CMS Final Rule Changes 2023
Centers for Medicare and Medicaid Services
E/M Reimbursement Evaluated
In Part 1 of this series talked about the changes to each component, what does the overall impact look like when you combine an increase or decrease in total RVU within a specialty, the increase or decrease in the GPCI values within each locality, and then the Nationwide Conversion Factor decrease of $1.55 per RVU? Great question! Results will vary based on each individual practice based on the services performed (codes billed) and the location of the practice.
We’ve evaluated E/M services alone and found that Outpatient Office Visit E/M services are seeing a reduction in reimbursement nationwide when compared to 2022 rates. The San Francisco and Sacramento localities within California, as well as localities in Oregon and Idaho are seeing the lowest reduction in reimbursement rates for E/M services where localities in New York, Alaska, Washington DC, Nevada as well as the Santa Barbara and Santa Cruz localities in California are seeing more significant reduction in reimbursement rates for E/M services.
It is important that you understand the impact of these adjustments on your individual practices service mix.
E/M Service Documentation and Level Selection
In CY2022 we saw changes to E/M Services in the office related to the documentation required and method to level selection, promoting level setting with medical decision-making and complexity versus time and H&P. In CY2023 we see that similar adjustments now apply to Emergency Department, Hospital Observation, Hospital Inpatient, Nursing Facilities, Home or Residence Services and Cognitive Impairment E/M Services. Ensuring that your coding staff, whether internal or third party, have a clear understanding of the adjustments made to coding guidelines and, even more finite, adjustments made to the definitions associated with terminology within the guidelines is crucial. In the office space, providers should have made adjustments to documentation during CY2022 based on these guideline changes so that they are able to bill for the work they are performing!
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 has continued to work to gather data regarding these services and, as such, has now added 54 additional services to the Telehealth Services List on a Category III basis. This means these codes are guaranteed to remain active codes through at least 2023. CMS will continue to evaluate these services and propose adjustments as time goes on.
CMS also finalized the proposal to allow providers to continue to bill with the place of service code that would have been reported had the service been performed in person. These claims will require a 95 modifier to identify that they were telehealth services.
The Telehealth List of Services can be found at the following link: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
Improved Access to Behavioral Health Services
Previously auxiliary personnel, specifically LMFTs and LPCs, could perform behavioral and mental health services under DIRECT Supervision of a physician or non-physician practitioner. CMS has adjusted the supervision requirement to GENERAL supervision of a physician or non-physician practitioner in an effort to increase access to services. Additionally, CMS has indicated that they intend to address payment for new codes that describe caregiver behavioral management training in CY2024 rulemaking.
Colorectal Cancer Screenings
The Final Rule for CY2023 expands coverage for certain colorectal cancer screening tests by reducing the minimum age from 50 to 45.
Reimbursement for discarded portion of certain drugs (JW Modifier)
Prior to CY2023 Final Rule, CMS Claims were submitted for certain drugs (some J code some Q code) led with the used qty of the drug on one line and the discarded units of the drug on a second line with JW modifier. Both lines are reimbursed by Medicare (and are subject to coinsurance). Pharmaceutical companies then issued refunds to CMS based on the units billed with JW modifier. This was the best way to capture units that were discarded.
CMS noted 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 though. Medicare has previously paid 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.
Effective January 1, 2023, the JW modifier must be used to report the discarded portion of these certain drugs.
Effective July 1, 2023 the CY2023 Final Rule REQUIRES that a new modifier (JZ) be used on a line item indicating that zero units were discarded.
Ambulatory Surgery Centers
In the CY2023 Final Rule CMS has finalized an increase of 3.8% for ASC payment rates. This increase is consistent with their policy to update the ASC payment system using the hospital market basket update. Of note, CMS estimates that this increase will result in an approximate nationwide cumulative total of $5.3 billion in payments to ASC’s.
If you would like help understanding how these changes will impact your practice in 2023 call V2V Management Solutions for an analysis of the impacts to your practice financial position. Acting quickly will provide your practice the best opportunity to plan any operational changes needed to avoid negative impacts to your financial position.
V2V is committed to following CMS Physician Fee Schedule updates and assessing how these changes could impact your practice. Please reach out for a personalized analysis of the impact of the proposed final to your practice.
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Disclaimer: V2V Management Solutions is a healthcare consulting firm. We are not licensed attorney’s or certified public accountants. This guide is not intended to replace legal or financial advice from your trusted resources. Before acting on any information provided check with the appropriate legal or financial team. This situation is a constantly evolving landscape be sure to research for most current information.The following content consists of key takeaways on information published in the above referenced articles, facts sheets, and our personal/professional experiences in financial management throughout a crisis.