MIPS Quality Measures for Audiologists

Claims-Based Quality Reporting for Medicare Part B Services

Audiologists who see Medicare Part B (outpatient) beneficiaries and exceed the low-volume threshold for claims may be required to participate in the Merit-Based Incentive Payment System (MIPS). Use the 2021 MIPS Eligibility Decision Tree [PDF] to determine if you are required to participate.

The Centers for Medicare and Medicaid Services (CMS) requires MIPS-eligible providers to report at least six quality measures for a minimum of 60% of the eligible Medicare patient visits to earn an incentive payment and avoid future penalties. Because audiologists have eight measures they are eligible to report, they can choose any six measures. They are:

See also: Explore 2022 MIPS Measures and Activities

How to Report Quality Measures

  1. Complete a CMS-1500 form [PDF] as you normally would for reimbursement, using diagnosis ( ICD-10-CM) and procedure ( CPT) codes.
  2. If the patient encounter for that claim meets the criteria for quality reporting, add the appropriate quality data code (QDC) on the claim.
  3. The QDC you select will either be a MIPS-specific G-code or CPT II code (CPT II codes may also require a modifier), as outlined in the measure specifications. QDCs are reported in the following areas of the claim form:
    • Box 21: ICD-10-CM (diagnosis) codes
    • Box 24D:
      • CPT (procedure) code for the service provided
      • QDC code on the line following the CPT code for the applicable service
      • CPT II code modifier, in the modifier section on the same line as the CPT II code (If the QDC is a G-code, a modifier is not needed)

See also: 2021 Part B Claims Submission Quick Start Guide [PDF]

Keys to Reporting Success!

  • Identify the patient population (e.g., age, clinical condition).
  • Identify the CPT code that triggers reporting.
  • Report the QDC (episode/visit) during the 12-month reporting period (Jan-Dec) when the applicable CPT code is reported.
    • Complete the quality action and report the QDC that represents performance met for each eligible encounter, whenever appropriate.
  • Document everything in the medical record (for example, the standardized tool used and the follow-up plan).
  • Report multiple QDCs with associated CPT codes for an encounter on the same claim, not separately.
  • Do not leave the QDCs off claims when reporting is required. You can’t resubmit corrected claims for MIPS reporting purposes.

MIPS Quality Measures for Audiologists

All information included here is summarized from CMS’ Medicare Part B claims measure specifications and supporting documents [ZIP]. Audiologists can use the search or filter functions within the CMS MIPS measures and activities tool to view and download full CMS measure specifications. See the appendix of the 2021 Part B Claims Submission Quick Start Guide [PDF] for an example of how measures are reported on a claim form.

Key

Performance met

You completed and documented the quality action fully for that eligible encounter. You will receive points toward your overall score in the quality category.

Denominator exception or exclusion

You did not perform the quality action for that eligible encounter because there was a documented medical reason the patient was not eligible for the quality action. You will receive partial points toward your overall score in the quality category.

Performance not met 

You did not perform the quality action for that eligible encounter (for example, you forgot to perform the action or you forgot to report the quality code on the claim form). You will not receive any points and will lower your overall score in the quality category.

    To avoid a 9% penalty in 2024 based on 2022 reporting, a minimum of 60% of eligible Medicare claims must include a quality code identified with 

    Performance met

    .

    Measure 130: Documentation of Current Medications in the Medical Record

    Key Terms to Know

    Current Medications: Medications the patient is presently taking including all prescriptions, over-the-counter, herbal and vitamin/mineral/dietary (nutritional) supplements with each medication’s name, dosage, frequency and administered route 

    Route: Documentation of the way the medication enters the body (some examples include but are not limited to: oral, sublingual, subcutaneous injections, and/or topical)

    Not Eligible (Denominator Exception): A patient is not eligible if there is documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list (e.g., patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient's health status).

    Reporting Criteria Patients 18 years and older with the following procedure code(s) for every billed encounter including telehealth visits.
    CPT Codes 92626, 92537, 92538, 92540, 92541, 92542, 92544, 92545, 92548, 92550, 92557, 92567, 92568, 92570, 92588

    Quality Data Codes (QDCs)

    Pick one QDC to report on the same claim as the applicable CPT code.

    G8427

    Performance met

    Eligible clinician attests to documenting in the medical record that they obtained, updated, or reviewed the patient’s current medications.

