CY 2023 Medicare Physician Fee Schedule- Industry News, July 2022

CMS Releases CY 2023 Medicare Physician Fee Schedule (MPFS) Proposed Rule

On July 7, the Centers for Medicare and Medicaid Services (CMS) issued the Calendar Year (CY) 2023 Medicare Physician Fee Schedule (MPFS) proposed rule.

The proposed CY 2023 MPFS conversion factor is $33.08, a decrease of $1.53 to the CY 2022 MPFS conversion factor of $34.61. This conversion factor accounts for the statutorily required update to the conversion factor for CY 2023 of 0%, the expiration of the 3% increase in MPFS payments for CY 2022 as required by the Protecting Medicare and American Farmers From Sequester Cuts Act, and the statutorily required budget neutrality adjustment to account for changes in Relative Value Units (RVUs).

Numerous items are addressed in the proposed rule, including changes to payment provisions and policies for the Quality Payment Program (QPP) and its component participation methods – the Merit-Based Incentives Payment System (MIPS) and Advanced Alternative Payment Models (APMs).

The rule also addresses Relative Value Scale Update Committee (RUC) recommendations CPT® codes relating to x-ray of knee joint, 3D rendering and interpretation, ultrasound guidance, fluoroscopic guidance, and arthrodesis decompression, among others. The Centers for Medicare and Medicaid Services (CMS) has proposed to redefine the values for new CPT® codes for neuromuscular ultrasound and percutaneous arteriovenous fistula creation. Other relevant items for which CMS seeks feedback include clinical labor update values, practice expense data collection and methodology, expanded colorectal cancer screening coverage, improved global surgical package valuation, changes to health care delivery and payment for E/M services, telehealth flexibilities, direct supervision flexibilities, split or shared services, billing for discarded single-use drugs, and much more.

CMS also proposed the intention to accept and move forward with the AMA CPT® Editorial Panel changes to “Other E/M” visits, which include inpatient and observation visits, emergency department (ED) visits, nursing facility visits, domiciliary or rest home visits, home visits, and cognitive impairment assessment, except critical care services. The proposed accepted changes will align the medical decision make or time-based framework of the outpatient and office E/M visits which were changed in 2021. CMS did indicate they were not in agreement with the AMA regarding the application of prolonged services codes and proposed three new prolonged Other E/M services HCPCS codes.

To be assured consideration, comments regarding the proposed rule must be received by mail or electronic comment no later than 5 p.m. on September 27, 2022.

CMS Releases CY 2023 HOPPS/ASC Payment Systems Proposed Rule

On Friday, July 15, 2022, the calendar year (CY) 2023 Hospital Outpatient Prospective Payment System (HOPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule was released by the Centers for Medicare and Medicaid Services (CMS).

The proposed CY 2023 HOPPS conversion factor is $86.785, a 2.7 percent increase, for hospitals meeting the reporting criteria, and $85.093 (utilizing the 2 percent reduction) for those that do not meet criteria.

Various items of interest are addressed in the proposed rule, including standardizing Ambulatory Payment Classifications (APCs) payment weights, complexity adjustments in ambulatory surgical centers (ASCs), adjustments to the Inpatient Only (IPO) list, and continuing composite APCs for multiple imaging procedures. The rule also addresses new technology APCs for two new imaging services as well as payments for drugs, biologicals and radiopharmaceuticals, and the 340B drug discount program.

Additionally, information is provided regarding proposed updates to the definitions for general and personal supervision and clarification that certain non-physician practitioners (NPPs) are allowed to supervise diagnostic tests to the extent they are authorized under their scope of practice and applicable State law.

To be assured consideration, comments regarding the proposed rule must be received by mail or electronic comment no later than 5 p.m. on September 13, 2022.

CY 2023 Proposed Rule Resources

For further information on CMS’ CY 2023 MPFS and HOPPS proposed rules, a review of RCCS’ comprehensive summaries is recommended.

ICD-10-CM 2023 Delivers Multitude of Changes

The Centers for Medicare and Medicaid Services (CMS) releases updates to the ICD-10-CM Official Guidelines for Coding and Reporting and ICD-10-CM diagnosis codes to be used during the upcoming fiscal year. The code updates are typically released in mid-June, while revisions to the guidelines are released near the end of July, effective October 1, 2022.

Below is a high-level overview of some of the impending changes. It is strongly recommended to review the 2023 ICD-10-CM update and Official Guidelines for Coding and Reporting to ensure you are prepared implement any applicable changes.

