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Breaking: Proposed PFS chops fees 4%, approves E/M remake, previews code changes

Payment cuts are in the offing for Part B providers in 2023, along with a series of other projected changes targeting E/M services, COVID-related billing flexibilities and value-based care, according to the proposed 2023 Medicare physician fee schedule released today.
After legislative reprieve buoyed fees in 2022, CMS again is taking a hack at its primary rate-setting mechanism. The proposed 2023 conversion factor is $33.08, down $1.53, or 4.4%, from the current-year conversion factor of $34.61, according to the 2,066-page proposed rule.
The 2023 anesthesia conversion factor is projected to fall to $20.72 in 2023, a 3.9% decrease year-to-year from the $21.56 rate in 2022.
Aligning with recent E/M changes
By and large, CMS is giving the go-ahead to align its billing requirements with recent guideline changes put forth by the AMA that would integrate the full family of E/M services with the guidelines that currently govern office visit codes 99202-99215.

That means “other” E/M services, such as inpatient codes 99221-99223 and 99231-99233, would adhere to the office visit guidelines that allow code level selection to be determined by medical decision-making (MDM) or time, according to the agency, The history and exam elements would no longer be a factor.
The AMA guideline changes, effective Jan. 1, 2023, will delete all observation care codes (99217-99220, 99224-99226) and merge them with the initial and subsequent hospital care codes, and make numerous other changes, most of which CMS is going forward with, according to the proposed rule.

One area where CMS diverges is in its approach to prolonged services. Instead of using CPT codes put forth by the AMA, CMS is launching a series of three prolonged service codes – GXXX1, GXXX2 and GXXX3 – that providers can use depending on their setting. (See below for more on the proposed prolonged service codes.)
More highlights from the rule
  • 44 CPT codes previewed. CMS previewed 44 new CPT codes for services that range from integumentary services such as removal of sutures or staples that do or do not require anesthesia to services in the CPT manual’s Medicine chapter, and orthoptic training supervised by a physician or other qualified health care professional. CMS intends to cover most of the services, but two codes will have a carrier-priced pay status, two will be noncovered and one – the new prolonged service code – will be invalid.
  • Potentially misvalued codes. CMS is asking for comment on whether to value a long list of cataract and retinal procedure codes in a non-facility (office) setting and whether it is safe for the procedures to be performed there after a nominator requested the agency to release non-facility values. Affected codes include: Goniotomy (65820), transluminal dilation of acqueous outflow canal (66174), cataract codes 66982, 66984, 66989, and 66991 as well as retinal procedures, 67015, 67036, 67039-67043, 67108 and 67113. Another nominator requested revaluation for code 20931, an add-on code for structural allograft for spine surgery, stating that the code was undervalued. CMS was tepid on whether the nominator “has provided sufficient evidence to demonstrate” whether the code was misvalued, but requests comment and independent analysis and studies in support or disagreement with the nomination.
  • E/M work RVU adjustment. It’s no surprise that the pending revisions to E/M services in the non-office setting prompted CMS to tinker with the codes’ work relative value units (RVU). The average adjustment works out to a .05 cut. However, CMS did not propose across-the-board cuts. Of the 33 codes slated for adjustment, 12 would see a slight boost to work RVUs, and five would stay as is.
  • Audio-only telehealth services. The ability to report audio-only services under the COVID-19 telehealth waiver will be around after the public health emergency (PHE) expires, but no matter what happens, CMS wants providers to add modifier 93, which indicates an audio-only service, effective Jan. 1, 2023. CMS intends to adopt the telehealth waiver extension that Congress passed in Consolidated Appropriations Act of 2022. The extension locks in a wide range of telehealth waivers for 151 days after the PHE expires, including the audio-only exceptions that have been so popular with providers.
  • MDM-based split (or shared) services spared. CMS intends to delay the requirement that practices use time to determine who performed the substantive portion of a visit in the facility setting until Jan. 1, 2024. In the 2022 final Medicare physician fee schedule CMS gave the time-only policy a Jan. 1, 2023, effective date. However, based on feedback from the medical community, practices would be able to use either medical decision-making or time for another year.
  • Global surgical package: CMS is looking to restart the conversation about valuation of the estimated 4,000 surgical codes with 0, 10 and 90-day global periods. The agency is seeking public comment on what services are currently performed during the global period and how technology and other issues such as the PHE may have had an impact, among other issues. “We continue to believe that: (1) there is strong evidence suggesting that the current RVUs for global packages are inaccurate; (2) many interested parties agree that the current values for global packages should be reconsidered, whether they believe the values are too low or too high; and (3) it is necessary to take action to improve the valuation of the services currently valued and paid under the PFS as global surgical packages,” the agency states.
Medicare Shared Savings Program 
In Shared Savings, to “reverse certain trends” – including reduced membership as well as shortfalls in “health equity” (i.e. access to ACOs by underserved groups) – the agency will “provide advance shared savings payments (referred to as advance investment payments) to low revenue ACOs … that serve underserved populations” and increase payments on that basis. That could mean, for example, when the Shared Savings ACO serves “areas with high deprivation.” Some ACOs will get other assistance, such as “more time to redesign their care processes to be successful under risk arrangements.” 
CMS will also help certain low-revenue ACOs in the BASIC track “even if they do not meet the minimum savings rate (MSR) to allow for investments in care redesign and quality improvement activities,” the agency says. 
To promote transition to an “all payer quality measure reporting” system, CMS will institute a “sliding scale” for high-risk ENHANCED track ACOs in danger of crashing on risk scores, among other incentives.  
Quality Payment Program/Merit-based Incentive Payment System (QPP/MIPS) 
Under the proposal, MIPS will migrate as planned to the MIPS Value Pathways (MVP) model in 2023, overhauling the previous scoring model. Participation in the first year is voluntary and limited to certain providers; program participants will be able to check their MVP eligibility at the QPP website.  
Five new MVPs are proposed to be added: Advancing Cancer Care, Optimal Care for Kidney Health, Optimal Care for Patients with Episodic Neurological Conditions, Supportive Care for Neurodegenerative Conditions, and Promoting Wellness.  This brings the inaugural MVPs to 12.
Other providers will continue to be scored on traditional MIPS measures: The scoring weights for 2023 in these categories are 30% for the Quality performance category, 30% for the Cost performance category, 15% for the Improvement Activities performance category, and 25% for the Promoting Interoperability performance category. There is also a new “population health measure” category. Cost scoring will be done for participants at the administrative level. 
The performance threshold for MIPS remains at 75 points. The data completeness threshold stays at 70% in 2023 but will be increased to 75% in 2024 and 2025.  
For Advanced APMs under the QPP, CMS proposes to “permanently establish” the 8% minimum Generally Applicable Nominal Risk standard. 
In anticipation of the end of the CMS Web Interface reporting option in 2024, CMS will “extend the incentive for reporting eCQMs/MIPS CQMs” for ACOs reporting MIPS (i.e., ACOs that report these electronic clinical quality measures will get a break on their quality performance scores).  
The agency is also issuing several RFIs related to the program including “MIPS Quality Performance Category Health Equity” and “Quality Measures that Address Amputation Avoidance in Diabetic Patients.” 
Vaccine administration 
In anticipation of a continuing COVID emergency, CMS will continue to cover at-home COVID-19 vaccinations in 2023 and make other adjustments per the geographic adjustment factor (GAF) and Medicare Economic Index (MEI) to make administration of vaccines cost-effective for providers. 
Innovations in dental, audio, behavioral, and pain management care 
CMS proposes some limited expansion in services for which Medicare is not known.  

