CMS Final Rule 2023
On November 1, 2022, the Centers for Medicare and Medicaid Services (CMS) issued the final rule for the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (HOPPS) for calendar year (CY) 2023. The below information is a high-level overview of the finalized rules and readers are encouraged to review RCCS’ more in-depth summaries as well as the final rules in their entirety.
- Finalized conversion factor (CF) = $33.0607
- California payment localities decreased from 32 to 29 – to be implemented in CY 2024
- Clinical labor rates updated for the first time in 20 years
- Three new prolonged E/M HCPCS codes
- G0316, G0317, G0318
- Accepted AMA CPT® changes to “Other E/M” visits with the exception of prolonged services codes
- Definitions for “initial” and “subsequent” amended
- Time-based coding – time must be “met or exceeded”
- Waivers and provisions due to the public health emergency (PHE), including telehealth codes will end 152 days post the end of the PHE
- Physicians will continue to append modifier 95 and POS code until the end of year in which PHE ends
- Colorectal cancer screening coverage updated
- Modifier JW is required to identify discarded drug amounts from single-dose containers
- Delay of rebasing and revising MEI cost weights
- FR modifier use to continue
- Five new MVPs, revision to previous seven
- Finalized conversion factor (CF) = $85.585 if reporting criteria met and $83.934 if criteria not met
- 340B drugs and biologicals to be paid at ASP plus 6
- LDCT APC assignments
- Scalp cooling assigned New Technology APC for CY2023
- NPPs may supervise diagnostic tests as so authorized under their scope of practice and state laws
- SmartClip™ Soft Tissue Marker denied transitional pass-through status in CY 2023
- Drugs and biologicals to receive separate payment if per day cost is greater than $135 with the exception of:
- Diagnostic radiopharmaceuticals
- Contrast agents
- Anesthesia drugs
- Drugs, biologicals, and radiopharmaceuticals that function as supplies or devices when used in a surgical procedure
- 43 drugs and biologicals pass-through payment status ended
- 49 drugs and biologicals pass-though payment status continued
- All biosimilar biological products eligible for pass-through payment continued
- Modifier JW required to identify discarded billing units of single-use drugs
- Modifier JZ required by 10.1.23
ACR Releases Updated Fluoro Dose Index
For the first time in 20 years, the American College of Radiology (ACR) task force has released the first radiation dose index registry for fluoroscopy procedures.
In the report published November 12, task force members created a document called the DIR-Fluoro Registry (DIR-Fluoro) based on their calculations of optimal radiation dose levels for 100 fluoroscopy-guided interventions based on reports from 10 hospital systems.
Dose data was collected on 50,501 cases from 100 common procedures. Comparing the most recent study to one published in 2003 shows that doses have decreased over time, which is likely reflective of the increased use of ultrasound as an adjunct to fluoro, changes in default dose rate settings of new fluoroscopes, the sue of added filtration, newer dose reduction technologies, and more widespread fluoroscopy training.
– Aaron Kyle Jones, PhD, of the University of Texas MD Anderson Cancer Center
2023 CPT® Code Updates
The long-anticipated 2023 CPT® updates have been released, and this year brings important changes to radiology services as well as to E/M services for 2023. The code updates will go into effect on January 1, 2023.
The American Medical Association (AMA) has modified the structure of E/M services that were previously based on history, exam, and medical decision making (MDM) or time to align with the updates previously made to office and other outpatient visits in 2021. These revisions impact hospital inpatient and observation care (for which there is now one set of codes to describe both services), consultations, emergency department services, nursing facility services, and home or residence services.
Beginning in 2023, for almost all E/M services, either medical decision-making or time may be used to determine the level of E/M service (though time is not used as a factor for determining level of service for ED visits). The extent of history & physical exam is no longer an element in selection of inpatient visits. The expectation is that the provider’s documentation will contain the components relevant and appropriate for the visit. History tells the story for the current chief complaint, while examination provides the objective data regarding the current chief complaint.
Inpatient and observation services have been rolled together, so codes 99218-99220 and 99224, 99226 have been deleted. For reporting initial observation care for a new or established patient, codes 99221-99223 should be used. For subsequent observation care for new or established patients, see codes 99231-99233.
To report a patient who was admitted and discharged from hospital inpatient or observation status on the same date, see codes 99234-99236. For patients admitted to hospital inpatient or observation care and discharged on a different date, see 99221-99223, 99231-99233, 99238, or 99239.
Office consultations should be coded using 99242-99245, while hospital inpatient or observation consultations for new or established patients should be coded using 99252-99255. The new guidelines for consultations clarify that consultations must be requested by another qualified health care professional, not by a family member or non-clinical individual (e.g., lawyer, social worker). Additionally, the consultant’s opinion and any services ordered and performed must be communicated in writing to the requesting physician or other healthcare professional.
Remember that Medicare does not accept the consultation codes, so the appropriate E/M level of service for the setting should be billed for consults for Medicare patients. It is important to verify individual payer policies for these CPT® codes. A consultation may only be billed once per stay per specialty and group.
