Orthopedic Coding Alert

Unless Congress acts, CF will be significantly cut.

The Centers for Medicare & Medicaid Services (CMS) has released the Medicare Physician Fee Schedule (MPFS). The 2023 conversion factor (CF) is already causing controversy.

Why? Barring some last-minute legislation, deep CF cuts are coming. The MPFS final rule was posted on Nov. 1, and the coding community has already voiced its concerns about the CF and how it will affect physician reimbursement next year.

“My initial reaction to this change is ‘Wow, that’s a big decrease. There is no way that is not going to hurt physicians,’” says Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington.

Check out this nuts-and-bolts rundown of the MPFS CF, as well as some tips your practice might use to tighten its belt in 2023.

Check Out the 2023 Conversion Factor

For 2023, the final MPFS CF is $33.06, a decrease of 4.5 percent (or $1.55) from the CY 2022 MPFS conversion factor of $34.60.

The 2023 MPFS CF is actually a higher decrease than the proposed 4.4 percent decrease put forth in the proposed final rule, according to a release from the American College of Emergency Physicians (ACEP).

“We were hoping that CMS would finalize a smaller cut to the MPFS conversion factor than the 4.4 percent reduction the agency proposed. Unfortunately, despite our comments, CMS wound up doing the exact opposite and finalized a slightly higher reduction,” ACEP reports.

To Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting, Inc. in Lansdale, Pennsylvania, the CF number was “very disappointing, especially during an economic period characterized by high inflation where we would also expect positive adjustments in the [CF]. This is compounded by COVID-related challenges,” she says.

All is not lost, however. Congress could step in before the end of the year and change the conversion factor. Whether it will remains to be seen, but there will be pressure on Congress to act.

“It’s now officially up to Congress to take action to avert this cut. … ACEP will continue making this issue one of its top legislative priorities, and we are hopeful that Congress will include some sort of fix in a year-end package,” according to ACEP.

Good News: Telehealth Expansion

“On a good note, CMS intends to adopt the telehealth waiver extension that Congress passed in Consolidated Appropriations Act of 2022,” says Falbo.

“The extension locks in a wide range of telehealth waivers for 151 days after the PHE [public health emergency] expires, including the audio-only exceptions that have been popular with providers; the waiver of geographic and other limits ordinarily required for telehealth services; and the ability of therapists, occupational therapists, speech-language pathologists, and audiologists to bill such codes under telehealth,” Falbo explains.

Practices Can Get Proactive to Offset CF Cut

Experts agree that there are a few aspects of coding your practice can control that could help streamline and maximize your reimbursement. Your adjustment to new reporting rules could be crucial in keeping your coding correct.

Remember: As with office/outpatient evaluation and management (E/M) codes in 2021, the AMA is changing descriptors for (or outright deleting) several code sets in the other E/M sections of CPT^®. In many cases, these changes mirror what the AMA did in 2021. The main feature of the E/M changes is that you will often be able to code based solely on time or medical decision making (MDM).

Experts say everyone should be coding by MDM when possible — especially given the CF cut in 2023.

“I think that at least part of the solution is better documentation and better templates are going to be key to that. The AMA has said over and over that billing [E/Ms] strictly by time is not going to get the physicians appropriate reimbursement,” Bucknam says. “Good documentation of the complexity of decision-making will typically net higher codes and higher billing and reimbursement. However, most of my physicians have not followed that. Time is just so much easier to document.”

Brink agrees that providers should be coding more based on MDM when possible; coding E/Ms based on time often results in undercoding the E/M service. Brink also says that practices should consider:

• “Updating their EMR [electronic medical record] templates to capture accurate coding of medical necessity to choose E/M code levels;
• “Educating providers to learn to code E/M services based on medical necessity rather than time;
• “Ensuring billing personnel accurately code what is documented by the provider;
• “Monitoring denials to ensure services are accurately coded; and
• “Getting providers up to date on the new CF.”

“In addition to education on the new AMA E/M changes, practices should review other areas of revenue opportunities such as telehealth and behavioral health coverage expansion,” recommends Falbo.

However, even these proactive measures won’t change the fact that 2023 looks to be a lean year. “I think there is better reimbursement to be obtained with the new rules for coding E/Ms, but that won’t make up for all of the loss,” says Bucknam. “Surgeons, for example, who make most of their revenue from procedures will not be able to improve their reimbursement with better documentation. I don’t think there is an easy solution to this problem.”

Practice managers are going to have to look closely at what they bill and how they are reimbursed to try to offset these losses, according to Bucknam. “Some services or supplies that may not have been separately billed in the past are going to have to be billed, and services and supplies that are not covered by insurance will have to be billed at a higher rate to make up the lost revenue.”