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CY2022 Medicare PFS cuts conversion factor, revamps billing policies

The final 2022 Medicare physician fee schedule is out, and the terms are in: Medical practices will confront key updates to split/shared services, critical care episodes and billing privileges, as well as a cut to the conversion factor that trims it nearly 4%.
CY2022 payment rates
The final CY2022 conversion factor, effective Jan. 1, falls to $33.59, down from $34.89 in 2021, according to the 2,414-page final rule released today [PDF]. The decrease is largely attributed to the end of the one-time payment increase that lawmakers authorized under the Consolidated Appropriations Act of 2021 (CAA), and comes despite intense lobbying by physician groups to stave off the year-to-year cuts.
“The PFS conversion factor reflects the statutory update of zero percent and the adjustment necessary to account for changes in relative value units and expenditures that would result from our finalized policies,” CMS states in a fact sheet to the final rule.
The final conversion factor is up one cent from the proposed conversion factor of $33.58 announced in July.
The anesthesia conversion factor will be $20.93 in 2022, down a good deal from the proposed rate of $21.04 – and the 2021 rate of $21.56.
Revamping E/M services
CMS will go ahead with many of its proposed revisions to split (or shared) visits and critical care visits. But it is taking a phased approach to its new billing rules for split (or shared) visits and scaled back its unpopular plan to ban payment for critical care services during the global surgery period for any service. Here are the highlights of the revised policies:
  • Split (or shared) visits can be performed in any facility setting and for critical care services.
  • Effective Jan. 1, 2022, split (or shared) visits, in all instances except critical care, will be reported by treating practitioner – i.e., physician or qualified health care professional – who performs the “substantive portion” of the visit as determined by history, physical exam, medical decision-making (MDM) or more than half of the total time of the encounter. Critical care will be billed by the treating practitioner based on time.
The "substantive portion" piece of the new policy could be hard to track, points out Betsy Nicoletti, CPC, president of Medical Practice Consulting in North Andover, Mass. "For shared services, they've left it vague for 2022 ... a 'substantive portion' of the history, exam or MDM. Not much guidance and an interim step," Nicoletti says. "I don't think anyone will like it or find it easy to say what was a substantive portion."
  • Split (or shared) visits can be reported for new and established patients and for initial and subsequent encounters.
  • A to-be-determined modifier must be reported with split (or shared) visits.
  • CMS will adopt the critical care guidelines in the CPT manual.
  • Critical care services can be paid in conjunction a procedure that has a global surgical period when the critical care not related to the procedure. Critical care during the pre- or post-operative period will be covered if the patient requires critical care “and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases),” CMS explains in the fact sheet.
  • CMS will create a modifier for use with critical care performed during the global surgical period.
In a separate policy, CMS finalized changes for teaching physicians billing E/M services. When using time as the defining factor to select an office or outpatient visit, “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,” CMS explains.
Note that under the so-called primary care exception, which allows for teaching physicians to bill for a resident-led encounter when the teaching physician is not physically present, only medical decision-making (MDM) – and not time – will be allowed for code level selection.
CMS slims therapy assistant reduction
A statutorily required 15% pay reduction for physical therapy assistants (PTA) and occupational therapy assistants (OTA) could apply to fewer encounters when it takes effect Jan. 1.
CMS has finalized its proposed policy to set a de minimus standard for timed therapy services that will allow full payment for cases when a PTA or OTA participates in providing care to a patient independent from the physical therapist/occupational therapist (PT/OT), but the PT/OT meets the Medicare billing requirements for the timed service on their own, without the minutes furnished by the PTA/OTA, by providing more than the 15-minute midpoint (that is, eight minutes or more).
The payment-reducing CQ and CO modifiers would not apply to such services. Also, in the limited cases when two 15-minute units of therapy remain to be billed when the therapist and assistant each provide between nine and 14 minutes of the same service, and the total time is at least 23 minutes but no more than 28 minutes. One of the units would be billed with the CQ/CO modifier and one without, under Medicare’s finalized policy.
The CQ and CO modifiers – and reduced payments – would therefore apply in these cases:
  • When the PTA/OTA independently provides a service, or a 15-minute unit of a service “in whole” without any involvement by the PT/OT.
  • For PTA/OTA involvement in services that are not defined in 15-minute increments including: supervised modalities, evaluations/reevaluations, and group therapy.
  • When the PTA/OTA provides eight minutes or more of the final unit of a case in which the PT/OT does less than eight minutes of the same unit of service. 