Codes 99354-99357 have been deleted for 2023. Prolonged services code 99418 was created to represent additional 15-minute increments of prolonged inpatient or observation service time with or without patient contact. This code is used with codes 99223, 99233, and 99236, consultation code 99255, and nursing facility codes 99306 and 99310. Prolonged service codes must only be billed with the highest-level code in the category or subcategory. Like with the outpatient prolonged service code 99417, CMS does not recognize this new code. CMS has created its own HCPCS code, G0316, to represent a 15-minute increment of inpatient/observation prolonged service time, and the entire 15-minute increment must be completed. CMS provided a table in the CY 2023 Medicare Physician Fee Schedule Final Rule which reviews the application of the new HCPCS prolonged service visit codes. At this time, it is unknown whether private payers will follow CMS or AMA guidelines with regard to prolonged services.
The CPT® manual includes tables outlining the new codes and the times required. This number of minutes must be met or exceeded when using total time on the date of the encounter to determine the service level.
Additional information and instructions, including a helpful table, can be found in the CPT® 2023 E/M Services guidelines.
In the interventional radiology setting, two new codes (36836 and 36837) were added for percutaneous arteriovenous fistula (AVF) creation (also called EndoAVF). Code 36836 describes this procedure when performed via a single access site, usually an arm vein and 36837 describes EndoAVF creation via two separate access sites (into a peripheral artery and a peripheral vein). An unlisted code (37799) should be used if this service is performed in the lower extremity (or any location other than the upper extremity).
Diagnostic imaging and imaging guidance (including venography or ultrasound) should not be separately reported with codes 36836 and 36837 in addition to a number of other interventional radiology procedures and services.
For diagnostic radiology, code 76882 (limited extremity ultrasound) was updated to include the term “focal evaluation.” The description was updated to clarify that this code should be used for limited or focal evaluation of specific non-vascular anatomic structure(s) (e.g., joint space only) OR tendon(s), muscle(s), nerve(s) and/or other soft tissue structure(s) or mass(es) that surround the joint (without assessing all of the required elements included in 76881).
Code 76883 was created to represent comprehensive ultrasound of extremity nerve(s) and accompanying structures throughout the entire anatomic course in one extremity. This code should not be reported in conjunction with 76882. However, if only one or two points within the extremity nerve(s) are evaluated (and not the entire anatomic course), 76882 should be reported instead of 76883.
In the Nuclear Medicine section, the SPECT codes (78803, 78830-78832) received updated descriptions to clarify the intention of this code family and to differentiate between single area or single acquisition examinations versus two or more separate acquisitions with two different radiopharmaceuticals on the same date of service or over two or more days.
Codes 0721T and 0722T represent quantitative CT tissue characterization. Code 0721T should be used when this service is performed retrospectively on a previously acquired CT scan, while 0722T, an add-on code, should be used with a concurrently obtained CT scan (in addition to the code for the diagnostic CT study). 0721T is not to be reported in conjunction with any other CT procedure code when performed of the same anatomy, while 0722T should be reported in addition to the diagnostic CT code.
Another new service is quantitative magnetic resonance cholangiopancreatography (or QMRCP). These codes, 0723T and 0724T, represent quantitative metrics of the biliary tree and pancreatic ducts derived from MRI images. Code 0723T represents QMRCP performed retrospectively on a previously acquired MR scan, while 0724T, an add-on code, represents QMRCP performed in conjunction with a concurrently acquired MR scan. 0723T should not be reported in conjunction with 74181-74183 or 76376, 76377, 0724T when evaluating the same organ, gland, tissue or target structure. Conversely, 0724T should be reported in addition to 74181-74183 when evaluating the same organ, gland, tissue, or target structure. 0724T also cannot be reported with 3D rendering (76376/76377) or 0723T.
Code 0743T has been added to represent biomechanical CT with vertebral fracture assessment. This code is differentiated from existing bone strength and fracture risk codes 0554T – 0557T in that 0743T includes vertebral fracture assessment. 0743T may be reported alone (when performed on an existing CT dataset) or in conjunction with 0558T when performed with a concurrently obtained CT scan. Do not report 0743T with codes 0554T-0557T or 0691T.
Codes 0749T and 0750T represent digital x-ray radiogrammetry-bone mineral density ( DXR-BMD) analysis. CPT® instructions state: “When the data from a concurrently performed wrist or hand X-ray obtained for another purpose is used for the DXR-BMD analysis, use the appropriate X-ray code in conjunction with 0749T. If a single-view digital X-ray of the hand is used as a data source, use 0750T.”
By becoming familiar with these changes before the end of the year, your practice can prepare to navigate the changes ahead with regard to coding radiology and evaluation and management services.
Noridian Notifies of Reimbursement Issue
Noridian Healthcare Solutions released a notice that two HCPCS codes associated with oncology radiopharmaceuticals had been reimbursed incorrectly. The HCPCS file associated with OPPS rate for HCPCS codes A9607 and A9800 for October 2022 contained incorrect payment rates for these codes.
The correct OPPS payment rate for A9607 (Pluvicto) is $218.875. The co-payment percentage is 20 percent. The correct OPPS payment rate for A9800 (Locametz®) is $848.000. The co-payment percentage is 0 percent. Claims are now being processed with the correct reimbursement.