Late in the day on July 7, the Centers for Medicare & Medicaid Services (CMS) released the 2,066-page 2023 Medicare Physician Fee Schedule Proposed Rule. The Proposed Rule covers a wide range of topics, and we are looking forward to digging into the details. Here are some early highlights.
- 5% Pay Cut. The 2023 conversion factor will be $33.08, down from the current $34.61. Last year, in the face of a similar reduction, Congress approved a 3% increase for 2022 only. Thus, we knew there would be at least a 3% reduction for 2023. The other 1.5% reduction is due to budget neutrality requirements, i.e., to offset the cost associated with other proposed changes in reimbursement (e.g., correcting misvalued codes).
- Appropriate Use Criteria (AUC). Concurrent with the publication of the Proposed Rule, CMS announced it will delay indefinitely the payment penalty period of the AUC program for advanced imaging services. The program, which was set to go into effect on January 1, 2023, requires imaging provider claims to include additional information regarding the ordering physician’s consultation with clinical decision support tools.
- Telehealth Services. Thanks to congressional action back in March, the waiver of the geographic and location requirements for Medicare telehealth coverage will continue for 151 days following the end of the public health emergency (PHE). CMS proposes to continue other PHE-related regulatory expansions of telehealth coverage for the same period (including, but not limited to, allowing payment for rural health clinics and federally qualified health centers furnishing telehealth services). CMS also proposes to expand the list of Category III services for which Medicare telehealth coverage will extend through December 31, 2023.
- Evaluation and Management (E/M) Services. CMS proposes to implement CPT changes in coding and documenting for “Other E/M Visits” (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment). These changes include new descriptor times (where relevant), revised interpretive guidelines for levels of medical decision-making, choice of medical decision-making or time to select code level, and elimination of the use of history and exam to determine code level.
- Split/Shared Visits. CMS is proposing to delay by one year the effective date of the split/shared visits policy finalized in CY 2022 (with a few exceptions). For CY 2023, clinicians will continue to have a choice of history, physical exam, or medical decision-making, or more than half of the total practitioner time spent to define the substantive portion, instead of using total time to determine the substantive portion.
- Medicare Shared Savings Program (MSSP) Overhaul. CMS proposes several changes to the MSSP to increase participation and advance equity, including longer glide paths to downside risk for accountable care organizations (ACOs). For example, any MSSP ACO presently participating in BASIC Track Level A or B can elect to forgo downside risk for the balance of its current agreement period. Beginning in 2024, CMS will offer new ACOs that meet certain criteria the opportunity to receive advanced shared savings payments to fund infrastructure development. CMS also proposes changes to benchmark calculations intended to grow and sustain long-term program participation. Finally, CMS proposes several changes to reduce the administrative burden.
- Behavioral Health Services. CMS proposes to expand access to behavioral health services by creating an exception to the direct supervision requirement for “incident to” billing. This change would permit behavioral health services to be furnished by licensed professional counselors, marriage and family therapists, and other types of practitioners under general supervision when these services are incident to the services of a physician or non-physician practitioner. Also, CMS proposes to create a new general behavioral health integration service personally performed by clinical psychologists (CPs) or clinical social workers (CSWs) to account for monthly care integration where the mental health services furnished by a CP or CSW are serving as the focal point of care integration.
- New Reimbursement for Chronic Pain Management and Treatment (CPM) Services. Beginning in 2023, Medicare would reimburse providers for furnishing a monthly bundle of services, including assessment and monitoring; administration of a validated pain rating scale or tool; the development and maintenance of a person-centered care plan; overall treatment management; coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic-pain-related crisis care; and ongoing coordination between relevant practitioners furnishing care. CMS proposes these services be personally performed by a physician or non-physician practitioner with the first 30 minutes of services reimbursed at approximately $80 (with additional reimbursement for each 15-minute increment).
- Request for Information: Medicare Potentially Underutilized Services. As part of its broader health equity strategy, CMS is asking stakeholders for ways to improve Medicare beneficiary access to high-value (i.e., “services that provide the best possible health outcomes at the lowest possible cost”), but potentially underutilized, services. CMS’ list of such services includes preventive services, annual wellness visits, diabetes management training, chronic care management, and behavioral health integration services.
- Request for Information: Global Surgical Package Valuation. In preparation for future rulemaking, CMS seeks stakeholder input on strategies for paying more accurately for the global surgical packages based on changes in healthcare delivery over the last several years.
Comments on the Proposed Rule (including responses to Requests for Information) are due September 6, 2022. PYA will provide additional analyses on these and other topics over the next several weeks.
To submit comments on the 2023 MPFS Proposed Rule to CMS, go here.
If you would like guidance related to the Medicare Physician Fee Schedule Proposed Rule, or for assistance with any matter regarding regulatory compliance, valuation, or strategy and transactions, one of our executive contacts would be happy to assist. You may email them below, or call (800) 270-9629.