prior to admission or at the time of admission.
  • Certification must include the reason for the inpatient admission, estimated duration and a tentative post-discharge plan.  A specific format is not required.
  • A physician should generally order an inpatient admission when he or she determines care is expected to transcend two midnights or involves a procedure designated by OPPS as an inpatient-only procedure.  However, physicians should be aware CMS has emphasized that there must be "no reasonable possibility that the care could have been adequately provided in an outpatient setting."
Inpatient status only applies prospectively from the time of formal admission.  The new rules are aimed at reducing long beneficiary stays as outpatients, and clarify that if the ordering practitioner expects a beneficiary to stay at least two midnights, they should be admitted as an inpatient.  Click here to view the rules.  For more instruction for orders and certifications, click here.

Academy Guidance on Reporting SLP Therapy Services
For 2013 CMS finalized several key changes to reporting requirements associated with the provision of therapy services, and for the past year has implemented a claims-based data collection strategy to collect data on patient function. The Academy has  summarized the changes with therapy caps and to therapy reporting requirements that became effective January 1 of this year.  Click here to view the summary.  

For additional guidance on therapy caps issued by CMS, visit the CMS website here

CMS Issues 2014 Final Rules for the Medicare Physician Fee Schedule and Hospital Outpatient/Ambulatory Surgical Centers (12/6/2013)
On November 26 CMS released the final 2014 Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective Payment System (HOPPS)/Ambulatory Surgical Centers (ASCs) rules. Key provisions within the MPFS include acceptance of 4 sinusitis measures for 2014 PQRS reporting and CMS’ retraction of their proposal to cap services paid more in the office at the outpatient or ASC rate. The Academy is reviewing both rules and will provide detailed summaries in the coming weeks. Links to both final rules are provided below.

CMS Provides Guidance for Filing Claims Following Recent SGR Fix (1/10/13)

Following the passage of legislation which will avoid the -26.5% cuts to Medicare payments for CY 2012, the Centers for Medicare and Medicaid Services (CMS) has issued guidance to providers regarding the filing of claims for January 2013. Specifically, CMS states they are reworking the 2013 Physician Fee Schedule to update the conversion factor (now $34.0230) and note that this process may require claims filed in early January to be held up for up to 10 business days (i.e. no later than January 15th, 2013). CMS expects these claims to be released into processing no later than January 16th. The claim hold should have minimal impact on physician/ practitioner cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after date of receipt. Claims with dates of service before January 1, 2013 are unaffected. 

Medicare Contractors are expected to post the new payment rates to their websites no later than January 23rd. Practices can eithe defer to submission of their charges until the new payment rates are posted or continue charging 2012 rates to avoid being paid at the reduced 2013 rate. Practices should also wait to charge patients directly for cost-sharing amounts until the 2013 rates are posted, as relative value units and limiting charges could change. In the meantime, please contact health policy at for any questions. 

Avoid CMS Quality Initiative Payment Penalties (9/5/2012)
Navigate CMS Quality Initiatives like PQRS, Electronic Health Record Meaningful Use and E-Prescribing with the help of the Academy. We have a page dedicated to helping you meet all the requirements of these quality programs. To learn more about the programs, click here.

CMS Convenes Call with Physician Community to Discuss Development of Value Based Modifier (5/3/12)
In early March, CMS sent quality and resource use reports (QRURs) to nearly 24,000 physicians in Iowa, Kansas, Missouri, and Nebraska. These reports will be used in the development and application of the value based modifier required under the Affordable Care Act (ACA). A report template is available here.

In many practices, the email alerting physicians in these states to the availability of their QRUR will have gone to one physician or employee who has been designated as the point of contact for materials for their Medicare contractor (Wisconsin Physician Services (WPS)) that processes claims in the four states. Physicians can access their QRURs through that individual or by going here. The reports will be available until the first week of June 2012. Physicians with questions about specific data within their individual report are asked to email

In addition, WPS and CMS are soliciting feedback through a series of calls with physicians, practice administrators and physician representatives. A call will be held at 10 am CDT on Tuesday, May 8th. The Academy encourages you and your practice manager to participate. The telephone number is 1-800-665-9175. The conference ID is 3769368182.

