Pulmonology Coding Alert

Know which telehealth services could be disconnected in 2023.

The calendar year (CY) 2023 Medicare Physician Fee Schedule (PFS) proposed rule was published in the Federal Register on July 29, 2022. The document from the Centers for Medicare & Medicaid Services (CMS) is full of information that could affect your practice’s bottom line.

Learn how the proposed rule could shape telehealth services and if inflation could be a pain for practices in 2023.

Understand the Decreased Conversion Factor

The estimated CY 2023 conversion factor (CF) is proposed as $33.0775, which, when compared to the CY 2022 CF of $34.6062, is a $1.5287 decrease — or roughly 4.4 percent. CMS calculated the decrease by removing the one-year 3 percent increase provided by the CY 2022 Protecting Medicare and American Farmers from Sequester Cuts Act followed by implementing a negative 1.55 percent budget neutrality adjustment.

Will Inflation Negate Positive Changes for Pulmonary?

If finalized, the proposed CF impacts PFS services positively, negatively, or not at all. Any of these are possible because the relative value unit (RVU) changes are contributing factors on the payment impact of the proposed policies.

The CY 2023 proposed rule lists allowed charges for several specialties. The allowed charges are estimated “based on CY 2021 utilization and CY 2022 rates.” For CY 2023, CMS is estimating the allowed charges of the Pulmonary Disease specialty as $1,395,000,000 — or $1.395 billion.

However, depending on changes to work, practice expense (PE), and malpractice RVUs, the allowed charges may increase, decrease, or remain the same. When totaled up, the estimated RVU changes create a combined impact on the allowed charges. In the CY 2023 proposed rule, the changes for Pulmonary Disease are as follows:

• Impact of work RVU changes: 1 percent
• Impact of PE RVU changes: 0 percent
• Impact of MP RVU changes: 1 percent
• Combined impact: 2 percent

CMS further breaks down the specialty-specific impacts by site of service at the “requests of interested parties.” Table 139 shows the payment charges for facilities and nonfacilities.

The CY 2023 estimated impact on allowed charges by setting for Pulmonary Disease is as follows:

However, while the estimated impact on allowed charges in total and for facilities show gains, inflation may end up costing practices in the long run. The U.S. inflation rate was 8.5 percent at the end of July 2022. “In reality, the practice expense may negatively affect the overall impact due to the rising cost of inflation. Even the [combined impact] 2 percent increase projected for Pulmonary Disease may not be fully realized due to rising overhead costs,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Hang Up on Certain Telehealth Services

Telehealth services policymaking continues to evolve in the CY 2023 Medicare PFS proposed rule. First, CMS proposes to extend coverage of the temporary codes it didn’t add to its Medicare telehealth services list under Categories 1, 2, or 3 during the public health emergency (PHE), until 151 days after the PHE ends, the proposed rule indicates.

Plus: CMS proposes to add 54 codes to Category 3 of the Medicare telehealth services list. Remember, however, that the agency had originally earmarked the Category 3 codes to “expire at the end of the year in which the PHE ends, but CMS extended coverage of those codes through December 31, 2023,” states an article by attorneys Rachel B. Goodman, Nathaniel M. Lacktman, and Thomas B. Ferrante with Foley & Lardner LLP.

“In this year’s proposed PFS rule, CMS declined any further extension, so all Category 3 codes will expire at the end of 2023. In the event the PHE extends well into 2023, CMS said it will consider a further extension of the Category 3 codes at that time,” explain Goodman, Lacktman, and Ferrante in their online legal analysis.

CMS aims to implement telehealth provisions that were outlined in the Consolidated Appropriations Act, 2022, too — and prepare Medicare clinicians for a post-COVID landscape.

Certain codes slated for expiration from the Medicare telehealth services list after 151 days following the end of the PHE include telephone evaluation and management (E/M) codes. These codes, listed on Table 10 of the proposed MPFS, are as follows:

• 99441 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion)
• 99442 (… 11-20 minutes of medical discussion)
• 99443 (… 21-30 minutes of medical discussion)

In the proposed rule, CMS states that “For telehealth services other than mental health care, two-way, audio-video communications technology is the appropriate standard that will apply for telehealth services after the PHE ends.”

“Given the fact that telephone E/M codes cannot take the place of a ‘face-to-face’ visit (as there is no video component), CMS will not continue to allow payment for these services post-PHE. They will return to a ‘Bundled’ payment status,” Pohlig says.