    The list must include all known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements and must contain the medication’s name, dosage, frequency, and route of administration

    G8430

    Denominator exception 

    		 Documentation of a medical reason(s) for not documenting, updating, or reviewing the patient’s current medications list (e.g. patient is in an urgent or emergent medical situation) 

    G8428

    Performance not met

    		 Current list of medications not documented as obtained, updated, or reviewed by the eligible clinician, reason not given


    Measure 134: Preventative Care and Screening: Screening for Clinical Depression and Follow-Up Plan

    Key Terms to Know

    Screening: Completion of a clinical or diagnostic tool used to identify people at risk of developing or having a certain disease or condition, even in the absence of symptoms.

    Standardized Depression Screening Tool: A normalized and validated depression screening tool developed for the patient population in which it is being utilized. The name of the age appropriate standardized depression screening tool utilized must be documented in the medical record. Examples of depression screening tools include but are not limited to:

    Follow-Up Plan: Documented follow-up for a positive depression screening must include one or more of the following: 

    Referral to a provider for additional evaluation and assessment to formulate a follow-up plan for a

    positive depression screen

    • Pharmacological interventions
    • Other interventions or follow-up for the diagnosis or treatment of depression

    Not Eligible (Denominator Exclusion): To use QDC G8433 (screening not complete, documented patient or medical reason), the patient must either have a specific medical diagnosis or the medical record must reflect that the patient was unwilling or unable to participate in the screening.

    Medical diagnoses that qualify for a denominator exemption include one or more of the following ICD-10-CM diagnoses related to depression or bipolar disorder: F01.51, F32.0-F32.5, F32.89, F32.9, F33.0-F33.3, F33.40-F33.42, F33.8, F33.9, F34.1, F34.81, F34.89, F43.21, F43.23, F53, O90.6, O99.340-O99.343, O99.345, F31.10-F31.13, F31.2, F31.30-F31.32, F31.4, F31.5, F31.60-F31.64, F31.70-F31.78, F31.81, F31.89, F31.9 (See the complete ICD-10-CM list for more detail on the range of codes).

    ASHA Note: These diagnoses should be assigned by a physician or mental health professional and documented in the medical record.

    Reporting Criteria Patients 12 years and older with the following procedure code(s), reported a minimum of once per calendar year, per patient.
    CPT Codes 92625

    Quality Data Codes (QDCs)

    Pick one QDC to report on the same claim as the applicable CPT code.
    Reporting Criteria

    G8431

    Performance met

    Screening for depression is documented as being positive and a follow-up plan is documented 

    G8510 

    Performance met

    Screening for depression is documented as negative, a follow-up plan is not required  

    G8433

    Denominator exception

    Screening for depression not completed, documented patient or medical reason

    G8432

    Performance not met

    		 Depression screening not documented, reason not given 

    G8511  

    Performance not met

    		 Screening for depression documented as positive, follow-up plan not documented, reason not given 

    Measure 155: Falls Plan of Care

    Key Terms to Know

    Fall: A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force

    Plan of Care: Must include: balance, strength, and gait training

    Balance, Strength, and Gait Training: Medical record must include documentation that balance, strength, and gait training/instructions were provided OR referral to an exercise program, which includes at least one of the three components: balance, strength or gait OR referral to physical therapy

    Note: Unlike other measures reported using only G-codes, measure 155 is reported using G-codes and/or CPT II codes that could include modifiers. If a modifier is required, it should be placed with the CPT II code in the modifier section in box 24D of the CMS-1500 claim form.

    Reporting Criteria Patients 65 years and older with two or more falls or one fall with injury in the past year and the use of the following procedure code(s) and CPT II code 1100F is submitted. Reported a minimum of once per calendar year.
    CPT Codes 92540, 92541, 92542, 92548

    Quality Data Codes (QDCs)

    Pick one QDC to report on the same claim as the applicable CPT code.

    0518F 

    Performance met

    Falls plan of care documented

    G9720 

    Denominator exclusion

    Patient receiving hospice services, patient not eligible

    Hospice services for patient provided any time during the measurement period

    0518F with 1P

    Denominator exception

    Risk assessment for falls not completed for medical reasons. Patient is not ambulatory, bed ridden, immobile, confined to chair, wheelchair bound, dependent on helper pushing wheelchair, independent in wheelchair or minimal help in wheelchair

    Note: Append modifier 1P to CPT II code 0518F

    0518F with 8P 

    Performance not met

    Falls plan of care not documented, reason not otherwise specified

    View Falls Risk Assessment & Balance Screening Protocols (Video duration: 22 min)

    Measure 181: Elder Maltreatment Screening and Follow Up Plan

    Key Terms to Know

    Screen for Elder Maltreatment: An elder maltreatment screen should include assessment and documentation of one or more of the following components: physical abuse, emotional or psychological abuse, neglect (active or passive), sexual abuse, elder abandonment, financial or material exploitation, and unwarranted control.

    Physical Abuse: Infliction of physical injury by punching, beating, kicking, biting, burning, shaking, or other actions that result in harm.

