Primary Care Coding Alert

Vaccination, CCM pricing increase should offset, experts feel.

First, here is the bad news from the final rule: “Beginning Jan. 1, 2022, CMS will decrease the conversion factor (CF) from $34.89 to $33.59. This looks like the biggest negative in the final rule,” notes Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

Even so, there’s plenty of good cheer for primary care in the rule. “There are more positives than negatives in the final rule. Among them, CMS is increasing the payment allowance for influenza, pneumococcal, and hepatitis B vaccine administration,” says Moore.

Here are three big takeaways that will help you celebrate the New Year.

Takeaway 1: Convert the Bad CF News to Good

When Medicare lowers the CF, it usually follows that payments for services are lowered accordingly. Simply put, the CF is a critical part of the resource-based relative value scale (RBRVS), the complex formula CMS uses to establish payment for services. CMS uses relative value units (RVUs) for services based on the work, practice expense (PE), and malpractice insurance (MP) involved. They are then “adjusted by geographic practice cost indices (GPCI) to reflect the variations in the costs of furnishing the services.” Then everything is multiplied by a final multiplier — the CF — to produce a dollar value using the following formula:

Payment = [(RVU work × GPCI work) + (RVU PE × GPCI PE) + (RVU MP × GPCI MP)] × conversion factor (CF).

So, it follows that a reduction of $1.30 in the CF should result in many services being valued lower next year. However, the finalized CY 2022 PFS estimated impact on total allowed charges by specialty for family practice is a one percent increase, according to CMS, while CMS believes that internal medicine will not be affected at all with an estimated zero percent impact. This is partly because increases in the RVUs of many key primary care services will more than offset the decrease in the CF for CY 2022.

But will the CF decrease go through? Possibly not. Some healthcare lobbying organizations, including the American Medical Association (AMA), are objecting to this, and are trying to get Congress to act. “The AMA is strongly advocating for Congress to avert this and other looming cuts to Medicare physician payments that, overall, will produce a combined 9.75 percent cut for 2022. This comes at a time when physician practices are still recovering the personal and financial impacts of the COVID public health emergency,” says AMA President, Gerald E. Harmon, MD, in a statement (URL: www.ama-assn.org/press-center/press-releases/ama-statement-physician-fee-schedule-final-rule).

So, “the impact of a lowered CF could change if Congress intervenes,” Moore points out.

Takeaway 2: Plan for These Modest Care Management Gains

“Another piece of good news in the final rule is that CMS is increasing payment for chronic care management (CCM) services,” says Moore, which includes gains in CCM, complex CCM, and a robust evaluation of the new principal care management codes that are now in play.

The following table tells you all you need to know:

Takeaway 3: Ramp Up Your Vaccination Charges

The last piece of good news for 2022 concerns the increase in one of primary care’s main services: influenza, pneumococcal, and hepatitis B vaccine administration. For 2022, CMS will pay $30 per dose for the administration of these vaccines, almost double last year’s rate of $16.94 per dose.

Additionally, the final rule states that CMS is going to “maintain the current payment rate of $40 per dose for the administration of the COVID-19 vaccines through the end of the calendar year in which the PHE ends.” “In light of reports from our clients saying they are receiving varying payment rates for administering COVID-19 vaccine, having CMS backing fairer payment through this extraordinary circumstance may make advocating for proper rates from private insurers more fruitful,” says Jan Blanchard, CPC, CPEDC, CPMA, Pediatric Solutions Consultant at Vermont-based PCC.

(To view the full final rule, go to public-inspection.federalregister.gov/2021-23972.pdf).