Noting that it already pays for dental and oral health services – albeit rarely – when they’re related to “beneficiary's primary medical condition,” CMS seeks comment on adding payment for such services related to “cancer treatment or joint replacement surgeries,” according to the agency. 
CMS also proposes new codes covering “a bundle of services furnished during a month that we believe to be the starting point for holistic chronic pain care, aligned with similar bundled services in Medicare”; services from an audiologist approved without a physician referral; and “a new General BHI service” performed by clinical psychologists or clinical social workers (CSW) as the focus of a care integration plan. 
More on prolonged care
The three prolonged service codes that CMS proposed for the E/M code set follow the pattern of G2212, the prolonged service code that CMS made active in 2021 for extended-time office visits. The agency introduced G2212 to replace CPT code 99417 because it disagreed with the time rules behind the AMA’s code.
The new prolonged service codes mirror that approach. “We are proposing to use GXXX1 instead of CPT code 993X0 because we disagree with the CPT instructions regarding the point in time at which the prolonged code should apply,” the agency states.
Providers would use GXXX1 for inpatient or observation care; GXXX2 for nursing facility care; and GXXX3 for the broad home-based care site of service. Below are the codes’ full descriptors, as currently proposed:
  • GXXX1 (Prolonged hospital inpatient or observation care evaluation and management service[s] beyond the total time for the primary service [when the primary service has been selected using time on the date of the primary service]; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact [list separately in addition to CPT codes 99223, 99233, and 99236 for hospital inpatient or observation care evaluation and management services]. [Do not report GXXX1 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 993X0, 99415, 99416]. [Do not report GXXX1 for any time unit less than 15 minutes]).
  • GXXX2 (Prolonged nursing facility evaluation and management service[s] beyond the total time for the primary services [when the primary service has been selected using time on the date of the primary service]; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact [list separately in addition to CPT codes 99306, 99310 for nursing facility evaluation and management service[s]. [Do no report GXXX2 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 993X0]. [Do not report GXXX2 for any time unit less than 15 minutes]).
  • GXXX3 (Prolonged home or residence evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (list separately in addition to CPT codes 99345, 99350 for home or residence evaluation and management services). (Do not report GXXX3 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 99417). (Do not report GXXX3 for any time unit less than 15 minutes))
Editor's note: This is a breaking news story. Stay tuned to Part B News for additional updates.

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