    Psychological Abuse : Willful infliction of mental or emotional anguish by threat, humiliation, isolation, or other verbal or nonverbal conduct.

    Neglect: Involves attitudes of others or actions caused by others-such as family members, friends, or institutional caregivers-that have an extremely detrimental effect upon well-being.

    Active Neglect: Behavior that is willful or when the caregiver intentionally withholds care or necessities. The neglect may be motivated by financial gain or reflect interpersonal conflicts.

    Passive Neglect: Situations where the caregiver is unable to fulfill his or her care giving responsibilities as a result of illness, disability, stress, ignorance, lack of maturity, or lack of resources.

    Note: Self-neglect is a prevalent form of abuse in the elderly population. Screening for self-neglect is not included in this measure. Resources for suspected self-neglect are listed under "Reporting Resources" below.

    Sexual Abuse: Forcing of undesired sexual behavior by one person upon another against their will who are either competent or unable to fully comprehend and/or give consent. This may also be called molestation.

    Elder Abandonment: Desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder.

    Financial or Material Exploitation: Taking advantage of a person for monetary gain or profit.

    Unwarranted Control: Controlling a person’s ability to make choices about living situations, household finances, and medical care.

    Follow-Up Plan: Must include a documented report to state or local Adult Protective Services (APS) or the appropriate state agency. Note: APS does not have jurisdiction in all states to investigate maltreatment of patients in long-term care facilities. In those states where APS does not have jurisdiction, APS may refer the provider to another state agency such as the state facility licensure agency for appropriate reporting.

    Not Eligible (Denominator Exception) – A patient is not eligible if one or more of the following reasons is documented:

    • Patient refuses to participate and has reasonable decisional capacity for self-protection
    • Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient’s health status

    *Documentation of an elder maltreatment screening must include identification of the tool used. Examples of screening tools for elder maltreatment include, but are not limited to: Elder Abuse Suspicion Index (EASI), Vulnerability to Abuse Screening Scale (VASS) and Hwalek-Sengstock Elder Abuse Screening Test (H-S/EAST). These tools are psychometrically sound instruments with demonstrated reliability and validity indices.

    Reporting Criteria Percentage of patients 65 years and older, reported a minimum of once a year when the following procedure code(s) are billed.
    CPT Codes

    92537, 92538, 92540, 92541, 92542, 92544, 92545, 92548, 92550, 92557, 92567, 92568, 92570, 92588, 92620, 92625, 92626

    Quality Data Codes (QDCs)

    Pick one QDC to report on the same claim as the applicable CPT code.

    G8733

    Performance met

    Elder maltreatment screen documented as positive AND a follow-up plan is documented

    G8734

    Performance met

    Elder maltreatment screen documented as negative, follow-up is not required

    G8535

    Denominator exception

    Elder maltreatment screen not documented; documentation that patient is not eligible for the elder maltreatment screen at the time of the encounter

    G8941

    Denominator exception

    Elder maltreatment screen documented as positive, follow-up plan not documented, documentation the patient is not eligible for follow-up plan at the time of the encounter

    G8536

    Performance not met

    		 No documentation of an elder maltreatment screen, reason not given

    G8735

    Performance not met

    		 Elder maltreatment screen documented as positive, follow-up plan not documented, reason not given

    Not sure how to report this measure on the claim form? See the 2021 Part B Claims Submission Quick Start Guide [PDF] for an example.
    Reporting Resources

    Federal reporting: In addition to state requirements, some types of providers are required by federal law to report suspected maltreatment. For example, nursing facilities certified by Medicare and/or Medicaid are required to report suspected maltreatment to the applicable State Survey and Certification Agency.

    For state-specific information to report suspected elder maltreatment, including self-neglect, the following resources are available:

    Measure 226: Preventative Care and Screening: Tobacco Use: Screening and Cessation Intervention

    This measure contains three submission criteria which aim to identify patients who were screened for tobacco use (submission criteria 1), patients who were identified as tobacco users and who received tobacco cessation intervention (submission criteria 2), and a comprehensive look at the overall performance on tobacco screening and cessation intervention (submission criteria 3).  

    Key Terms to Know

    Tobacco Use: Includes any type of tobacco

    Tobacco Cessation Intervention: Includes brief counseling (3 minutes or less), and/or pharmacotherapy. Note: For the purpose of this measure, brief counseling (e.g., minimal and intensive advice/counseling interventions conducted both in person and over the phone) qualifies. Written self-help materials (e.g., brochures, pamphlets) and complementary/alternative therapies do not qualify. Brief counseling also may be of longer duration or be performed more frequently, as evidence shows there is a dose-response relationship between the intensity of counseling provided (either length or frequency) and tobacco cessation rates (U.S. Preventive Services Task Force, 2015).