Please contact the health policy department at if you have received one of these reports or if you have any questions or comments.

CMS Issues Accountable Care Organization Final Rule- (10/25/11)
The Centers for Medicare and Medicaid Services issued their final rule for the Accountable Care Organization (ACO) Program. In the final rule, CMS addressed concerns the Academy presented in their written comments including reducing the number of quality measures and the elimination of the "two-sided risk" model from the Track 1 option that would have included shared savings and penalities. To see a chart outlining changes from the proposed rule to the final rule click here. To see the Academy's comments in June, click here.

MedPAC SGR Propsal

Medicare Payment Advisory Commission (MedPAC) Recommends Replacing SGR; Cutting Specialty Pay- (10/13/2011)

MedPAC voted to replace the Sustainable Growth Rate with new payment system that changes the current formulaic link between annual updates and cumulative expenditures for fee-schedule services and provide a stable ten year path for legislated fee-schedule updates without compromising beneficary access. The new recommended propsal has four parts which are

  • Instituting a three year 5.9% cut to specialty pay followed by a seven year freeze. Primary Care payment would remain frozen for ten years
  • Basing Relative Value Units (RVU) off of data from practitioner offices, Electronic Health Records, patient scheduling and billing systems rather than medical society surveys
  • Identify overprices services utilizing data collection in the second recommendation
  • Increasing opportunities for participation in models of care including Accountable Care Organizations, bundled payment pilots, and shared savings programs

The Academy supports the repeal and replacement of the SGR, but does not support these proposals. The Academy signed onto a letter from the American Medical Association expressing this opposition.

CMS Restores Previous Supervision Requirements for Videostroboscopy & Nasopharyngoscopy
On July 18, 2011, the Centers for Medicare and Medicaid Services (CMS) officially notified the Academy that it had restored the previous supervision requirements (i.e. no supervision level assigned) for videostroboscopy (31579) and Nasopharyngoscopy (92511) when performed by speech language pathologists; in a March meeting with CMS, Academy representatives made it very clear that we support direct supervision.  Learn more.  

Academy Offers Feedback on the Proposed Rule for Accountable Care Organizations (ACO)
On June 6, 2011, the Academy sent a comment letter to the Centers for Medicare and Medicaid Services (CMS) providing input on the ACO proposed rule. In the letter, we highlighted the importance of specialists in promoting care coordination and stressed that the current ACO model proposed by CMS would be very challenging to implement. We encouraged CMS to adopt surgical measures specific to otolaryngology and also recommended that CMS provide a payment option that includes shared savings only without mandatory shared-loss provision. 

Academy Advocates for Expanded National Coverage of Cochlear Implants for Sensorineural Hearing Loss - (May 26, 2011)
On May 11, 2011, Academy members - Jack Wazen MD, Debara Tucci MD, Craig Buchman MD, and staff attended a Medicare Evidence Development & Coverage Advisory Committee (MEDCAC) meeting to provide data on the effectiveness of cochlear implants (CI) in patients and urge CMS to expand its coverage for the device. Although MEDCAC, which makes recommendations to CMS about its coverage for devices, concluded there was not enough evidence to expand Medicare coverage for CIs, it plans to continue engaging specialty societies and CI manufacturers so it can obtain more robust data on health outcomes.

