- Physician fee schedule conversion factor decreases from prior year.
- CMS continues to support telehealth and virtual care delivery, including creating five new remote therapeutic monitoring codes.
- CMS is extending compliance deadlines for accountable care organizations related to quality reporting.
Need more guidance on the CMS payment rules?
On November 11, the Centers for Medicare & Medicaid Services (CMS) released the 2022 Physician Fee Schedule (PFS) Final Rule. This regulatory advisor will summarize some of the key changes, but does not include all provisions. To review the entire final rule, visit the Federal Register.
Table of Contents
I. Payment provisions
a. PFS conversion factor
b. Vaccine administration services
c. Revised policies for shared evaluation and management visits
d. Principal and chronic care management
e. Critical care services
f. Teaching physician services
g. Therapy services
h. Billing for physician assistant services
i. Medical nutrition therapy services
j. Opioid treatment program policies
k. Rural health clinics and federally qualified health centers
l. Rural health clinics payment
II. Extending telehealth, virtual care service
a. Telehealth in rural health clinics and federally qualified health centers
b. Remote therapeutic monitoring
III. Additional updates
a. Appropriate use criteria for advanced diagnostic imaging
b. Changes to co-insurance for additional procedures furnished during a colorectal cancer screening
c. Electronic prescribing of controlled substances
d. Medicare shared savings program
IV. Quality payment program updates
PFS conversion factor
On December 10, 2021, Congress passed the Protecting Medicare and American Farmers from Sequester Cuts Act. Included in this legislation is a single-year increase in the PFS of 3%, bringing the conversion factor in line with prior years. In addition, the act extended the moratorium on sequestration through March 31, 2022, and reduced the cut to 1% from April 1 to June 30, 2022. The full 2% sequestration cut will take effect July 1, 2022.
The current year (CY) 2022 PFS conversion factor is $33.59.
- Decrease of $1.30 from prior year (PY), reflecting a 0% statutory update and adjustment to account for changes resulting from finalized policies
Vaccine administration services
- CMS will pay $30/dose for administration of the influenza, pneumococcal, and Hep B vaccines
- The following payment rates for vaccinations and additional treatments related to COVID-19 will be maintained through the end of the calendar year in which the COVID-19 public health emergency (PHE) ends: o Current payment rate ($40/dose) for administration of COVID-19 vaccines, along with additional payment of $35.50 for in-home COVID vaccine administration o Interim payment rates ($450/administration in health care center, $750/in-home administration) for COVID-19 monoclonal antibody treatment under Part B
- Effective January 1 of year following the end of the PHE, COVID-19 monoclonal antibody products will be paid as biological products under section 1847A of the Act, payment rates and coding will be similar to existing rates and coding for other complex biological products
Revised policies for split (shared) evaluation and management (E/M) visits
CMS codified revised policies in the new regulation. Split E/M visits are defined as “visits provided in the facility setting by a physician and a non-physician practitioner (NPP) in the same group.” The visits should be billed, via an identifying claim modifier, by physician or practitioner who provides “substantive portion,” defined as taking history, performing physical exam, medical decision making, or more than 50% of total time. Note that substantive portion for the purposes of critical care may ONLY be 50% of total time. Additionally, billing for split visits requires documentation in record that identifies both the physician and NPP who performed the visit — the provider of substantive portion must sign and date the record.
Principal and chronic care management
To reflect the increased time spent by providers working with patients who have ongoing health care challenges, CMS is expanding the family of codes used for chronic care management (CCM), principal care management (PCM), and complex chronic care management (CCCM). With the addition of the following codes in CY 2022, the CCM/PCM/CCCM family now includes five code sets, each with a base and add-on code:
|99437||CCM services — Each additional 30 minutes by a physician or other qualified health care professional, per calendar month. List separately in addition to code for primary procedure.|
|99424||PCM services — For a single high-risk disease, first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month.|
|99425||PCM services — For a single high-risk disease, each additional 30 minutes provided personally by a physician or other qualified health care professional, per calendar month. List separately in addition to code for primary procedure.|
|99426||PCM services — For a single high-risk disease, first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month.|
|99427||PCM services — For a single high-risk disease, each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. List separately in addition to code for primary procedure.|
In addition to creating new codes for CCM and PCM, CMS is adopting two new CPT codes (99424 and 99426) to replace Healthcare Common Procedure Coding System (HCPCS) codes G2064 and G2065 in the rate calculation for general care management services billed by rural health centers (RHCs) and federally qualified health centers (FQHCs).