  • When both the PTA/OTA and the PT/OT each furnish fewer than eight minutes of a final 15-minute unit of service during a patient encounter.
Assess specialty impact
Along with other rate-setting updates, including revised code valuations, some specialties will see a lot of movement in their payment prospects, although most specialty impacts are minor, according to Table 136 of the final rule. Diagnostic testing facility takes the largest year-to-year gain with a +6% boost, followed by portable X-ray supplier (+2%). Conversely, interventional radiology and vascular surgery are each on track for a -5% loss in 2022.
Yet 52 of the 56 specialties that CMS pays are estimated to see a +1%, even or -1% pay change in the new year.
Telehealth updates
Category 3 Medicare telehealth services that were added for the COVID-19 public health emergency (PHE) and slated to be removed in 2022 or at the end of the PHE will be kept through 2023 at least, CMS says in the final rule. The agency says this will allow more comments from stakeholders before a final decision on the codes and “reduce uncertainty regarding the timing of our processes with regard to the end of the PHE.”
CMS will also add telehealth outpatient cardiac rehabilitation codes 93797 and 93798 and the related HCPCS codes G0422 and G0423 to these Category 3 codes. Virtual check-in code G2252 is added on a permanent basis. 
CMS is finalizing authorization of audio-only telehealth services for the diagnosis, evaluation or treatment of mental health disorders for certain established patients in their homes, if the provider dispensing these services can furnish two-way audio/video communications but the beneficiary is unwilling or incapable of using it. A new modifier for these services will be supplied at a later date.
Physician assistants can begin direct-billing Medicare
Under the change, mandated by the CAA, physician assistants (PA) will also be able to accept or reassign payment for their services. PAs working in all settings, in both rural and non-rural areas, will be able to take advantage of the new policy. However, as non-physician practitioners, PAs will continue to be paid at 85% of the physician allowable amount. They also will continue to be required to work under physician supervision.
Shared Savings   
Mandatory reporting of electronic clinical quality measures (eCQM) under the new Alternative Payment Model (APM) Performance Pathway (APP) has been delayed for Shared Savings Program ACOs, which have the option to report three eCQMs or MIPS CQM measures in 2023 and 2024 or stick with the current standard measures reporting through 2024. The popular CMS Web Interface reporting method will also remain available to participants through 2024, after which practices will need to switch to eCQMs and CAHPS for MIPS, and have CMS report two administrative claims data measures on their behalf. 
For those reporting the regular measures, the program performance threshold will be held at the 30th percentile through 2023. In 2024, it goes up to the 40th percentile.
As proposed, all Shared Savings ACOs that accept performance-based risk must establish a repayment mechanism such as a line of credit or bond to assure they’re good for the loss.  
Quality Payment Program
The one-year delay of the full switchover to the MIPS Value Pathways (MVP) program is finalized; most MIPS participants will start in the 2023 performance (2025 reporting) year, while multispecialty groups, which will be required to form subgroups for the MVP reporting process and would have started that in 2025 under the proposed rule, will now start in in the 2026 performance/2028 reporting year.  
Under MVP, MIPS performance will be reported in new categories that will be relevant to specific specialties, medical conditions or episode of cares. An MVP subgroup is 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,” according to CMS. 
Category weights are finalized for 2022 at 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.   
CMS is adding five episode-based MIPS cost measures: Melanoma Resection; Colon and Rectal Resection; Sepsis; Diabetes; and Asthma/Chronic Obstructive Pulmonary Disease [COPD]. It is also working on a process whereby all cost measures would be “developed by CMS’ measure development contractor.” 
Clinical social workers and certified nurse midwives are added to MIPS eligible providers.
More updates
  • CMS finalized its plan to remove two aged and out-of-date national coverage decisions (NCD). They are NCD 180.2 Enteral and Parenteral Nutritional Therapy (effective July 11, 1984) and NCD 220.6 Positron Emission Tomography (PET) Scans (Sept. 3, 2013). Removing the policies “better serves the needs of the Medicare program and its beneficiaries,” the agency stated in the final rule.
  • E-prescribing for opioids. CMS will delay the compliance deadline for electronic prescriptions for opioids covered by Part D again. The new compliance deadline for most prescriptions is Jan. 1, 2023. Prescriptions for patients in long-term care facilities won’t need to comply until Jan. 1, 2025.
This is a developing story. Stay tuned to Part B News for additional takeaways from the final 2022 Medicare physician fee schedule.
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