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Medicare Compliance & Reimbursement

Medicare Physician Fee Schedule:

Pocket These 5 Fee Schedule High Points

Published on Wed Nov 17, 2021

Telehealth, split/shared changes offer providers some positives.

Though you may see the conversion factor (CF) cut as a 2022 setback, there are some key policy updates that do offer providers some relief.

Context: The Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2022 Medicare Physician Fee Schedule (MPFS) on Nov. 2 — and it’s chock full of billing revisions, payment provisions, and more. The final rule is scheduled for publication in the Federal Register on Nov. 19.

Take a gander at five policy changes that may impact your bottom line:

1. Understand the changes to split/shared E/M services. “CMS is proposing to continue its current policy allowing billing of certain ‘split’ or ‘shared’ E/M visits by a physician, when the visit is performed in part by both a physician and a non-physician practitioner (NPP), who are in the same group and the physician performs a substantive portion of the visit,” explains Michael A. Granovsky, MD, CPC, FACEP, president of LogixHealth, a national ED coding and billing company. “CMS is limiting split or shared to E/M codes only, not procedures.”

Plus, CMS offers other insight on split/shared services in the rule, including how time factors into the E/M visits, reporting for new and established patients, modifiers, documentation, and codification of the revised policies.

Important: In a new definition, CMS explains that whoever provides the “substantive portion of the visit” bills for the services — whether it’s the physician or the NPP. “For 2022, the substantive portion can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which can only be more than half of the total time),” CMS says in the fact sheet. But, “by 2023, the substantive portion of the visit will be defined as more than half of the total time spent.”

Table 26 from the final rule details the possibilities of determining the substantive portion of different visit types, Granovsky says.

2. Know that Medicare telehealth services are still evolving. CMS is continuing to monitor the “Category 3” codes that it temporarily added during the COVID-19 public health emergency (PHE) to its Medicare telehealth services list. But, the rule does finalize keeping “certain services” on the list through Dec. 31, 2023, to give CMS more time to evaluate the services, the fact sheet indicates.

“Category 3 telehealth services in the final rule include home visits for established patients, emergency department visits, critical care services, and hospital and nursing facility discharge day management services,” says partner attorney Eric D. Fader with law firm Rivkin Radler LLP in online legal analysis. “CMS also extended the inclusion of two new cardiac rehab codes through calendar year 2023.”

Behavioral health: CMS also added audio-only communications to its definition of interactive telecommunications system for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders offered to established patients in their homes, the rule indicates. A new modifier for these services was also finalized in the rule.

3. CMS follows through on the CAA mandate for PA Services. Section 403 of the Consolidated Appropriations Act, 2021 (CAA) mandated the removal of the federal requirement to only pay physician assistants’ (PAs) employers or independent contractors for services provided by the PAs by Jan. 1, 2022. Starting next year, “PAs may bill Medicare directly for their professional services, reassign payment for their professional services, and incorporate with other PAs and bill Medicare for PA services,” the fact sheet says.

4. Expect higher payments for immunization administration. Commenters on the proposed rule highlighted the “complex landscape” on vaccinations that emerged during the pandemic and the critical importance of preventative immunizations, the final rule says.

Due to the myriad of public input, “effective January 1, 2022, CMS will pay $30 per dose for the administration of the influenza, pneumococcal and hepatitis B virus vaccines,” the agency says. On top of that, the current payment rate for COVID-19 vaccines will remain status quo at $40 through the duration of the PHE. After the PHE ends, CMS plans to align the COVID shot rates with other Part B vaccine rates, the fact sheet indicates.

5. See the latest on teaching physician payments. To better align with the CY 2021 changes to office/outpatient E/M visit codes, CMS revised its teaching physician policies for selecting the correct E/M visit levels. “When time is used to select the office/outpatient E/M 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,” notes the fact sheet.

“CMS clarifies that Medicare will not pay teaching physicians for shared services unless the physician exercises full, personal control over the portion of the case for which the physician is seeking payment,” Granovsky explains.

Why? “Under the primary care exception, time cannot be used to select visit level. Only [medical decision-making] MDM may be used to select the E/M visit level, to guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the total medically necessary time required to furnish the E/M services,” CMS says.

Resources: Find the rule at https://public-inspection.federalregister.gov/2021-23972.pdf.

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