Reimbursement

Physician Fee Schedule 2022: What you need to know

The AOA’s public policy staff share the highlights doctors need to know about the PFS.

The Centers for Medicare & Medicaid Services (CMS) recently published the final rule for the Medicare Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) for calendar year (CY) 2022. In the rule, CMS finalized proposals for Principal Care Management and Chronic Care Management services recommended by the AOA, telehealth services, MIPS Value Pathways co-developed by the AOA, and provisions authorized under the Consolidated Appropriations Act of 2021. CMS also increased payments for administration of COVID-19 vaccines and other preventive health immunizations.

View the entire final rule in the Federal Register.

AOA staff will discuss changes to the 2022 Medicare Physician Fee Schedule and Quality Payment Program during a live webinar on Dec. 15, 2021, at 6 p.m. CT. The AOA’s public policy staff have also assembled the following highlights to know about the 2022 PFS.

Highlights from the 2022 Physician Fee Schedule

Principal Care Management and Chronic Care Management Services: CMS accepted the RUC-recommended work relative value units (RVUs) and practice expense inputs without refinements for Principal Care Management and Chronic Care Management services. The AOA successfully advocated for the new codes and value changes through the RUC survey process. Starting in CY 2022 there will be four new CPT codes for Principal Care Management (99424 (currently G2064), 99425, 99426 (currently G2065), and 99427) and one new CPT code for Chronic Care Management (99437). The revised RVUs for the remaining Chronic Care Management CPT codes (99490, 99439, 99491, 99487 and 99489) can be found in Table 19 of the rule.

CY 2022 PFS Conversion Factor and Rate-setting: For CY 2022, the conversion factor (CF) for the PFS will be $33.59, a $1.30 decrease from the current CF of $34.89. The CF reflects a zero percent statutory update, a -1.10 percent budget neutrality adjustment, and expiration of the 3.75 percent temporary payment increase provided by the Consolidated Appropriations Act, 2021 (CAA) for CY 2021. For anesthesia services, CY 2022 CF will be $20.93, a $0.63 decrease from the current CF of $21.56. CMS also finalized proposals involving practice expense that concludes implementation of the four-year transition of the market-based supply and equipment pricing updates, along with clinical labor rate updates.

Evaluation and Management (E/M) Visits: For CY 2022, CMS finalized several policies related to the recent E/M visit codes which took effect on January 1, 2021. In addition, CMS clarified and finalized changes for split/shared E/M visits furnished in the facility setting by a physician and non-physician practitioner (NPP), critical care services, and services furnished by teaching physicians involving residents.

Specifically for split/shared E/M visits, CMS revised several conditions for payment. Starting in 2023, the practitioner who provides the substantive portion of the visit (more than half of the total time spent) will be allowed to bill for the visit. For 2022, the substantive portion can be based on history, physical exam, medical decision-making (MDM), or more than half of the total time (except for critical care services).

Split/shared visits can be reported for new and established patients for initial or subsequent visits, and for prolonged services. In the rule, CMS confirms that a modifier is required on the claim to identify split/shared services, but does not clarify which modifier to use. However, CMS does clarify that modifier -52 (reduced services) cannot be used to report split/shared E/M visits. Documentation in the medical record must identify the two individuals who performed the visit, and the individual providing the substantive portion must sign and date the medical record.

For critical care services, CMS confirmed that critical care services can be furnished as split/shared services concurrently to the same patient on the same day by more than one practitioner representing more than one specialty. Critical care services may also be paid on the same day as other E/M visits if documentation shows the visit was provided prior to the critical care service, was medically necessary, separate and distinct. Practitioner must report modifier -25 on the claim. Critical care services unrelated to a procedure within a global surgical period may also be paid separately. CMS is creating a new modifier for use on such claims.

For office/outpatient E/M visits furnished in a teaching setting, CMS finalized and clarified that when time is used to select the visit level, 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. Only MDM may be used to select the E/M visit level.