NIA to Recognize ICACTL Accreditation of Advanced Imaging Services - (02/10/2011)
Due to our advocacy effort led by Gavin Setzen, MD, the National Imaging Associates (NIA) has agreed to recognize accreditation for advanced imaging from the Intersocietal Commission for the Accreditation of Computed Tomography Laboratories (ICACTL) from February 14, 2011. ICACTL is one of the three accreditation organizations that CMS has approved to certify advanced imaging services and is currently the only organization that accredits cone-beam CT scanners. View letter we sent to the NIA


Audiology Services

New OTO-Tech and Audiology Billing Resources - (2/16/2012)
We received a number of questions regarding the requirements for billing audiology services. In response to these questions, the Academy has developed new resources clarifying CMS' coding and billing parameters for physicians, auxililary personnel, and audiologists performing audiology diagnostic tests and incedent to services.

FAQs on Audiology- Provides clarification and guidance for proper billing of audiologic services.

Clarifying Medicare Audiology Billing Services: Audiology and OTO-Techs- answers questions on audiology billing and what services OTO-techs can bill.

New Bundled Codes for Audiological Services - (01/05/2010)
There are three new codes for CPT 2010 that have bundled together several audiology tests. These new codes were created because the Centers for Medicare and Medicaid Services (CMS) discovered that these tests were frequently billed together in the Medicare population. As a result, CMS felt that they were paying multiple times for the pre- and post- work that was included in each of the CPT codes.  CMS requested that the American Medical Association (AMA) CPT Editorial Panel and the Relative Value Update Committee (RUC) create bundled codes to address the situation, and to recommend relative values for the new codes.

Consultation Codes

The Academy is Advocating for You! - (07/29/2010)
The Health Policy department is aware of the challenges that CMS’s elimination of the consultation codes poses to our members. As a result, apart from our comment letter to CMS opposing this change in the CY 2011 proposed rule for the Medicare Physician Fee Schedule (MPFS), the Academy joined the AMA and a coalition of other medical societies to disseminate a survey to obtain tangible data on the negative impact of the regulation. After our analysis of the survey results, we sent a letter to CMS and plan to address this issue in our comment letter to the agency on the proposed rule for the CY 2011 MPFS.  Highlights from the survey

FAQs on CMS’ Revisions to its Payment Policy for Consultation Services - (12/17/2009)
We created this document to clarify and address the Center for Medicare and Medicaid’s (CMS) decision to eliminate the use of all consultation codes (inpatient and office/outpatient codes for various places of service except for Telehealth consultation G-codes).

Electronic Health Records (EHR)

First Medicare Electronic Health Record (EHR) Incentive Payments Issued - (5/26/2011)
On May 20, CMS announced that it would begin sending out the first incentive payments (IP) for the Medicare EHR Incentive Program. If you have successfully attested to meeting meaningful use and have met all other program requirements, expect to receive your 2011 incentive payments soon. The maximum IP you can receive for your first participation year is $18,000. More

Attestation for the Medicare EHR Program Has Begun - (04/21/2011)
Attestation for the Medicare EHR Incentive Program began on April 18, 2011. To ensure you receive your incentive payment from Medicare, you must attest through CMS' web-based Medicare and Medicaid EHR Incentive Programs Registration and Attestation System.

Registration for the EHR Incentive Programs Begins on January 3, 2011 - (01/06/2011) 
Beginning January 3, 2011, registration will be available for eligible professionals who wish to participate in the Medicare EHR incentive program.  On January 3, registration in the Medicaid EHR Incentive Program will also be available in Alaska, Iowa, Kentucky, Louisiana, Oklahoma, Michigan, Mississippi, North Carolina, South Carolina, Tennessee, and Texas.  In February, registration will open in California, Missouri, and North Dakota.  Other states likely will launch their Medicaid EHR Incentive Programs during the spring and summer of 2011.


