Last week, CMS issued a final rule addressing several topics, including changes to the physician fee schedule (PFS) and changes to Medicare Part B payment policies. Key changes include a net reduction in the PFS conversion factor of $1.30, changes to policies for split (or shared) evaluation and management (E/M) visits, critical care services, and services furnished by teaching physicians involving residents, and revisions to the Medicare Shared Saving Program among other issues. The regulations go into effect on January 1, 2022.
2022 Rate-setting and Conversion Factor
CMS finalized a series of standard technical proposals involving practice expense, including standard rate-setting refinements, the implementation of the fourth year of the market-based supply and equipment pricing update, and changes to the practice expense for many services associated with the update to clinical labor pricing. After all adjustments, the calendar year (CY) 2022 PFS conversion factor is $33.59, a decrease of $1.30 from the CY 2021 PFS conversion factor of $34.89.
Changes to Billing Polices
CMS is making several changes to various billing policies.
Split or Shared E/M Services. CMS refined certain longstanding policies for split or shared E/M visits in an effort to reflect the current practice of medicine, the evolving role of non-physician practitioners (NPPs), and to clarify the Medicare conditions of payment for these services. The CY 2022 PFS final rule establishes the following:
Split (or shared) E/M visits are defined as E/M visits provided in the facility setting by a physician and a NPP in the same group.
For 2022, the substantive portion of the visit can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which can only be more than half of the total time). By 2023, the substantive portion of the visit will be defined as more than half of the total time spent.
Split or shared visits can be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services.
A modifier is required on the claim to identify these services.
Documentation in the medical record must identify the two individuals who performed the visit and the person providing the substantive portion must sign and date the medical record.
Critical Care Services. The CY 2022 PFS final rule establishes the following:
Critical care services are defined in the CPT Codebook prefatory language for the code set.
The CPT Codebook listing of bundled services are not separately payable.
Medically necessary critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty, and critical care services can be furnished as split/shared visits.
Critical care services can be paid on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty, if various conditions are met, including that the E/M visit was provided prior to the critical care service when the patient did not require critical care, the visit was medically necessary, and the services are separate and distinct, with no duplicative elements from the critical care service provided later in the day.
Critical care services can be paid in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed. CMS is creating a new modifier for use on such claims to identify that the critical care is unrelated to the procedure.
Teaching Physician Services. The CY 2022 PFS final rule establishes that only the time spent by the teaching physician in qualifying activities, including time that the teaching physician was present with the resident performing those activities, can be included for purposes of visit level selection. Under the primary care exception, time cannot be used to select visit level.
Telehealth Services. The CY 2022 PFS final rule does the following:
Extends through the end of CY 2023, the inclusion of certain services added temporarily to the telehealth services list that would otherwise have been removed from the list as of the later of the end of the COVID-19 Public Health Emergency (PHE) or December 31, 2021;
Extends inclusion of certain cardiac and intensive cardiac rehabilitation codes through the end of CY 2023;
Implements the statutory amendments requiring that an in-person, non-telehealth visit must be furnished at least every 12 months for the services to continue, that exceptions to the in-person visit requirement may be made based on beneficiary circumstances, and that more frequent visits are also allowed as driven by clinical needs on a case-by-case basis; and
Limits the use of an audio-only communications to mental health services furnished by practitioners who have the capability to furnish two-way, audio/video communications, but where the beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology.
Therapy Services. The CY 2022 PFS final rule does the following:
Creates new modifiers so that CMS can identify and make payment for physical therapy and occupational therapy services furnished in whole or in part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs) at 85% of the otherwise applicable Part B payment amount; and
Revises the policy for the de minimis standard.
Physician Assistant (PA) Services. The CY 2022 PFS final rule permits Medicare to make direct payments to PAs for professional services furnished under Part B. Under current law, payments can only be made to the employer or independent contractor of a PA.
Vaccine Services. The CY 2022 PFS final rule:
Continues the additional payment of $35.50 for COVID-19 vaccine administration in the home under certain circumstances through the end of the calendar year in which the PHE ends; and
Continues to pay for COVID-19 monoclonal antibodies under the Medicare Part B vaccine benefit through the end of the calendar year in which the PHE ends. During this interim time, CMS will also maintain the $450 payment rate for administering a COVID-19 monoclonal antibody in a healthcare setting, as well as the payment rate of $750 for administering a COVID-19 monoclonal antibody therapy in the home.
Opioid Treatment Program (OTP). The CY 2022 PFS final rule:
Allows OTPs to furnish counseling and therapy services via audio-only interaction (such as telephone calls) after the conclusion of the COVID-19 PHE in cases where audio/video communication is not available to the beneficiary, including circumstances in which the beneficiary is not capable of or does not consent to the use of devices that permit a two-way audio/video interaction, provided all other applicable requirements are met; and
States that CMS is issuing an interim final rule with comment to maintain the payment amount for methadone at the CY 2021 rate for the duration of CY 2022.
Medicare Shared Savings Program (MSSP)
With respect to MSSP, the CY 2022 PFS final rule does the following:
Finalizes a longer transition for Accountable Care Organizations (ACOs) to prepare for reporting electronic clinical quality measures/Merit-based Incentive Payment System clinical quality measures (eCQM/MIPS CQM) under the Alternative Payment Model (APM) Performance Pathway (APP). This policy is an effort to respond to ACOs’ concerns about the transition to all-payer eCQM/MIPS CQMs.
Finalizes delaying the increase in the quality performance standard ACOs must meet to be eligible to share in savings until performance year (PY) 2024, by maintaining the 30th percentile of the MIPS quality performance category score for PY 2023, and makes additional revisions to the quality performance standard to encourage ACOs to report all-payer measures.
Finalizes revisions to the repayment mechanism arrangement policy.
Finalizes policies regarding the Shared Savings Program application process by modifying the prior participation disclosure requirement, so that the disclosure is required only at the request of CMS during the application process, and by reducing the frequency and circumstances under which ACOs submit sample ACO participant agreements and executed ACO participant agreements to CMS.
Finalizes changes to the beneficiary notification requirement to set forth different notification obligations for ACOs depending on the assignment methodology selected by the ACO to help avoid unnecessary confusion for beneficiaries.
Finalizes revisions to the definition of primary care services that are used for purposes of beneficiary assignment. The updated definition will be applicable for determining beneficiary assignment beginning with PY 2022.
Summarizes public comments on the MSSP’s benchmarking methodology and risk adjustment methodology.
Other topics addressed in the final rule include: coverage and payment for medical nutrition therapy and related services, beneficiary coinsurance for additional procedures furnished during the same clinical encounter as a colorectal cancer screening, requirements related to rural health clinics and federally qualified health centers, electronic prescribing of controlled substances, reporting by certain manufacturers of drug pricing information for Part B, the determination of the average sales price of certain self-administered drug products, Part B payments for Section 502(b)(2) drugs, laboratory specimen collection fees and travel allowances, the payment penalty phase of the Appropriate Use Criteria (AUC) program, coverage of pulmonary rehabilitation services, the open payments financial transparency program, Medicare provider enrollment requirements, and the Medicare ground ambulance data collection system.
The final rule is available here. The CMS fact sheet is available here.
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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.
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