Oncology & Hematology Coding Alert

This year’s MPFS mixes the good and the bad with the delayed.

The 2023 Medicare Physician Fee Schedule (MPFS) final rule is a real mixed bag for oncology. While CMS continues to delay two important oncology initiatives, you now have a new drug modifier in play, along with a finalized rule for lowered colorectal cancer screening age requirements.

Here’s what you need to know to stay on top of all the Medicare rulings for the coming year.

Prepare for a Bigger CF Decrease Than Originally Proposed

For 2023, the final MPFS conversion factor (CF) is $33.06, a decrease of 4.5 percent from the CY 2022 MPFS conversion factor of $34.61. This is actually higher than the 4.4 percent decrease put forth in the proposed rule, much to the dismay of the healthcare industry. “There’s not really anything good to say about that. The substantial drop from 2022 to 2023 CF is the largest decrease in several years. With sequestration and pay-as-you-go cuts, hem/ onc providers are feeling the impact,” comments Stephanie A. Thebarge, CPC, CPCO, CPMA, CPPM, CPB, CEMC, CHONC, compliance manager at New England Cancer Specialists in Scarborough, Maine.

CMS estimates that the impact of the CF decrease, along with all the other changes to procedure and evaluation and management (E/M) service relative value units (RVUs), will be -1 percent to hematology/oncology, radiation oncology, and radiation therapy centers.

Take Note of This CRC Screening Age Decrease

The 2023 MPFS also finalizes two important oncology initiatives. The first will lower “the minimum age for CRC [colorectal cancer] screening tests from 50 to 45 years of age for certain Medicare covered CRC screening tests that currently include a minimum age of 50 as a limitation of payment or coverage,” according to the final rule.

Significantly, “this past year, this policy was implemented among some commercial payers, so it really is a smart move for Medicare to fall in line,” Thebarge notes.

Additionally, “as finalized, a screening colonoscopy would continue to not have a minimum age limitation,” while CMS will also “expand coverage of CRC screening tests to include a follow-on screening colonoscopy after a non-invasive stool-based test returns a positive result,” according to the final rule. This means, beginning Jan. 1, 2023, CMS is paying “for both the initial non-invasive screening stool-based test and the follow-on screening colonoscopy test … at 100 percent (no applicable copayment percentage)” per the final rule.

Add JZ Modifier to JW for Part B Drugs

Another initiative that will impact your practice if it supplies and reports the drugs administered to patients is the addition of modifier JZ (Zero drug amount discarded/ not administered to any patient).

You are already using modifier JW (Drug amount discarded/not administered to any patient) when your provider administers part of a single-dose container and discards the rest. Starting July 1, 2023, per the final rule, you will need to use the new, related JZ modifier when there are no discarded amounts from a single-dose container subject to modifier JW rules. Modifier JZ has an effective date of Jan. 1, 2023, but Medicare opted to give providers until July 1 to start using JZ. Claims processing edits will begin Oct. 1, 2023, with Medicare checking use of both JW and JZ.

Unfortunately, this will place an added administrative burden on some hematology/ oncology practices. Not only will they have “to build this additional modifier into their systems for single-dose and single-use package drugs,” but practices will now be “subject to more CMS audits, when either modifiers are not present,” potentially leading to “an uptick in either claim rejections, denials, and RAC audits in Q4 of 2023,” according to Thebarge.

Tip: You will use modifier JZ on the claim line with the administered amount.

Hold Off on New Split/Shared Visit Billing

CMS also announced they will be delaying implementation of the new definition of substantive portion for split/shared billing until CY 2024. You’ll continue to bill for the whole service in one of two ways:

• by the provider who performed the substantive portion of the visit (currently defined as “the provider (physician or APP) who performed the patient history, physical examination, or medical decision making (MDM) 
• or by the provider who spent more than half of the total time rendering the service) rather than using just the substantive portion definition of “more than half of the total time.” This definition was supposed to be used exclusively beginning Jan. 1, 2023.

This is partly due to CMS receiving pushback from the healthcare industry. In a March 2022 letter to CMS administrator Chiquita Brooks-LaSure, at least 47 medical organizations, including the AMA, strongly urged CMS to discontinue its split/shared visits policy and not move forward with the transition set to take effect in 2023. The organizations felt the policy wouldn’t allow providers to effectively co-manage patients’ needs and was contrary to clinical alignment (https://searchlf.ama-assn.org/letter/documentDownload?uri=/unstructured/binary/letter/LETTERS/Sign-on-letter-to-CMS-re-Split-or-Shared-Visits-Final-03-29-22.pdf).

The delay is also to allow providers a transition year to get acclimated to the 2023 evaluation and management (E/M) guidelines for the remainder of the E/M categories, including 99221-99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination …) and 99281-99285 (Emergency department visit for the evaluation and management of a patient …).

And Wait a Little Longer for Proposed ROM Billing

Last, CMS is delaying implementation of another initiative: the radiation oncology model (ROM). On Aug. 29, 2022, CMS decided to delay the current start date of ROM to a date to be determined, saying they are “reviewing our current coding and payment policies for the radiation therapy services, including whether we should adopt the revised CPT^® coding that was established in CY 2015 to allow for coding and payment consistency,” according to the final rule.

Find it here: The final rule is available at www.federalregister.gov/d/2022-23873/page-69404. For a fact sheet on the CY 2023 Physician Fee Schedule Final Rule, please visit www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-final-rule.