CMS Releases 2023 MPFS Proposed Rule (2022)


CMS Releases 2023 MPFS Proposed Rule (1)

On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) released the 2023 Medicare Physician Fee Schedule (MPFS) proposed rule, which includes payment provisions and policy changes to the Quality Payment Program (QPP) and Alternative Payment Model (APM) participation options and requirements for 2023.

MPFSKey Proposals and AdditionalPotential Medicare Reductions:

(Video) 2023 Medicare Physician Fee Schedule Proposed Rule: Everything you need to know to prepare

For 2023, CMS proposes a Conversion Factor (CF) of $33.0775 which is a decrease of $1.53 or -4.42% from the 2022 conversion factor of 34.6062.

  • This significant reduction in the CF accounts for the expiration of the 3.00% increase in PFS payments for CY 2022 as required by the Protecting Medicare and American Farmers from Sequester Cuts Act, in addition to the statutorily required budget neutrality adjustment to account for changes in Relative Value Units.
  • The separately calculated Anesthesia CF is proposed at 20.7191, a -3.91% decrease from the 2022 conversion factor of $21.5623.

Key Takeaways:
CMS estimates an impact to allowed charges from policy changes in the rule as outlined below. These impacts are due in part due changes in the RVUs and the second year of the transition to clinical labor pricing updates.


(Please note: These estimates do not include the impact on payments from the expiration of the congressionally mandated 3.00% boost to the 2022 CF.)

  • Anesthesiology: -1%
  • Diagnostic Radiology: -3%
  • Interventional Radiology: -4%
  • Emergency Medicine: +1%
  • Critical Care: +1%
  • Nuclear Medicine: -3%
  • Pathology: -1%
  • Radiation Oncology/Therapy Centers: -1%
  • Internal Medicine: +3%
  • Independent Laboratory -1%

Additional Potential Medicare Reductions:

(Video) 2023 Medicare Physician Fee Schedule Proposed Rule Part III

  • In addition to the proposed cut to the CF, the second of two sequestration cuts was implemented on July 1, 2022, at -1%, bringing the total sequestration cut to -2% which will continue without Congressional intervention.
  • Also, the lack of full funding of the American Rescue Plan meant that the Medicare program would contribute 4% under the “PAYGO” (Pay as You Go) rules and that cut will come back into the Medicare fee schedule in 2023. In total, hospital-based physicians face in the approximate range of -10% in 2023 without Congressional intervention.

Appropriate Use Criteria (AUC):
CMS did not address the appropriate use criteria (AUC)/clinical decision support (CDS) mandate for
advanced diagnostic imaging services in this rule. CMS posted an update on its website indicating that
the current educational and operations testing period will continue beyond January 1, 2023, even if the
COVID-19 public health emergency (PHE) ends in 2022. The notice states that the agency is unable to
forecast when the payment penalty phase of the program will begin. Read more at CMS.gov.


Additional highlights of the MPFS Proposed Rule include:
Evaluations and Management (E/M) Services:

As part of the ongoing updates to E/M visits and the related coding guidelines that are intended to
reduce administrative burden, the AMA CPT Editorial Panel approved revised coding and updated
guidelines for Other E/M visits, effective January 1, 2023.


Like the approach CMS finalized in the CY 2021 MPFS final rule for office/outpatient E/M visit coding and
documentation, CMS is proposing to adopt most changes in coding and documentation for Other E/M
visits including: hospital inpatient, hospital observation, emergency department, nursing facility, home
or residence services, and cognitive impairment assessment, effective January 1, 2023. This revised
coding and documentation framework would include CPT code definition changes (revisions to the
Other E/M code descriptors), and for the first time would mean that AMA CPT and CMS would follow
the same coding guidelines, including:


• New descriptor times (where relevant).
• Revised interpretive guidelines for levels of medical decision making.
• Choice of medical decision making or time to select code level (except for services such as
emergency department visits (time has never been a component of ED E/M services except
critical care) and cognitive impairment assessment, which are not timed services).
• Eliminated use of history and exam to determine code level (instead there would be a
requirement for a medically appropriate history and exam).

(Video) MIPS 2023 Proposed Rule


Split (or Shared) Visits (Where services are performed by advance practice clinicians.)
CMS had previously finalized in the 2022 MPFS final rule a new January 1, 2023 billing policy for
instances in which a physician delivers an E/M service along with an advanced practice clinician (APC).
Recall that E/M services billed under an APC reimburse at 85% of the MPFS unless there is a
documented shared service by the supervising physician.