Highlights of Changes:

  • 2023 Tabular List Updates
    • Von Willebrand disease specification updates (D68.00 – D68.09)
    • Heparin-induced thrombocytopenia updates (D75.821-D75.829)
    • Malignant pericardial effusion (I31.31)
    • Added codes for:
      • Long-term drug therapy for distinct type of chemotherapeutic drugs (Z79.630-Z79.634)
      • Myelosuppressive agents (Z79.64)
  • Revision to the Code Assignment and Clinical Criteria section
    • Clarifies that if there is conflicting medical record documentation, the provider should be queried
  • Update to Documentation of Complications of Care to add:
    • “the documentation must support that the condition is clinically significant. It is not necessary for the provider to explicitly document the term ‘complication.’ For example, if the condition alters the course of the surgery as documented in the operative report, then it would be appropriate to report a complication code. Query the provider for clarification if the documentation is not clear as to the relationship between the condition and the care or procedure.”
  • Coding Guideline Updates
    • Chapter 2 (Neoplasms)
      • Admission/encounters for treatment of primary site – if the malignancy is chiefly responsible for occasioning the patient admission/encounter and treatment is directed at the primary site, the primary malignancy should be listed as the principal/first-listed diagnosis.
        “The only exception to this guideline is if the administration of chemotherapy, immunotherapy or external beam radiation therapy is chiefly responsible for occasioning the admission/encounter. In that case, assign the appropriate Z51.– code as the first-listed or principal diagnosis, and the underlying diagnosis or problem for which the service is being performed as a secondary diagnosis.”
      • Admission/encounters for treatment of secondary site – instructions were added to direct users to new subsection I.C.2.t for secondary malignant neoplasm of lymphoid tissue. This new paragraph advises:
        “When a malignant neoplasm of lymphoid tissue metastasizes beyond the lymph nodes, a code from categories C81-C85 with a final character ‘9’ should be assigned identifying ‘extranodal and solid organ sites’ rather than a code for the secondary neoplasm of the affected solid organ. . For example, for metastasis of B-cell lymphoma to the lung, brain and left adrenal gland, assign code C83.39, Diffuse large B-cell lymphoma, extranodal and solid organ sites.”

There are many anticipated changes coming later this year to ICD-10-CM coding which will impact diagnosis code selection and specificity. Be sure to take time to review the published updates in order to familiarize yourself with this latest information, and you’ll be prepared to use these codes appropriately when they take effect.

Dozens Charged in $1.2 Billion Telemedicine Fraud Scheme

On Wednesday, July 20, 2022, The Department of Justice (DOJ) released news of criminal charges brought against 36 defendants for alleged fraudulent telemedicine, cardiovascular and cancer genetic testing, and durable medical equipment (DME) schemes totaling more than $1.2 billion.

The targeted schemes, which were investigated nationwide, primarily involved payment of illegal kickbacks and bribes by laboratory owners and operators in exchange for the referral of patients by medical professionals who were working with fraudulent telemedicine and digital medical technology companies. The telemedicine schemes are estimated to total more than $1 billion of the alleged amount of losses.

As alleged in court documents, one specific case charged the operator of serval clinical laboratories, who is alleged to have paid over $16 million in kickbacks to marketers who, in turn, paid kickbacks to telemedicine companies and call centers in exchange for doctors’ orders. These orders for cardiovascular and cancer genetic testing, which were not used in treatment of patients, were used to submit over $174 million in false and fraudulent claims to Medicare.

“The Centers for Medicare & Medicaid Services continues to aggressively investigate fraud, waste and abuse and has taken action to protect patients, critical health care resources and to prevent losses to the Medicare Trust Fund,” said CMS Administrator Chiquita Brooks-LaSure.

Public Health Emergency Extended

On July 15, 2022, the public health emergency (PHE) was renewed once again. Effective July 15, 2022, as part of the continued response to the COVID-19 pandemic, the PHE and included waivers and flexibilities will be renewed for an additional 90 days. The PHE will now be extended to October 15, 2022.

NCCN® Releases New Breast CA Guidelines

The National Comprehensive Cancer Network® (NCCN®) has published new guidelines for Breast Cancer Screening and Diagnosis. The guidelines are published to assist people in understanding their personal risk and educate them on when and how often to be screened for breast cancer.

The newly released recommendations assert that all women should begin breast cancer screening risk assessments through their primary provider starting at age 25 and continuing every one to three years. Assessments should include family history, blood work, discussion of breast changes, and physical exam. NCCN® also maintains starting at age 40, women with average risk should begin with annual screening mammograms. For women with an increased risk of developing cancer (i.e., known genetic risk of family history), the guidelines recommend starting screening at an earlier age and may include breast MRI in addition to mammography.

New HCPCS Codes for PET Radiopharmaceuticals, Other Cancer Drugs

The Centers for Medicare and Medicaid Services (CMS) recently announced new HCPCS Level II codes for several new cancer drugs and PET radiopharmaceuticals to be effective October 1, 2022. New HCPCS were created for Fluorodopa F-18 (A9602), used in PET scans for Parkinsonian syndromes, PLUVICTO™ (A9607), a prostate-specific membrane antigen-PET imaging agent, LOCAMETZ® (A9800), also used in PSMA-directed therapy, and several more drugs and biologicals.

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EOM Resources

In June, the Centers for Medicare and Medicaid Services (CMS) announced the Enhancing Oncology Model (EOM). Below are some resources on this voluntary payment model.