Medicare requirements for physician supervision of speech-language pathologists conducting videostroboscopy (CPT 31579) and nasopharyngoscopy (CPT 92511) will move from the strictest level of oversight back to no national supervision level starting in October.
Beginning on Jan. 1, the Centers for Medicare and Medicaid Services (CMS) for the first time required personal physician supervision of these two procedures when provided to Medicare patients by speech-language pathologists; in other words, until October, an otolaryngologist must be in the room.
The decision was prompted by a speech-language pathologist’s inquiry to a CMS regional office regarding Medicare supervisory requirements. Because the two procedures are primarily diagnostic in nature, the agency ruled that their codes needed supervision levels, according to a June 16 letter from CMS Administrator Donald M. Berwick, MD, to Sen. Susan M. Collins, R-Maine. The agency selected in-room supervision.
In-Office vs. In-Room
But both the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the American Speech-Language-Hearing Association (ASHA) objected to what they view as an onerous requirement. In a March meeting with CMS officials in Baltimore, both organizations urged government officials to change Medicare rules to direct supervision, meaning that a physician must be immediately available in the office suite when a speech-language pathologist performs either of the two procedures.
“We weren’t there to ask for no supervision,” said Charles F. Koopmann, Jr., MD, a professor of otolaryngology at the University of Michigan who participated in the March meeting. “I made that very clear to CMS, and ASHA agreed, that we were there to go from in-the-room supervision to in-the-office supervision and that was all,” added Dr. Koopmann, who is the AAO-HNS representative to the AMA/Specialty Society Relative Value Scale Update Committee.
The organizations argued that it is appropriate for trained speech-language pathologists to perform the procedures under in-office supervision. “We feel you need to be in the office complex but not in the room,” Dr. Koopmann explained.
ASHA made the case that speech-language pathologists perform the procedures safely and that in-the-room supervision is an inefficient use of physicians’ time. “There is not one report of one problem occurring in the years that speech-language pathologists have been doing this,” said Steven White, PhD, ASHA director of health care economics and advocacy.
The CMS decision to impose an in-room supervision rule necessitated a major change in how speech-language pathologists and otolaryngologists perform these procedures in many different medical environments across the country, said Clark A. Rosen, MD, director of the University of Pittsburgh Voice Center and chair of the AAO-HNS Voice Committee.
The various models included practices in which otolaryngologists performed the two procedures themselves, those in which speech-language pathologists conducted them and a supervising otolaryngologist reviewed the results, and hospital-based clinics in which speech-language pathologists performed the procedures independently upon referral from a primary care physician and then reported back to that doctor.
The January ruling, said Dr. Rosen, “put a spotlight on how otolaryngologists and speech-language pathologists take care of patients with voice problems and bill for their services.” Although otolaryngologists’ opinions on the necessary level of supervision vary, many of them, including Dr. Rosen, are not comfortable with speech-language pathologists performing the two procedures without any supervision from otolaryngologists, Dr. Rosen said.
“If the speech-language pathologist sends a copy of the video to the pediatrician, the primary care physicians, the allergist, the pulmonologist, they don’t know what they’re looking at,” Dr. Rosen added. Before the January move to in-room supervision, he said “it was not uncommon in the United States for there to be no otolaryngology involvement, and the speech-language pathologist was the only person truly viewing that examination.”
In its June 16 letter to Sen. Collins, CMS reversed its decision after a review prompted by widespread objection to the January rule change. In the letter, Dr. Berwick stated that CMS will remove the supervision level effective Oct. 1. “We recognized that, while physicians perform these diagnostic procedures, speech pathologists also perform these procedures to evaluate and treat a patient’s functional/use problems,” he explained.
Initiating a Dialogue
The letter restores Medicare’s previous supervision requirement of no nationally assigned supervision level. “Thus, a properly trained [speech-language pathologist] performing videostroboscopy or nasopharyngoscopy will not need to have a physician on the premises or exercising supervision,” explained a July 13 ASHA press release. Individual Medicare administrative contractors may establish local supervision requirements for these procedures in their speech-language pathology local coverage determinations, ASHA added.
“We are pleased, but we want to assure our otolaryngology colleagues that they’re still in the picture, too,” ASHA’s Dr. White said. He pointed out ASHA’s preferred practice patterns, which state: “All patients/clients with voice disorders are examined by a physician, preferably in a discipline appropriate to the presenting complaint. The physician’s examination may occur before or after the voice evaluation by the speech-language pathologist.” Speech-language pathologists “are not doing any medical diagnostic work with these procedures,” Dr. White said. “It’s all functional in nature.”
But Dr. Rosen said the differentiation between functional and diagnostic work when it comes to the two procedures is “smoke and mirrors.” For example, “instead of saying the patient has a cyst, the speech-language pathologist will say, ‘there is a lesion on the vocal fold’ or ‘there is an irregularity to the edges of the vocal fold,’” he said. “There are these code words that people have developed, but in practice speech-language pathologists are truly doing diagnostic procedures.”
He sees the process that occurred with CMS as a missed opportunity to engage in a dialogue that would result in ensuring optimal care for patients. In Dr. Rosen’s view, “that means, specifically, that otolaryngologists are involved, not just MDs, and that there is an appropriate window during which there is a personal review of the examination by the otolaryngologist. If the MD is not in the room, I think that’s okay, but it has to be an otolaryngologist that reviews the results, probably within 72 hours.”
The AAO-HNS plans to reiterate to CMS its position “that the decision to remove the supervision level completely is not desirable and that the supervision level of direct would be the correct level to assign to the two procedures,” according to an item in the Academy’s “The News.” ENT TODAY