|HCPCS Code||New CPT Code||CMS Description|
|G2064||99424||PCM — First 30 minutes provided personally by a physician or other qualified health care professional, per calendar month.|
|G2065||99426||PCM — First 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.|
Critical care services
CMS refined longstanding policies for critical care services (CCS) as defined in the CPT codebook, including that:
- Bundled services listed in the CPT codebook are not separately payable.
- CCS may be provided concurrently to the same patient on the same day by more than one practitioner if representing more than one specialty, and may be provided as split visits.
- CCS may be paid on same day as other E/M visits by the same practitioner or a different practitioner in the same specialty if there is documentation that the E/M was provided prior to CCS, the patient did not require CCS at the time the E/M visit was performed, the visit is medically necessary, and the services are “separate and distinct, with no duplicative elements from the critical care service provided later in the day.”
- A modifier must be reported on the claim for these critical care services.
- CCS may be paid separately in addition to a procedure with a global surgical period if critical care is unrelated to the surgical procedure.
- Pre/postoperative care may be paid separately if the patient is critically ill and the critical care is unrelated to the specific injury/surgical procedure performed.
Teaching physician services
CMS finalized and clarified that when time is used to select the office/outpatient E/M visit level, only the time spent by the teaching physician can be included for purposes of visit level selection. This includes time that the teaching physician is present while the resident is performing activities.
CMS is completing implementation of section 53107 of the Bipartisan Budget Act of 2018, requiring that payment for physical and occupational therapy services furnished “in whole or in part” by physical or occupational therapy assistants (PTAs or OTAs) be paid at 85% of the otherwise applicable Part B payment amount. In 2022, CMS is revising the de minimis model used to determine whether a service was provided “in whole or in part” by PTAs or OTAs. Beginning January 1, the revised de minimis policy allows a 15-minute timed service to be billed without a modifier in cases where a PTA/OTA participates independently, but the physical or occupational therapist meets Medicare billing requirements on their own, without the time spent by the assistant. Under this policy, PTA/OTA minutes are not considered for Medicare billing purposes.
Billing for physician assistant services
As required under the Consolidated Appropriations Act, 2021 (CAA), beginning January 1, 2022, physician assistants (PAs) may bill Medicare directly for professional services, rather than requiring billing to pass through an employer or independent contractor. PAs may additionally incorporate with other PAs to bill Medicare for PA services.
Medical nutrition therapy services
CMS has established regulations to describe services provided by registered dietitians and nutrition professionals, as well as making conforming amendments to regulations regarding assignment requirements for PAs, nurse practitioners, clinical nurse specialists, and certified nurse midwives. The rule updates payment regulation for medical nutrition therapy (MNT) services to clarify that MNT services are paid at 100% of 85% of the PFS amount, without cost sharing. Additionally, CMS has finalized removing the requirement that MNT referral be made by the “treating” physician — additional physicians may make a referral to MNT services.
Opioid treatment program payment policy
CMS finalized its proposal to allow opioid treatment programs (OTPs) to provide counseling and therapy services via audio-only interaction after the end of the COVID-19 PHE in cases where audio/visual communication is not available to the beneficiary. OTPs will be required to use a service-level modifier for audio-only services billed using counseling and therapy add-on codes. CMS is additionally 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, as well as seeking comment on OTP utilization patterns for methadone.
Rural health clinics (RHCs) and federally qualified health centers (FQHCs)
CMS has finalized its proposal to implement section 132 of the CAA, making FQHCs and RHCs eligible for payment for hospice attending physician services when provided by a physician, nurse practitioner, or physician assistant who is employed or working under contract for an FQHC or RHC starting January 1, 2022. CMS has also finalized allowing RHCs and FQHCs to bill for transitional care management and other care management services furnished for the same beneficiary during the same services period.
