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CMS cuts conversion factor, offers PAs billing privileges, takes aim at E/M services

In a sprawling Part B fee schedule released today, CMS proposed a 4% decrease to the Medicare conversion factor, revised policies for numerous E/M services, physician assistant billing freedoms and a loosening of telehealth coverage policies.
Conversion factor and payments
The proposed 2022 conversion factor comes in at $33.58, down $1.31 from the current-year conversion factor of $34.89, according to the 1,747-page proposed 2022 Medicare physician fee schedule.
The rate cut is a result of mandated budget neutrality adjustments and the expiration of the one-year 3.75% fee increase that was set in motion by the Consolidated Appropriations Act (CAA) of 2021.
The 2022 anesthesia conversion factor is projected to fall to $21.04 in 2022, a 2% decrease year-to-year from the $21.56 rate in 2021.
The combined impact of the proposed 2022 conversion factor decrease will have a far more muted effect on specialties than the 2021 rulemaking period, which saw wild swings in payments. Most specialties, for instance, will see payment changes of 1% or 2%, either positive or negative, in 2022, according to CMS’s payment projections.
However, there are several outliers. Interventional radiology is projected to see a -9% payment cut in 2022, according to Table 123 in the proposed rule. Vascular surgery would see a -8% reduction. The biggest gainer – and the only specialty above 2% in the black – is portable X-ray supplier, which CMS expects to see 10% in payment gains. Numerous others, including endocrinology and family practice, would see a 2% pay increase overall.
Take note of other important updates from the 2022 proposed rule:
  • Physician assistants (PAs) would be paid directly under Part B. CMS proposes to begin direct payment to PAs for professional services they provide. Right now, Medicare can only make payment to the PA’s employer or provider for whom the PA is an independent contractor. Under the proposal, Pas would also be able to accept or reassign payment for their services.
  • New CPT codes. The proposed rule includes your earliest look at 68 new CPT services that will be released in the 2022 CPT manual. New additions range from four new principal care management codes in the E/M chapter to six catheterization codes for congenital heart defects in the Medicine chapter.
While the proposed rule does not release the final codes you’ll report next year, Table 13 contains the more essential full descriptors for the new codes along with the proposed work relative value units. Additional discussion of the codes is contained throughout the proposed rule and will be discussed in greater detail in upcoming issues of Part B News and other DecisionHealth publications.
  • Split/shared and critical care guidelines are up for review. You have a chance to shape policy for critical care services (99291-99292) split/shared visits in the facility setting. CMS pulled the guidelines for these services in response to a Good Guidance petition in May and is putting the guidelines through the rule-making process as required by the Good Guidance rule. The new policies would include official adoption of CPT guidance for critical care services and a new modifier to report split/shared visits, if CMS’ proposed plans go through unchanged.
  • Enforcement of eRx for controlled substances could be delayed. Providers could have up to an extra year to prepare for enforcement of section 2003 of the SUPPORT Act, which requires electronic prescribing of controlled substances (EPCS) for schedule II, III, IV, and V controlled substances covered through Medicare Part D. The rule would roll out with exceptions designed to make compliance easier for some providers, such as prescribers who write “100 or fewer controlled substance prescriptions for Part D drugs per calendar year.” CMS intends to delay the start of compliance actions “to January 1, 2023, in response to stakeholder feedback. However, we are soliciting comment on whether the original date of January 1, 2022, should remain, in light of the proposed exceptions to the mandate.”
Telehealth updates
No new codes have been added to the ones CMS has been generous about allowing providers to use regardless of status during the pandemic. CMS says it "found that none of the requests we received by the February 10th submission deadline met our Category 1 or Category 2 criteria for permanent addition to the Medicare telehealth services list."
However, CMS announced that it plans to grant greater leeway to mental health services provided via telehealth. "CMS is proposing to implement recently enacted legislation that removes certain statutory restrictions to allow patients in any geographic location and in their homes access to telehealth services for diagnosis, evaluation, and treatment of mental health disorders," the agency states in the proposed rule.
Outside of menta health services, several proposed codes for urodynamics, biofeedback, neurological and psychological testing, therapy procedures and physical therapy evaluations, therapy test and measurement, therapy personal care, personal care and evaluation and therapy services were knocked out of contention. 
Proposed for permanent addition to Category 3 but also knocked out because “not separately billable under Medicare PFS” were several psychotherapy and education and training for patient self-management codes. Neurostimulators and meurostimulators Analysis-Programming codes were rejected for temporary status 3 addition.   
CMS is “proposing to revise the timeframe for inclusion of the services we added to the Medicare telehealth services list on a temporary, Category 3 basis” and to “to retain all services added to the Medicare telehealth services list on a Category 3 basis until the end of CY 2023.”  
But dozens of codes CMS added on an interim basis to respond to the PHE for COVID-19 that were not extended on a temporary Category 3 basis in the CY 2021 PFS final rule are listed to be cut, pending comments to the rule.  
CMS may “amend the current regulatory requirement for interactive telecommunications systems” to allow greater use of audio-only telehealth, at least for mental health disorders furnished to established patients in their homes, but with stricter guidelines and a new modifier.
Quality Payment Program
CMS is moving forward with the Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) program that it proposed in 2019 and held back last year – but not right away: Participants will begin “transitioning to MVPs in the 2023 MIPS performance year.” The seven “clinical areas” CMS will then debut, in which eligible providers will be judged against their peers’ performance, are rheumatology, stroke care and prevention, heart disease, chronic disease management, lower extremity joint repair (e.g., knee replacement), emergency medicine and anesthesia. Meantime CMS will work on "MVP development criteria" for the program.
The category scoring weights for 2022 are 30% for the quality performance category (-10% from 2021), 30% for the cost performance category (+10 from 2021), 15% for the improvement activities performance category, and 25% for the Promoting Interoperability performance category. The performance threshold leaps from 60% to 75% and the data completeness criteria threshold will be 70%. The exceptional performance threshold, in its last year of existence, will be 89 points.  
Shared Savings Program
There is some stasis for the program -- the CMS Web Interface collection type, scheduled to be removed in 2022, will hang in until the end of 2023 at least. But the MIPS Value Pathways (MVP) APM Performance Pathway (APP) quality scoring system the agency adopted in 2021 will go full steam ahead, giving participating ACOs one set of quality metrics to satisfy their quality reporting requirements under both the Shared Savings Program and the MIPS. 
CMS was going to toughen the quality performance standards (ACOs) had to meet before being eligible to share in savings, but those standards will be frozen for another year. 
Also, Shared Savings gets stricter about ACOs anteing up for shared risk: CMS says “ACOs accepting performance-based risk must establish a repayment mechanism (i.e., escrow, line of credit, surety bond) to assure CMS that they can repay losses for which they may be liable upon reconciliation.”
Editor's note: This is a breaking news story. Check back to Part B News for additional updates.
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