• The key determinant for deciding if there was a shared service is if the physician provided key
elements of the history, exam, or medical decision making ─ OR half of the total time spent
treating the patient.
• There were significant concerns that in hospital-based settings, the rule (set for implementation
on January 1, 2023) would have required only time as the determinative element, and that the
majority of APC services would then be reimbursed at 85% of the fee schedule. After significant
advocacy by multiple stakeholders, CMS has delayed the policy that would have based the
determination of the billing practitioner solely on time. This policy is proposed for delay until
January 1, 2024 while CMS collects additional input.


Expand Telehealth Coverage:
• CMS is proposing making several services that are temporarily available as telehealth services
for the PHE available through CY 2023 on a Category III basis, which will allow more time for
collection of data that could support their eventual inclusion as permanent additions to the
Medicare telehealth services list.
• CMS is also proposing to extend the duration of time that services are temporarily included on
the telehealth services list during the PHE, but are not included on a Category I, II, or III basis for
a period of 151 days following the end of the PHE, in alignment with the Consolidated
Appropriations Act, 2022 (CAA, 2022).


Highlights of the Quality Payment Program (QPP):
CMS stated they are limiting proposals for traditional MIPS and focusing on further refining
implementation of MIPS Value Pathways (MVPs).
2023 Proposed Performance Threshold and Performance Category Weights:
The performance threshold for the 2023 performance year is proposed to be 75 points, same as 2022.
• Beginning with 2023, CMS will no longer offer an exceptional performance adjustment.
• The category weights for the 2023 performance year are proposed to remain the same as the
2022 weights:
o Quality – 30%,
o Cost – 30%
o Promoting interoperability – 25%
o Improvement Activities – 15%

(Video) 2023 Medicare Physician Fee Schedule Proposed Rule Part III


Data Completeness Requirements:
• For 2023, CMS is proposing quality measure submissions should continue to account for at least
70% of total exam volume – same as 2022.

• CMS proposed to increase this threshold to 75% beginning with the 2024 and 2025 performance
years.


Quality Category – Measure Scoring System
• Beginning with 2023 CMS will change the scoring range for benchmarked measures to 1 to 10
points, doing away with the 3-point floor.
• Score existing non-benchmarked measures at 0 points even if data completeness is met
• New measures will continue to be scored at a minimum of 7 points for their first year and a
minimum of 5 points in their second year.
• CMS is maintaining the small practice bonus of 6 points that is included in the Quality
• performance category score.
• CMS also continues to award small practices 3 points for submitted quality measures that do not
meet case minimum requirements or do not have a benchmark.


MIPS Value Pathways (MVPs)
CMS is proposing 5 new MVPs and revising the 7 previously established MVPs that would be available
beginning with the 2023 performance year.
• Advancing Cancer Care
• Optimal Care for Kidney Health
• Optimal Care for Patients with Episodic Neurological Conditions
• Supportive Care for Neurodegenerative Conditions
• Promoting Wellness

(Video) CMS 2022 Proposed Rule: What You Need to Know with Dr. Dan Mingle


Advanced Alternative Payment Models
For payment years 2019 through 2024, Qualifying APM Participants (QPs) receive a 5 percent APM
Incentive Payment. After performance year 2022, which correlates with payment year 2024, there is no
further statutory authority for a 5 percent APM Incentive Payment for eligible clinicians who become
QPs for a year.


CMS is concerned that the statutory incentive structure under the QPP beginning in the 2023
performance year. corresponding 2025 payment year, could lead to a drop in Advanced APM
participation, and a corresponding increase in MIPS participation. As a result, CMS concluded that it
would forego action for the 2023 performance period and 2025 payment year. They instead are seeking
public input in identifying potential options for the 2024 performance period and 2026 payment year of
the QPP.

FAQs

How often is the Medicare physician fee schedule Mpfs updated? ›

MPFS payment is determined by the fee associated with a specific Current Procedural Terminology (CPT) code and is adjusted by geographic location. The fee schedule is updated annually by the Centers for Medicare and Medicaid Services (CMS) with new rates going into effect January 1 of each year.