Rural health clinics payment
Rural health clinic reimbursements were significantly changed under the CAA. CMS finalizes several clarifying policies. For RHCs “grandfathered-in,” CMS clarifies that their upper payment limits be based on final, not interim, cost report rates for cost reports in either 2020, or 2021 if the grandfathered RHC does not have a cost reporting period ending in 2020. CMS clarifies that an RHC with an ownership change may still retain RHC status as long as several requirements are met, such as location and assignment of Medicare provider agreement. In response to stakeholder feedback, CMS made several changes to whether and which RHCs can file consolidated reports.
Extending telehealth, virtual care service
CMS has extended inclusion of select telehealth services that were set to expire at the end of the COVID-19 PHE or December 31, 2021 through December 31, 2023. Additionally, CMS implemented the following changes:
- Extending inclusion of cardiac and intensive cardiac rehab codes through CY 2023
- Adopting coding and payment for longer virtual check-in service, including finalizing HCPCS code G2252, which is cross-walked to CPT code 99442
- Clarifying that mental health services include services for treatment of substance abuse disorders
- Expanding the current definition of “interactive telecommunications system” to include audio-only technology when used for telehealth in the mental health space
- Expansion is limited to circumstances in which practitioners have the capability to provide two-way audio/visual communications, but the beneficiary is unable to use such technology or does not consent to its use
- CMS increases the originating fee to $27.59 for 2022
As required by the CAA, CMS implemented removal of geographic restrictions and adding the home of the beneficiary as an allowable origination site for telehealth provided for the purpose of diagnosis, evaluation, and/or treatment of a mental health disorder.
CMS finalizes that an in-person, non-telehealth service with the physician/NPP must take place within six months PRIOR to the telehealth service. CMS finalizes that an in-person visit must occur at least every 12 months for these services, with exceptions based on documented beneficiary circumstances, and more frequent visits are allowed following clinical needs on a case-by-case basis.
Telehealth in rural health clinics and federally qualified health centers
In addition to the other telehealth provisions in the rule, CMS has finalized its proposal to revise regulatory language for RHC or FQHC mental health visits to include telehealth visits. This change will allow reporting and payment for mental health visits via telehealth to be in line with current procedures, including the audio-only provision based on beneficiary circumstances. Similar to the other telehealth provisions, an in-person visit must occur every 12 months for these services, although exceptions may be made based on patient circumstances.
Remote therapeutic monitoring (RTM)
CMS created five new codes related to RTM, modeled after the codes created for remote physiological monitoring (RPM) in the CY 2021 PFS Final Rule. In contrast to the RPM codes, which are E/M only, the RTM codes are general medicine codes, and CMS finalizes that they may be billed by practitioners that are not eligible to provide E/M services, such as physical therapists. Additionally, while RPM data must be physiologic and digitally uploaded, RTM may include non-physiologic, patient-reported data. Two of the codes (98980 and 98981) include professional work, while the other three (98975, 98976, and 98977) are practice expense-only. See additional information on the codes below:
|98975||RTM (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response) — Initial setup and patient education on use of equipment.|
|98976||RTM — Device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days.|
|98977||RTM — Device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days.|
|98980||RTM treatment management services — Physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month, first 20 minutes. CMS established work relative value units (RVU) of .62 for CY 2022.|
|98981||RTM treatment management services — Physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month, each additional 20 minutes. List separately in addition to code for primary procedure. CMS established work RVU of .61 for CY 2022.|
Appropriate use criteria for advanced diagnostic imaging (AUC)
CMS has been implementing AUC as required by the Protecting Access to Medicare Act. CMS has currently been in the testing and educating stage of implementing AUC, which had already been extended due to the PHE. CMS is now finalizing another extension of the effective date for AUC claims processing edits and payment penalty phase to begin the later of January 1, 2023, or January 1 that follows the declared end of the PHE.
