ACE Alert: Physician Fee Schedule Insights

Physician Fee Schedule Insights

By now, everyone is aware of the CMS proposed rule published in July. Comments are due to CMS by September 6th, so you still have time to voice your opinion. To view the CMS summary of the proposed rule, go to:  https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule

Much has been published about the payment cuts of about 4%. History shows that Congress usually comes in at the last hour in December and keeps the payments at the current levels or slightly higher.  I wouldn’t expect a raise for 2023, but I don’t think I would believe that the decrease at the 4% level will occur.

With that said, here are some things that have not been highly publicized but are essential. CMS proposes revising the formula for how the RVU component is calculated. Currently, Physician Work is valued at 50.9%, and they propose decreasing that to 47.3%. They are reviewing practice expenses which was weighted at 44.8%, and increasing that to 51.3% and then finally, the malpractice component, which was at 4.3% would be valued at 1.4%. For groups that have a lot of office/overhead expenses, you should see an increase, but for specialty practices like anesthesia or those who practice chronic pain in an outpatient/ASC setting, they will see a decrease in the overall payment component.  

Another interesting proposal for chronic pain is the two new G codes that have been created. If you perform chronic pain services, you should pay attention and see how many of your patients this would apply to. The rule does have the definition of chronic pain and has a requirement of at least a 30-minute face-to-face visit with a physician or NP/PA per month with specific documentation requirements. This rule would be set up to be billed only once in a calendar month. Practices that plan to bill the code should create a special template to be sure you are hitting all the documentation requirements and a special financial class that does not allow them to be billed more than monthly. 

For our providers who bill shared services, CMS proposes a one-year delay on the requirement to bill these services under the provider who spent the most time with the patient. This delay was heavily lobbied by the AMA and 46 specialty societies that would see a 15% payment reduction in these services if billed under the NP/PA. They will continue to allow shared services to be billed under the physician as long as the physician documents one of the substantive portions of the visit, including history, exam, medical decision making, or spending more than half of the total time of the visit.

Most of our Chronic Pain practice are already complying with the electronic prescribing of controlled substances that were put in place last year. Still, they do plan to start with enforcement actions in 2023 for providers who are not e-prescribing. 

On the telehealth side, they will continue to cover these services as they have in the past year during the pandemic. Watch for a 2023 announcement on the end of the pandemic as the interim rates will only be effective for 151 days after the pandemic ends. The rumor is that they will continue to cover telehealth (video and audio), but they will not cover telephone only. Make sure documentation is clear as to the mode of communication they are using for each individual visit. 

For our anesthesia clients, there is good news regarding expanding coverage for colorectal cancer screening. Look at the final rule for expanding the coverage definition to see the age drop to 45 years and inclusion of a follow-up screening colonoscopy after a Medicare-covered non-invasive stool-based screening test that returns a positive result. This update will clarify that the anesthesia colonoscopy services will be paid at 100%, and no liability will be placed on the patient.

MIPS is another hot mess. They will keep the score rating at 75 points, but essentially, the performance bonus goes away in 2023. It also ties the bonuses to actual budget neutrality, so basically, the fund is limited to what they collect from the physicians penalized to cover the bonus payments to those exceeding the threshold.  

There is one new measure for pain physicians that you will want to report on, which is querying the Prescription Drug Monitoring Program.  It counts under the interoperability section and is worth 10 points, and it will include Schedule II, Schedule III and Schedule IV drugs.  

I am sure I have missed other key elements for your practices to consider, but I wanted to make you aware of some changes based on the proposed rule.

If we can do anything to assist you in your compliance auditing or coding, please contact us. We are always here to help.

ACE Team

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