What does Mpfs mean? ›

Medicare Physician Fee Schedule (MPFS) Quick Reference Search Guide.

What are MPFS payments? ›

The Centers for Medicare and Medicaid Services (CMS) uses the Medicare Physician Fee Schedule (MPFS) to reimburse physician services. The MPFS is funded by Part B and is composed of resource costs associated with physician work, practice expense and professional liability insurance.

What will the Medicare Part B premium be in 2023? ›

Medicare Part B premiums will fall in 2023, the first year-over-year decrease in more than a decade. The standard Part B monthly premium will drop to $164.90 next year, down from $170.10 in 2022.

Has the 2022 Medicare fee schedule been released? ›

In implementing S. 610, the Centers for Medicare & Medicaid Services (CMS) released an updated 2022 Medicare physician fee schedule conversion factor (i.e., the amount Medicare pays per relative value unit) of $34.6062.

What is the difference between facility and non facility fees? ›

In a Facility setting, such as a hospital, the costs of supplies and personnel that assist with services - such as surgical procedures - are borne by the hospital whereas those same costs are borne by the provider of services in a Non Facility setting.

How much is each RVU worth? ›

The current Medicare conversion factor is $37.89 per RVU. In other words, Medicare would pay $37.89 for a code worth 1 RVU, $75.78 for a code worth 2 RVUs, $378.90 for a code worth 10 RVUs and so on, regardless of the type of service.

Can you bill a Medicare patient for a non covered service without an ABN? ›

Medicare requires an ABN be signed by the patient prior to beginning the procedure before you can bill the patient for a service Medicare denies as investigational or not medically necessary. Otherwise, Medicare assumes the patient did not know and prohibits the patient from being liable for the service.

What is the Medicare Final Rule? ›

The Centers for Medicare & Medicaid Services today issued a final rule that updates the inpatient prospective payment system rates by 2.6% in FY 2023 compared to FY 2022. The increase reflects a 4.1% market basket update, less 0.3 percentage point for productivity, plus 0.5 percentage point required by statute.

What is CMS Final Rule? ›

The Home and Community-Based Services (HCBS) Final Rule ensures individuals have full access to the benefits of community living and the opportunity to receive services in the most integrated setting appropriate.

How do I get my $800 back from Medicare? ›

All you have to do is provide proof that you pay Medicare Part B premiums. Each eligible active or retired member on a contract with Medicare Part A and Part B, including covered spouses, can get their own $800 reimbursement.

Is Medicare premiums going up in 2023? ›

The Biden-Harris Administration has made expanding access to health insurance and lowering health care costs for America's families a top priority, and today, the Administration is announcing that people with Medicare will see lower premiums for Medicare Advantage and Medicare Part D prescription drug plans in 2023.

At what income level do Medicare premiums increase? ›

In 2022, higher premium amounts start when individuals make more than $91,000 per year, and it goes up from there. You'll receive an IRMAA letter in the mail from SSA if it is determined you need to pay a higher premium.

How do you pay for Medicare Part B if you are not collecting Social Security? ›

If you have Medicare Part B but you are not receiving Social Security or Railroad Retirement Board benefits yet, you will get a bill called a “Notice of Medicare Premium Payment Due” (CMS-500). You will need to make arrangements to pay this bill every month.

What is the premium for Medicare for 2022? ›

In 2022, the premium is either $274 or $499 each month ($278 or $506 in 2023), depending on how long you or your spouse worked and paid Medicare taxes. You also have to sign up for Part B to buy Part A. If you don't buy Part A when you're first eligible for Medicare (usually when you turn 65), you might pay a penalty.

What are the cuts to Medicare in 2022? ›

The US Centers for Medicare & Medicaid Services (CMS) recently proposed a nearly 4.5% cut to the Medicare conversion factor, a key element for calculating Medicare payments. Combined with the pending 4% Pay-As-You-Go (PAYGO) cut, surgical care reimbursement will be reduced by 8.5% next year.

How much will the premium be for Medicare Part B in 2022? ›

The Centers for Medicare & Medicaid Services (CMS) has announced that the standard monthly Part B premium will be $164.90 in 2023, a decrease of $5.20 from $170.10 in 2022. This follows an increase of $21.60 in the 2022 premium, largely due to the cost of a new Alzheimer's drug.