CMS Proposes New Exemption Categories under the Medicare E-Rx Program - (06/02/2011)
As a result of the advocacy of the Academy and several specialty societies, the Centers for Medicare and Medicaid Services (CMS), on May 26, issued a proposed rule, which if finalized will add new exemption categories for physicians to avoid the 2012 Medicare E-Rx penalty. If you fall under any of these new exemptions, you must attest as such through an on-line web portal by October 1, 2011. If you do not fall under any exemption categories, by June 30, 2011, you must still report on 10 unique electronic prescribing events (using the e-Rx measure G8553 on your Medicare claims) associated with office visits. More on the new exemption categories

Avoiding Penalties in the 2011 Electronic Prescribing (eRx) Incentive Program - (02/24/2011)
For calendar year 2012, eligible professionals who are not successful electronic prescribers based on their Medicare Part B claims submitted between January 1, 2011 to June 30, 2011 may be subject to a -1% penalty. To find out whether the 2012 eRx penalty will not apply to you, please visit

Healthcare Reform

Summary of Workshop on Accountable Care Organizations (ACOs)  - (11/2/2010) 
ACOs were mandated by Congress in the Patient Protection and Affordable Care Act (PPACA).  ACOs will be integrated delivery systems comprising of doctors, hospitals, and other providers whose reimbursement will partially be based on meeting certain quality and cost targets. The provision for ACOs under PPACA requires that they are started by January 1, 2012. On October 5, 2010, some federal agencies hosted a workshop to discuss processes they can adopt to reduce the probability of ACOs stifling competition, promoting innovation within ACOs, and ensuring that the current anti-trust, physician self-referral and civil monetary penalty laws don’t impede the ACOs from accomplishing their quality and cost saving goals.

AAO-HNS Summary of Patient Protection and Affordable Care Act


CMS Issues Comparative Billing Reports on Advanced Diagnostic Imaging (3/1/2012)
On February 16th, the Centers for Medicare and Medicaid Services (CMS) issued Comparative Billing Reports explaining provider's billing and payment patterns compared to their peers. At this time, CBRs are not intended to be punitive or sent as an indication of fraud, but are intended as a proactive statement that will help providers identify errors in their billing practice.

For more informaiton on Comparative Billing Reports, see the Academy's Advanced Imaging webpage.

Advanced Imaging Accreditation
Providers who furnish the technical component (TC)  for advanced imaging services (MRI, PET, CT, and nuclear medicine imaging) must be accredited by January 1, 2012 by the:

  • American College of Radiology (ACR)
  • Intersocietal Accreditation Commission (IAC)
  • The Joint Commission (TJC)

Learn more about the accreditation process

Academy Sends Comment Letter on ACR Appropriateness Criteria      (4/21/2011)
The Academy provided input on the American College of Radiology’s (ACR) Appropriateness Criteria. The ACR created these evidence based guidelines to assist referring physicians in making the most appropriate imaging or treatment decisions for specific medical conditions. We thank Gavin Setzen, MD, for leading this endeavor and also the Academy’s Imaging, Allergy, Asthma & Immunology, Equilibrium, Hearing, Pediatric Otolaryngology, Rhinology and Paranasal Sinus, and Skull Base Surgery committees.  

Medicare Physician Fee Schedule

2011 MPFS Conversion Factor Update  - (01/13/2011)
On December 15, 2010, President Obama signed into law, “The Medicare and Medicaid Extenders Act of 2010.”   This law prevented the 25% cut to the Medicare Physician Fee Schedule (MPFS) that would have been effective from January 1, 2011. The conversion factor for 2011 is now $33.9764. The overall impact of the 2011 MPFS for otolaryngologists is +3% based on the mix of services provided.

New Time Guidelines for Filing Medicare Claims - (11/1/2010)
Under the Patient Protection and Affordable Care Act (PPACA), claims with dates of service October 1, 2009, through December 31, 2009, must be submitted by December 31, 2010. Providers will need to submit claims for services performed in the last three months of 2009 by December 31, 2010. For those services furnished on or after January 1, 2010 providers must submit the claims for these services before the end of one calendar year after the date of service. There are three exceptions to this provision: when a Medicare beneficiary becomes retroactively eligible for Medicare benefits but was not entitled when the service was performed initially, dual eligible Medicare/Medicaid patients and retroactive disenrollment from Medicare Advantage plans or PACE provider organizations.

Page Last Updated on May 3, 2012