    Submission Criteria 1: Patients Who Were Screened for Tobacco Use at Least Once
    Reporting Criteria All patients 18 years and older, reported a minimum of once a year when the following procedure code(s) are billed.
    CPT Codes 92540, 92557, 92625

    Quality Data Codes (QDCs)

    Pick one QDC to report on the same claim as the applicable CPT code. If you provided a screening and intervention during the same encounter, see Submission Criteria 2 or 3.

    G9902 

    Performance met

    Patient screened for tobacco use and identified as a tobacco user

    G9903

    Performance met

    Patient screened for tobacco use and identified as a tobacco non-user

    G9904 

    Denominator exception

    Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason) 

    G9905 

    Performance not met

    Patient not screened for tobacco use, reason not given

    Note: Submit this QDC when a patient is screened for tobacco use and tobacco status is unknown. 
    Submission Criteria 2: All Patients Who Were Identified as a Tobacco User and Who Received Tobacco Cessation Intervention
    Reporting Criteria All patients 18 years and older who were screened for tobacco use and identified as a tobacco user, reported a minimum of once a year when the following procedure code(s) are billed.
    CPT Codes 92540, 92557, 92625

    Quality Data Codes (QDCs)

    Pick one QDC from Submission Criteria 2 and report with QDC G9902 from Submission Criteria 1 if the patient has been identified as a tobacco user.

    G9906 

    Performance met

    Patient identified as a tobacco user received tobacco cessation intervention (counseling and/or pharmacotherapy) on the date of the encounter or within the previous 12 months

    Note: You must report two G-codes (G9902 and G9906) on the claim form for this quality action.

    G9907 

    Denominator exception

    Documentation of medical reason(s) for not providing tobacco cessation intervention on the date of the encounter or within the previous 12 months (e.g., limited life expectancy, other medical reason) 

    Note: You must report two G-codes (G9902 and G9907) on the claim form when the quality action is not performed for documented medical reasons.

    G9908 

    Performance not met

    Patient identified as tobacco user did not receive tobacco cessation intervention on the date of the encounter or within the previous 12 months (counseling and/or pharmacotherapy), reason not given

    Note: You must report two G-codes (G9902 and G9908) on the claim form when the quality action is not performed and there is no reason given. 
    Submission Criteria 3: All Patients Who Were Screened for Tobacco Use and, if Identified as a Tobacco User Received Tobacco Cessation Intervention, or Identified as a Tobacco Non-User

    Note: Unlike other measures reported using only G-codes, Submission Criteria 3 for measure 226 is reported using G-codes or CPT II codes that could include modifiers. If a modifier is required, it should be placed with the CPT II code in the modifier section in box 24D of the CMS-1500 claim form.

    Reporting Criteria Patients 18 years and older with the following procedure code(s) for every billed encounter.
    CPT Codes 92540, 92557, 92625

    Quality Data Codes (QDCs)

    Pick one QDC to report on the same claim as the applicable CPT code. Remember to append the appropriate modifier for a CPT II code, when indicated.

    G0030

    Performance met

    Patient screened for tobacco use and received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user

    1036F 

    Performance met

    Current tobacco non-user

    G0028

    Denominator exception

     

    Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy, other medical reason)

    G9909

    Denominator exception

    		 Documentation of medical reason(s) for not providing tobacco cessation intervention on the date of the encounter or within the previous 12 months if identified as a tobacco user (e.g., limited life expectancy, other medical reason)

    G0029

    Performance not met

    Tobacco screening not performed or tobacco cessation intervention on the date of the encounter or within the previous 12 months not provided, reason not otherwise specified

    Measure 261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness 

    Reporting Criteria All patients aged birth and older, reported a minimum of once a year when any combination of the following diagnosis and procedure code(s) are billed for the same patient encounter.
    ICD-10-CM Codes H81.10, H81.11, H81.12, H81.13, R42
    CPT Codes 92540, 92541, 92542, 92544, 92545, 92546, 92548, 92550, 92557, 92567, 92568, 92570, 92575  

    Quality Data Codes (QDCs)

    Pick one QDC to report on the same claim as the applicable CPT code.

    G8856

    Performance met

    Referral to a physician for an otologic evaluation performed

    Note: The physician receiving the referral, or providing care currently, should preferably be specially trained in disorders of the ear. 

    G8857

    Denominator exception 

    		 Patient is not eligible for the referral for otologic evaluation measure (for example, patients who are already under the care of a physician for acute or chronic dizziness)

    G8858

    Performance not met

    		 Referral to a physician for an otologic evaluation not performed, reason not given

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