Is POS 10 facility or non facility? ›

Database (updated September 2021)
Place of Service Code(s)Place of Service Name
07Tribal 638 Free-standing Facility
08Tribal 638 Provider-based Facility
09Prison/ Correctional Facility
10Telehealth Provided in Patient's Home
54 more rows

Is POS 11 facility or non facility? ›

By definition, a “facility” place-of-service is thought of as a hospital or skilled nursing facility (SNF) or even an ambulatory surgery center (ASC) (POS codes 21, POS 31 and POS 24, respectively), while “non-facility” is most often associated with the physician's office (POS code 11).

Is POS 21 facility or non facility? ›

21 Inpatient Hospital A facility, other than psychiatric, which primarily provides diagnostic, therapeutic (both surgical and nonsurgical), and rehabilitation services by, or under, the supervision of physicians to patients admitted for a variety of medical conditions.

What has the highest RVU? ›

Among the six specialty groups, radiologists have the highest volume of work RVUs, with a median of 8,862 work RVUs per year.

What is the difference between work RVU and total RVU? ›

wRVUs take into account the complexity of each interaction. They assign every CPT code used in billing a specific wRVU. The wRVU then gets added to the other two RVUs (practice expenses and insurance). Together, they become the total RVU.

How much is an RVU worth 2022? ›

The Proposed Rule reported a 2022 Conversion Factor (CF) of $33.5848 per Relative Value Unit (RVU), but the Final Rule adjusts the figure slightly upward to $33.5983. This is a reduction of 3.71% from the 2021 CF of $34.8931.

What is a GY modifier? ›

The GY HCPCS modifier indicated that an item or service is statutorily non-covered or in not a Medicare benefit.

Why do we use modifier GZ? ›

The GZ modifier indicates that an Advance Beneficiary Notice (ABN) was not issued to the beneficiary and signifies that the provider expects denial due to a lack of medical necessity based on an informed knowledge of Medicare policy.

Why is getting an ABN so important? ›

The ABN allows you to decide whether to get the care in question and to accept financial responsibility for the service (pay for the service out-of-pocket) if Medicare denies payment. The notice must list the reason why the provider believes Medicare will deny payment.

What will the Medicare donut hole be in 2023? ›

Once you and your plan have spent $4,430 on covered drugs in 2022 ($4,660 in 2023), you're in the coverage gap. This amount may change each year. Also, people with Medicare who get Extra Help paying Part D costs won't enter the coverage gap.

What changes are being proposed for Medicare? ›

The biggest change Medicare's nearly 64 million beneficiaries will see in the new year is higher premiums and deductibles for the medical care they'll receive under the federal government's health care insurance program for individuals age 65 and older and people with disabilities.

What is final rule? ›

Legal Definition of final rule

: a rule promulgated by an administrative agency after the public has had an opportunity to comment on the proposed rule.

What are the 4 elements of emergency preparedness required by the CMS Final Rule? ›

ASPR TRACIE has compiled a Resources at Your Fingertips document that can help facilitate compliance with the four core elements of the CMS rule:
  • Emergency Plan;
  • Policies and Procedures;
  • Communication Plan; and.
  • Training and Testing.

What are the 4 key factors of the HCBS rule? ›

If you get HCBS, the Rule says you have rights. You have the right to: • Live in the community. Have a person-centered plan. Have freedom.

Is FHIR mandatory? ›

Last year, the U.S. Centers for Medicare and Medicaid Services finalized a requirement for the use of Fast Healthcare Interoperability Resources (FHIR) among many CMS-regulated payers and providers by July 1, 2021.

How do you qualify to get 144 back from Medicare? ›

How do I qualify for the giveback?
  1. Are enrolled in Part A and Part B.
  2. Do not rely on government or other assistance for your Part B premium.
  3. Live in the zip code service area of a plan that offers this program.
  4. Enroll in an MA plan that provides a giveback benefit.
14 Jan 2022

How do you qualify for Medicare premium refund? ›

To get a refund or reimbursement from Medicare, you will need to complete a claim form and mail it to Medicare along with an itemized bill for the care you received. Medicare's claim form is available in English and in Spanish.

