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Cover story: Audiology Dismisses Quality Initiative as Confusing, but Penalties Will Compel Compliance

Pallarito, Karen

doi: 10.1097/01.HJ.0000415181.42548.e5
Cover Story

Audiologists have been eligible to take part in a Medicare quality reporting program since 2009 and to earn bonuses for successfully reporting their results since 2010. Only a small percentage, however, of the nation's audiologists have any experience with the Physician Quality Reporting System (PQRS), formerly known as the Physician Quality Reporting Initiative (PQRI).

Just 212 of 6,073 eligible audiologists — a meager 3.5 percent — participated in 2010, according to recently released data from the Centers for Medicare and Medicaid Services (CMS). (See FastLinks.) That is a slight increase from 2009 when 138 (2.3%) of 5,923 eligible audiologists participated. But it is appreciably lower than the percentage of all eligible physicians and healthcare practitioners who participated in 2010: only 244,145 (24%) of the one million eligible physicians and healthcare professionals took part.

By and large, most hearing healthcare providers are poorly informed about the government's quality-of-care initiative, and many consider the process confusing. “I've heard of it, but it wasn't conveyed to me as something I was eligible for,” said Jody C. Pianin, an audiologist at the Florida Medical Clinic in Wesley Chapel.

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CMS is involved in an array of healthcare programs and demonstrations aimed at transforming Medicare's fee-for-service payment system. The agency's goal is to move toward value-based purchasing by taking into account the quality and efficiency of care that practitioners provide, not just the volume of services provided. (Centers for Medicare & Medicaid Services. Roadmap for Implementing Value Driven Healthcare in the Traditional Medicare Fee-for-Service Program; see FastLinks.) PQRS, which Congress established through the Tax Relief and Health Care Act of 2006, allowed CMS to take a step toward an outcomes-based payment system for physicians and other providers of Part B services. (See FastLinks.)

The voluntary program kicked off in the latter half of 2007, and physicians and certain healthcare professionals who reported on specific quality measures were eligible for bonus payments. Audiologists were not included in the program at that time.

Congress passed the Medicare Improvements for Patients and Providers Act in 2008, extending PQRS bonuses through 2010 and adding audiologists to the list of eligible participants. (See FastLinks.) That year the Audiology Quality Consortium, whose members represent 10 audiology organizations — the American Speech-Language-Hearing Association, the American Academy of Audiology, the Academy of Doctors of Audiology, and others — launched an effort to engage audiology in PQRS and to develop quality measures for audiologists. (See FastLinks.)

“We've been aware that … as CMS goes so does the world eventually, so we wanted to make sure that an audiology presence was reflected in this system so that we were part of the greater healthcare community,” explained Paul K. Farrell, AuD, ASHA's associate director of audiology professional practices.

The consortium initially discussed eight potential measures before paring the list to four, Dr. Farrell said, and CMS ultimately accepted three measures for the 2010 PQRS. These measures gauged audiologists' referrals to physicians for evaluating patients with congenital or traumatic deformity of the ear, a history of active drainage from the ear within the previous 90 days, or a history of sudden or rapidly progressive hearing loss.

When Congress passed the Patient Protection and Affordable Care Act in 2010, it extended bonuses to providers through 2014. (See FastLinks.) The act, however, also can impose financial penalties on practitioners who do not report quality measures beginning in 2015. Eligible professionals who do not participate in PQRS will face a 1.5 percent reduction in Part B payments in 2015 and a two percent reduction in 2016 and beyond. Debbie Abel, AuD, AAA's senior education specialist of business practices, said she suspects that the “disincentive” for not reporting will likely drive greater PQRS participation by audiologists and other healthcare professions in the next few years.

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No preregistration is required to participate in PQRS; practitioners merely attach the appropriate G-codes to a claim. The codes specify, for example, the patient's condition, such as sudden or rapidly progressive hearing loss, whether the patient was referred to a physician for an evaluation, and the reason if a patient was not referred. The G-code also notes if a patient is already under a physician's care.

“It's really just adding a code to a claim form,” said Lisa Satterfield, ASHA's director of health care regulatory advocacy. “Audiologists can complete the claim form by hand or electronically. Some of them may have coders that do it for them, some do it themselves, or some contract out to clearinghouses,” she explained.

Bonuses are calculated as a percentage of estimated allowable Part B charges for the calendar year, and are doled out the following year. Bonus amounts in 2010 and 2011 were two percent and one percent, respectively. Providers may earn a 0.5 percent bonus from 2012 to 2014.

Qualifying for bonuses, however, can be tricky. Audiologists who reported quality measures in 2010 on claims submitted to CMS were required to include 80 percent of patients fitting the measure. The bar was lowered in 2011. Audiologists had to report on only 50 percent of patients fitting the measure because, unlike other healthcare providers, audiologists do not have a specific measures group. “If you miscalculate … you won't get credit,” said coding expert Barbara J. Cobuzzi, the president of CRN Healthcare Solutions in Tinton Falls, NJ, and a former member of the American Academy of Professional Coders' executive board.

The reporting process is much simpler for healthcare providers who use a third-party company called a registry to file claims with CMS, Ms. Cobuzzi said. By using a registry, the data can be submitted retrospectively, she explained, but when it is based on a claim, “you have to do it concurrently with the claim and you can't miss a thing.”