Telehealth Services under the PFS: Given the uncertainty about when the COVID-19 Public Health Emergency (PHE) will end, CMS will retain all Category 3 services temporarily added to the Medicare telehealth services list through December 31, 2023, including certain cardiac and intensive cardiac rehabilitation codes (CPT codes 93797 and 93798, and HCPCS codes G0422 and G0423). CMS will allow telehealth services for diagnosis, evaluation, or treatment of a mental health disorder to be provided in the patient’s home, as authorized under the Consolidated Appropriations Act, 2021, and will require interval in-person visits every 12 months, instead of every 6-months as proposed. CMS will also allow use of audio-only technology for mental health services and will revise the definition of “interactive telecommunications system” to reflect the policy change.

Vaccine Administration Services: Effective January 1, 2022, CMS will pay $30 per dose for administration of the influenza, pneumococcal and hepatitis B virus vaccines. In addition, CMS will maintain the current payment rate of $40 per dose for the administration of the COVID-19 vaccines through the end of the calendar year in which the PHE ends. After the PHE ends, the payment rate for COVID-19 vaccine administration will be set at a rate to align with the payment rate for the administration of other Part B preventive vaccines.

CMS will also continue the additional payment of $35.50 for COVID-19 vaccines administered in the patient’s home, and maintain the $450 payment rate for administering a COVID-19 monoclonal antibody in a health care setting, as well as the payment rate of $750 for administering a COVID-19 monoclonal antibody therapy in the home through the end of the calendar year in which the PHE ends.

Colorectal Cancer Screening: As proposed, starting January 1, 2022, CMS will gradually reduce the amount of coinsurance a patient pays for planned colorectal cancer screening tests that require additional related procedures (e.g., removal of polyps) until the coinsurance is zero. For CY 2022, the coinsurance amount will be equal 20 percent of the lesser of the actual charge for the service or the amount determined under the fee schedule that applies to the test, and decrease thereafter (15 percent for CYs 2023 through 2026, 10 percent for CYs 2027 through 2029, and zero beginning CY 2030).

Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs): CMS finalized its proposals to allow RHCs and FQHCs to conduct mental health visits via telehealth, increase payment limits, and
receive payment for hospice services, as authorized under the Consolidated Appropriations Act. CMS will also allow RHCs and FQHCs to concurrently bill for chronic care management and transitional care management services and administer COVID-19 vaccines.

Electronic Prescribing of Controlled Substances: CMS will delay start of the compliance actions required for electronic prescribing of schedule II, III, IV, and V controlled substances covered through Medicare Part D until January 1, 2023. CMS will also delay the start date for compliance actions for Part D prescriptions written for beneficiaries in long-term care facilities to January 1, 2025. CMS finalized certain exceptions for electronic prescribing of controlled substances and will allow prescribers to request a waiver where circumstances beyond the prescriber’s control prevent the prescriber from being able to electronically prescribe controlled substances covered by Part D.

Appropriate Use Criteria (AUC) Program: CMS finalized its proposal to begin the payment penalty phase of the AUC program for advanced diagnostic imaging services on either January 1, 2023, or the January 1st following the end of the COVID-19 PHE in consideration of the impact of the pandemic on practitioners, providers and patients.

Medicare Provider Enrollment: CMS finalized all of the provider enrollment regulatory revisions as proposed. The changes will expand the agency’s authority to deny or revoke a provider’s or supplier’s Medicare enrollment under certain circumstances, and establish specific rebuttal procedures in regulation for providers and suppliers whose Medicare billing privileges have been deactivated. In addition, the revisions will exempt certain types of independent diagnostic testing facilities (IDTF) from supplier standards.

Quality Payment Program Highlights

MIPS Value Pathways: CMS finalized its proposal with modification to implement seven new MIPS Value Pathways (MVPs) beginning with the 2023 MIPS performance period/2025 payment year. The first round of MVPs includes the Optimizing Chronic Disease Management MVP the AOA co-developed with CMS. The Quality Measures and Improvement Activities included in the Optimizing Chronic Disease Management MVP can be found in Table D of the rule.

Related reading:

Concerning trends in primary care physician demand and compensation

The 3 biggest traps to watch out for in physician employment contracts

1 comment

  1. How are physicians supposed to keep their doors open when our reimbursement continues to drop every year but our employee and benefit costs as well as overhead continue to go up with inflation? Just not right

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