Medicare Compliance & Reimbursement

Get ready now for behavioral health, E/M, split/shared updates.

There’s no doubt the 4.5 percent conversion factor (CF) reduction is a major letdown in the fee schedule, but that doesn’t mean there aren’t some positive policy updates ahead for 2023.

Details: The Centers for Medicare & Medicaid Services (CMS) issued the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) on Nov. 1 — and it’s filled with a myriad of billing revisions and payment provisions with special attention to the hot-button topics of today like mental health, telehealth, and evaluation and management (E/M) services. The final rule is scheduled for publication in the Federal Register on Nov. 18.

Peruse these five key MPFS policy changes that could affect your wallet next year:

1. CMS reduced barriers to behavioral health services. To better align with the CMS Behavioral Health Strategy, the agency finalized adding “an exception to the direct supervision requirement” of its “incident-to regulation … to allow behavioral health services to be provided under the general supervision of a physician or non-physician practitioner (NPP), rather than under direct supervision, when these services or supplies are furnished by auxiliary personnel … incident to the services of a physician (or NPP),” a fact sheet says.

CMS also finalized the creation of a new general behavioral health integration (BHI) code to describe services “personally performed by [clinical psychologists] CPs or clinical social workers (CSWs) to account for monthly care integration where the mental health services furnished by a CP or CSW are serving as the focal point of care integration,” the fact sheet explains.

The agency also intends to work on creating more behavioral services and management codes for the 2024 rulemaking cycle.

2. MPFS aligned telehealth services with CAA, 2022, provisions. CMS followed through on its proposals to implement the telehealth services requirements laid out in the Consolidated Appropriations Act, 2022. CMS will extend coverage of the temporary codes it didn’t make permanent on the Medicare telehealth services list during the public health emergency (PHE), until 151 days after the PHE ends, the final rule indicates. CMS will also extend specific PHE-inspired telehealth flexibilities for 151 days after the PHE ends.

Under the final rule, CMS finalized continuing to let providers bill for place of service (POS) as if the service was furnished in-office. Medicare practices will still need to append modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) to indicate the services were administered via telehealth, a fact sheet explains. As it stands, providers can continue to bill with POS code “that would be used if the telehealth service had been furnished in-person through the later of the end of CY 2023 or end of the year in which the PHE ends,” CMS clarifies.

But: When the PHE ends, providers will need to adapt to a post-COVID coding landscape, the final rule indicates. Starting on the 152nd day after the PHE concludes, providers will need to indicate the appropriate POS code, the agency says. CMS finalized these options:

• POS 02 (Telehealth provided other than in patient’s home)
• POS 10 (Telehealth provided in patient’s home)

3. Other E/M services got the 2021 update spin. CMS continued its initiative to reduce administrative burdens with another round of E/M updates. “Similar to the approach we finalized in the CY 2021 [M]PFS final rule for office/ outpatient E/M visit coding and documentation, we finalized and adopted most of these AMA CPT^® changes in coding and documentation for Other E/M visits (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment) effective January 1, 2023,” CMS says.

Updates to these E/M codes include: new descriptor times where necessary; interpretive guideline revisions for medical decision-making (MDM) levels; time or MDM option for code level selection; and elimination of history and exam to determine code level, according to the fact sheet.

4. CMS delayed the split/shared rollout. First, under the CY 2022 final rule, CMS solidified implementing its split/shared policy that the provider who administers the “substantive portion of the visit” bills for the services — whether it’s the physician or the nonphysician practitioner (NPP).

However, in the CY 2023 proposed rule, the agency suggested pushing the start date back and finalized that delay in the final rule.

“As finalized, clinicians who furnish split (or shared) visits will continue to have a choice of history, or physical exam, or medical decision making, or more than half of the total practitioner time spent to define the ‘substantive portion’ instead of using total time to determine the substantive portion, until CY 2024,” the fact sheet explains.

5. Vaccine payment amounts will be updated annually now. With the onslaught of COVID-19, preventative vaccine administration has become a hot topic. CMS made some “refinement” to payment policies surrounding the Medicare Part B benefit, with includes the “influenza, pneumococcal, hepatitis B, and COVID-19 vaccines and their administration,” the rule says.

First, payment amounts for vaccine administration will now be annually updated and determined by Medicare Economic Index (MEI) increases. Payments will also be “adjust[ed] for the geographic locality based upon the geographic adjustment factor (GAF) for the [M]PFS locality in which the preventive vaccine is administered,” a fact sheet says.

Plus, the additional payment for at-home COVID vaccinations will remain in place for CY 2023.

Stay tuned: We will continue to analyze the MPFS final rule in future issues of Medicare Compliance & Reimbursement.

Resource: Find the final rule at www.federalregister.gov/public-inspection/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other.