Unlike audiologists, many healthcare providers are able to qualify for bonuses by simply reporting on all the measures in a particular group, such as diabetes, back pain, or coronary artery disease. Healthcare providers need to report on only 30 Medicare patients in a year using this method. Audiologists do not have this option because no measures group exists for the services they provide.

Errors in the reporting process, including missing or improper codes or incorrect diagnoses, can make participants ineligible for bonuses. Only 129 of the 212 audiologists who participated in Medicare's quality reporting initiative in 2010 — roughly 61 percent — earned bonus payments for the year, according to CMS data. The payout totaled $23,666.09, or an average of $183.46 per audiologist. Incentive payments to audiologists ranged from a low of 80 cents to a high of $1,330.92.

That's peanuts compared with what certain medical and surgical specialties can earn. Bonuses to cardiologists totaled $44.75 million, with an average payment of $6,582.86 per physician. Internists received $35.27 million in bonus payments for an average of $2,226.27 per physician. Otolaryngologists reaped almost $2.29 million, averaging $2,280.98 per doctor.

Dr. Abel dismissed the profession's lack of a measures group as a reason for their scant involvement in PQRS. “In spite of educative efforts by the national professional audiology organizations, most audiologists have not embraced this voluntary reporting program because many thought it would be confusing and costly to implement, which is likely not true,” she explained.

Richard J. Hetsko, AuD, the owner of Oberlin Hearing Care in Ohio, said he just does not see the value in being involved. “I felt for the hassle and the amount of people I might refer, it wouldn't be worth the time and effort to participate,” he noted, adding that he might consider it if more reporting measures were added. One new measure, in fact, has been added for 2012: referral for patients with acute or chronic dizziness.

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Kelly Hansen, an audiologist at Trinity Hearing & Balance Center in FL, recently began reporting to PQRS because she thought it was inevitable. Getting started was the hard part. “I don't know how easy they make it for us to do it,” she said. “They tell you to read this, go here, look at this, but it's a little overwhelming.”

Dr. Hansen sought assistance from AAA. “It's just a matter of getting someone to take a few hours. You have to change your superbill. You have to look at diagnosis codes differently, so it just took a little time, but once you do it, it's fine,” she said.

The applicable G modifier is added for each of the reported measures in box 24D on the CMS 1500 standardized claim form when reporting on the four eligible PQRS measures for audiologists (i.e., 188, 189, 190, and 261), explained Dr. Abel. “You indicate the charges of the performed CPT procedures that are included for those measures and a zero for each modifier you utilize, as well as the appropriate ICD-9 diagnosis codes for each specific measure. It's that easy,” she added.

For Suzanne McCorry, AuD, the director of audiology at Coastal Hearing & Balance Center in Neptune, NJ, reporting quality measures to Medicare was not optional. Physicians in the center's ENT practice were participating in PQRS, and they wanted audiologists to take part, too, she said.

Implementing it and explaining it was a challenge, Dr. McCorry said, but once it was in place, it was not that difficult. “We use electronic health medical records, so it's just a few more clicks in the template,” she said.

Using electronic medical records (EMRs) makes PQRS easier to set up and execute, Ms. Cobuzzi noted. While neither ASHA nor AAA have data on audiologists' use of EMRs, she said she would not be surprised if EMR penetration were less than 10 percent in the audiology community. But Dr. Abel said EMRs are not a prerequisite to participating, noting that “many private practice audiologists have been successfully reporting on the PQRS audiology measures without having transitioned to EMR at this point.”

The perceived hassle isn't the only deterrent. A few audiologists expressed cynicism about a government program that compels audiologists to report additional data and imposes penalties for not doing so.

“When you're saying, OK, this is something that Medicare wants me to participate in, my first gut reaction is, no way!” said one California clinic owner who asked not to be identified. “I don't want to be on anybody's radar. It's bad enough that I have to, but now you're saying there's the potential that they will even decrease my reimbursement even more as a punishment.”

C. Scot Frink, the owner of the Salem Audiology Clinic in Oregon, questioned the need for extra coding on audiologists' part. “For the little I know about it, it sounds like they're creating more redundancies, more work for us for less reimbursement, and whenever you have redundancies in a bureaucracy, it's a waste of taxpayer dollars,” he said.

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Despite the low participation rate documented in CMS's latest report, the Audiology Quality Consortium has not changed its position. “The inclusion of the profession of audiology as an eligible discipline means that we are recognized as providing a significant influence on the quality of healthcare for the services that we provide,” said ASHA's Dr. Farrell.

Going forward, the consortium's goals are to continue educating audiologists about the program and to seek endorsement of the four audiology reporting measures by the National Quality Forum, a standards-setting organization in Washington, D.C.

Dr. McCorry, for one, said she recognized that it is about demonstrating quality patient care, not earning bonuses. “The reason to do it is we're trying to create an efficient medical system here,” she said. It is really about making sure that “things are done the right way for people.”

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* Download CMs' 2010 data at

* Read about the CMS report on value-driven healthcare at

* More information about the 2006 Tax Relief and Healthcare Act is available at

* Learn more about Medicare's Improvements for Patients and Providers Act at

* Visit AQC to learn more about PQRs' quality measures at

* View the 2010 Patient Protection and Affordable Care Act at

* Check out HJ' R&D Blog at

* Click and Connect! Access the links in The Hearing Journal by reading this issue on

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