Changes to co-insurance for additional procedures furnished during a colorectal cancer screening
CMS has finalized implementation of section 122 of the CAA, providing a special co-insurance rule for procedures that are planned as colorectal screening tests but become diagnostic tests when the practitioner identifies the need for additional services. Section 122 reduced over time the amount of co-insurance a beneficiary will pay for that type of service. Co-insurance will be a percentage of the lesser of the actual charge for service or amount determined under the fee schedule, summarized as follows:
|2023 – 2026||15%|
|2027 – 2029||10%|
|2030 and beyond||0%|
Electronic prescribing of controlled substances (EPCS)
CMS implemented the second phase of mandate requiring EPCS by finalizing in regulation certain exceptions to the EPCS requirement. The exceptions are as follows:
- Prescriber and dispensing pharmacy are same entity
- Prescriber issues fewer than 100 controlled substance prescriptions for Part D drugs/calendar year
- Prescriber is in the geographic area of emergency or disaster as declared by a governmental entity
- Prescriber has been granted a CMS-approved waiver for extraordinary circumstances, including technological failures, cybersecurity attacks, or other emergency
Despite this implementation, CMS is delaying the start date for compliance actions to January 1, 2023 or 2025 for prescriptions written to beneficiaries in long-term care facilities.
Medicare shared savings program
CMS has finalized a longer transition period for accountable care organizations (ACOs) to prepare for electronic clinical quality measure reporting. The CMS web interface will be available for an additional three years, through performance year 2025. Also being delayed is the increase in required performance standards for ACOs to be eligible for shared savings. The Merit-Incentive Based Performance Program (MIPS) quality performance category score will be maintained at the 30th percentile for performance year 2023. CMS also finalized revisions to the repayment mechanism to reduce the percentage used to determine the repayment amount by 50%.
Quality payment program updates
Under MIPS, CMS gives the following look at finalized weights by category.
|Performance Category||2020 MIPS Payment Year||2021 MIPS Payment Year||2022 MIPS Payment Year|
CMS makes changes under each of the four performance categories — readers may want to review those. Of note, under the cost category, CMS added 10 episode-based measures and revised the Total Per Capita Cost measure and the Medicare Spending Per Beneficiary Clinician measure.
CMS finalizes a performance threshold of 45 points in 2022 payment year/2020 performance year increased to 60 points in 2023 payment year/2021 performance year. For exceptional performance, the threshold for 2022 and 2023 payment years/2020 and 2021 performance years will be 85 points.
After feedback from practitioners that traditional MIPS requirements are both confusing and burdensome, and that selecting meaningful and applicable quality measures can be challenging, as previously outlined, CMS is moving away from the traditional MIPS system to the MIPS Value Pathways (MVPs). In the CY 2022 Final Rule, CMS has described seven MVPs that will be available for relevant providers in performance year 2023:
- Advancing rheumatology patient care
- Coordinating stroke care to promote prevention and cultivate positive outcomes
- Advancing care for heart disease
- Optimizing chronic disease management
- Adopting best practices and promoting patient safety within emergency medicine (finalized with modification)
- Improving care for lower extremity joint repair (finalized with modification)
- Support of positive experiences with anesthesia (finalized with modification)
Participation in the MVPs will be optional in 2023, with CMS moving to make them mandatory by performance year 2028. Reporting requirements for each MVP includes the following performance categories: quality, improvement activities, cost, and a “foundational layer” performance category that includes population health measures. Each performance category includes options for participants to select measures that are relevant to their practice. In addition to creating more structure for reporting, CMS is implementing subgroup reporting to better allow patients and clinicians to access information that is meaningful. The subgroups are defined as “a subset of a group which contains at least one MIPS eligible clinician and is identified by a combination of the group TIN, the subgroup identifier, and each eligible clinician’s NPI,” and will help create data that is more comparable across providers and geographies. MVP scoring will generally align with the scoring utilized under the traditional MIPS system.
How we can help
Wondering how new payment and policy decisions may impact you and your organization? CLA’s team of health care professionals is here to help. Contact us today for assistance interpreting and navigating the range of changes made by CMS in this update.