CMS Proposed Rule 2023
Centers for Medicare and Medicaid Services
CMS has published the CY2023 Proposed Rule outlining changes to the Medicare Physician Fee Schedule and associated billing and payment policies and will be accepting comments related to the Proposed Rule until September 6th. We’ve highlighted some items of significance below.
Medicare calculates payments on the long standing formula methodology listed below. The complexity of this formula leaves many opportunities for a minor adjustment to one component to ultimately impact the payment made to healthcare entities.
[(wRVU x wRVU GPCI) + (peRVU x peRVU GPCI) + (mpRVU x mp GPCI)] x Conversion Factor = Payment Amount
Perhaps the most straightforward component in the formula is the Conversion Factor. Simply being the dollar value multiplier for all professional fees it’s simple to compare over time. The proposed CY2023 Conversion Factor is $33.08, a decrease from the CY2022 Conversion Factor of $34.61.
Adjustments to the Geographic Practice Cost Index (GPCI) values, in CY2023 will also impact the end result of the formula. CMS is also seeking comment on proposed adjustments to how GPCI’s are calculated. Essentially, their proposal would use 2017 Physician Practice Census data as a base instead of the 2006 data that was used to weight the current GPCI values. Overall 47 localities see a decrease in GPCI values and 63 see an increase. Louisiana, Nevada, Washington DC and various areas in New York lead the decreases while Texas, Georgia and various California localities lead the increases in GPCI values.
Annually CMS also makes adjustments to each of the RVU components further complicating the end result of the payment formula. Nationwide, regardless of locality, these adjustments impact each specialty differently.
In CY2022 we saw changes to E&M Services performed in the office as it related to the documentation required and method to level selection. This change promoted level setting with medical decision making and complexity versus time and H&P. CY2023 proposed changes would make the same adjustments to Emergency Department, Hospital Observation, Hospital Inpatient, Nursing Facilities, Home or Residence Services and Cognitive Impairment E&M Services.
The Public Health Emergency put into place by COVID-19 meant that Telehealth services rules were adjusted rapidly to allow patients to be seen remotely on a wide scale basis. CMS is proposing that several services which were only made available because of the PHE be available for a longer term basis by making the associated codes Category III codes allowing for more time for data collection. Ultimately this could lead to a more favorable outcome and make telehealth a more permanent fixture in every day practice, public health emergency or not.
- Proposed rule for 2023 would decrease screening age
- Screening age decreased from 50 to 45
Currently CMS Claims submitted for these items (some J code and some Q code) SHOULD be billed with the used qty of the drug on one line then the discarded units of the drug on a second line with JW modifier. Both lines are reimbursed by Medicare (and are subject to coinsurance) however pharmaceutical companies issue refunds to CMS based on the units billed with JW modifier since they were discarded. CMS notes that it is likely, that some providers incorrectly bill the total units on one claim line without splitting out the administered and the discarded units separately. Medicare pays claims both ways but this has created some unreliable data as to how much of any given drug is being administered and how much is being discarded. The Proposed Rule for CY2023 would REQUIRE a new modifier (JZ) be used on a line item indicating that zero units were discarded. This would qualify that all units were administered and in fact zero rebate is due to CMS.
CCMS is seeking comment on all portions of the CY2023 Proposed Rule and will be accepting those comments until September 6th but encourage commenters to submit as early as possible to allow ample time for review and consideration. The entire proposed rule can be found at https://public-inspection.federalregister.gov/2022-14562.pdf. Comments should be submitted to https://www.regulations.gov/ (in commenting please refer to file code CMS-1770-P). CMS will publish the final rule for CY2023 in October of 2022, and it will be effective starting January 2023.
New CMS rule on split/shared encounters to be delayed until 2024
Amanda Rumpke MSN, APRN-CNP
Calendar Year 2023 Medicare Physician Fee Schedule Proposed Rule
Medicare Parts A and B
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