Who is the largest Medicare Advantage provider? ›

Medicare Advantage Enrollment by Firm or Affiliate, 2022
  • UnitedHealthcare (7.9 million; 28%)
  • Humana (5.0 million; 18%)
  • BCBS plans (4.1 million; 14%)
  • CVS Health (3.1 million; 11%)
  • Kaiser Permanente (1.8 million; 6%)
  • Centene (1.4 million; 5%)
  • Cigna (.6 million; 2%)
  • All other insurers (4.6 million; 16%)
25 Aug 2022

What is Medicare fee schedule? ›

A fee schedule is a complete listing of fees used by Medicare to pay doctors or other providers/suppliers. This comprehensive listing of fee maximums is used to reimburse a physician and/or other providers on a fee-for-service basis.

What does the global period of 000 mean in Medicare Rbrvs physician fee schedule? ›

000 - Endoscopic or minor procedure with related preoperative and postoperative relative values on the day of the procedure only included in the fee schedule payment amount; evaluation and management services on the day of the procedure generally not payable.

What components make up the Medicare physician fee schedule? ›

The Medicare Physician Payment Schedule's impact on a physician's Medicare payments is primarily a function of 3 key factors: The resource-based relative value scale (RBRVS) The geographic practice cost indexes (GPCI)
...
2022 Medicare physician payment schedules
  • Physician work.
  • Practice expense (PE)
  • Malpractice (MP) expense.

Is the 2020 Medicare fee schedule available? ›

The Centers for Medicare and Medicaid Services (CMS) has released the 2020 Medicare Physician Fee Schedule final rule addressing Medicare payment and quality provisions for physicians in 2020. Under the proposal, physicians will see a virtually flat conversion factor on Jan. 1, 2020, going from $36.04 to $36.09.

What percentage does Medicare pay for? ›

You'll usually pay 20% of the cost for each Medicare-covered service or item after you've paid your deductible. If you have limited income and resources, you may be able to get help from your state to pay your premiums and other costs, like deductibles, coinsurance, and copays. Learn more about help with costs.

What might trigger a Medicare post payment audit? ›

The most common trigger for a post-payment audit is provider profiling and data mining to identify aberrant billing practices and outliers. In addition, post-payment audits can also be triggered by complaints made by patients or employees about the practice.

How Much Does Medicare pay for GP visit? ›

If you see a GP Medicare will pay 100% of the cost if the GP bulk bills. If they don't bulk bill, Medicare will pay 100% of the public rate and you will have to pay any extra if the doctor charges more.

What is included in 90 day global period? ›

Medicare defines the global period as that period of time during which a physician may not bill for related office visits. The global period may be 90, 10, or 0 days. According to Medicare, a major surgery has a global period of 90 days, and a minor surgery has a global period of either 10 or 0 days.

What modifier is used for global period? ›

Modifier 58 case example

This modifier typically is appended to a subsequent surgical procedure when the disease process requires additional surgical intervention for management of the entire condition. Modifier 58 may be appended only during the global period and restarts the global period.

What are global periods based upon? ›

A global period is a period of time starting with a surgical procedure and ending some period of time after the procedure. Many surgeries have a follow-up period during which charges for normal post- operative care are bundled into the global surgery fee.

What are the three elements of RVU? ›

CMS calculates an individual GPCI for each of the RVU components -- physician work, practice expense and malpractice.

What is the difference between work RVU and total RVU? ›

wRVUs take into account the complexity of each interaction. They assign every CPT code used in billing a specific wRVU. The wRVU then gets added to the other two RVUs (practice expenses and insurance). Together, they become the total RVU.

How much is each RVU worth? ›

The current Medicare conversion factor is $37.89 per RVU. In other words, Medicare would pay $37.89 for a code worth 1 RVU, $75.78 for a code worth 2 RVUs, $378.90 for a code worth 10 RVUs and so on, regardless of the type of service.

What is CMS Final Rule? ›

The Home and Community-Based Services (HCBS) Final Rule ensures individuals have full access to the benefits of community living and the opportunity to receive services in the most integrated setting appropriate.

How much is an RVU worth 2022? ›

The Proposed Rule reported a 2022 Conversion Factor (CF) of $33.5848 per Relative Value Unit (RVU), but the Final Rule adjusts the figure slightly upward to $33.5983. This is a reduction of 3.71% from the 2021 CF of $34.8931.

How many RVU is a 99214? ›

How the E/M code RVU increases could affect family physicians' pay
Code2020 work RVUs2021 work RVUs
992110.180.18
992120.480.7
992130.971.3
992141.51.92
6 more rows
18 Jan 2021

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