Head Off 2022 Medicare Physician Fee Schedule Change Errors

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Head Off 2022 Medicare Physician Fee Schedule Change Errors

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Medicare physician fee schedule

The November 3rd release of CMS’ 2022 Medicare Physician Fee Schedule (PFS) is chock full of changes that have the potential to significantly modify how you bill and receive payment next year.

Unfortunately, one of the most disappointing changes is that Congress has decided not to renew the additional 3.75% conversion factor rate added during the pandemic. As a result, next year’s new rate will be $33.59 (a reduction of $1.30 from 2021’s base rate).

The overall reduction in Medicare’s conversion factor from last year is approximately 3.85%, but this is only the beginning. The American Medical Association (AMA) warns that the reduction could be as high as 10% for some outpatient practices when you take all changes into account. The Association hopes that Congress will intervene and help avoid this steep reduction to already strapped physician practices across the country.

Here is a summary of the changes that are most likely to affect your practice:

1. Tele-Mental Health: Medicare physician fee schedule.

a. Geographic Barriers: Removal of geographic barriers for the “diagnosis, evaluation, or treatment” of mental health issues.
b. Home Sites: Patients will be allowed to attend telehealth appointments from their homes for the “diagnosis, evaluation, or treatment” of mental health issues. The previous rule did not include the home as a qualified healthcare site.
c. In-Person Timetable: Medicare physician fee schedule.

i. Your provider must see patients for an “in-person, non-telehealth service” at least six months before their initial telehealth visit.
ii. Your office must also establish a regular in-person meeting schedule for subsequent appointments.
iii. At a minimum, you must see your telehealth patients in person at least once every year. You can make an exception to the timing of your in-person visits based on patient circumstances.
iv. If you do not adhere to the above in-person timetable, you are required to clearly document the reason for the change.
v. You can meet in person with patients more often than this schedule based on patient care needs.

d. Audio-Only: The addition of a new modifier will authorize payment for audio-only communications. The modifier will indicate to Medicare that although you have the ability to provide two-way audio and video communications with a patient, your patient made the decision to receive audio-only services.

2. Vaccine Administration: Medicare physician fee schedule.

a. You will receive $30 per dose for the administration of influenza, pneumococcal, and hepatitis B vaccines.
b. COVID-19 vaccine administration will continue to be reimbursed at $40 per dose “through the end of the calendar year in which the ongoing” Public Health Emergency (PHE)
c. If you administer the COVID vaccine to patients in their homes, under specific circumstances, you will continue to receive the additional payment of $35.50 per dose. Once the PHE ends, you will still be eligible to receive this additional reimbursement through the end of that year.

3. COVID Monoclonal Antibody treatments: Medicare reimbursement for these services is effective through the end of the year in which the PHE ends based on the following criteria:

a. When provided in a healthcare setting, Medicare will reimburse you $450 for these treatments.
b. If you provide treatment in patient homes, Medicare will pay $750 for the treatment.

4. Split-Shared Services:

a. Determining/Reporting Services:

i. To be considered a split-shared service, an evaluation and management (E/M) service must be provided in a facility by both a physician and NPP from the same group.
ii. New and established patients, initial and subsequent visits and prolonged services can be billed as split-shared services.
iii. The clinician that provides a “substantive portion of the visit” should bill for the E/M service based on the following criteria by year:

– 2022 – The history, physical exam, medical decision-making, or more than half of the total time. The exception is critical care services, which can only be more than half of the total time.
– 2023 – More than 50% of the total time spent.

iv. New and established patients, initial and subsequent visits and prolonged services can be billed as split-shared services.
v. There will be a specific modifier that identifies split-shared services for billing.

b. PT/OT Assistants: The new CQ and CO modifiers allow physical therapy and occupational therapy assistants to bill for evaluation and management (E/M) services that qualify at 85% of the amount that physical and occupational therapists receive. The dates of service must be after January 1, 2022, and a physical or occupational therapist must supervise the services.
c. Critical Care Services: Effective in 2022, you can receive payment for critical care split-shared services.

5. Physician Assistants (PAs): Effective January 1, 2022, PAs will be authorized to receive payments directly from Medicare for the services they provide (previously, PAs were only eligible to receive payment to an employer or independent contractor). PAs will also be allowed to reassign their reimbursement and “incorporate with other PAs and bill Medicare.”

6. Critical Care Services: Medicare physician fee schedule. 

a. Concurrent Care: Critical care services can be provided to “the same patient on the same day by more than one practitioner representing more than one specialty.”
b. Modifier: You will be required to utilize a new modifier to identify unrelated critical care services, but they must be considered medically necessary.
c. E/M Services: You can receive reimbursement for critical care services provided on the “same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty….” To be reimbursed for these services, you must adhere to three criteria and report modifier 25 when submitting your claim:

i. Your provider must document that the “E/M visit was provided prior to the critical care service at a time when the patient did not require critical care.”
ii. The services provided must be medically necessary.
iii. Your documentation must clearly indicate that the “services are separate and distinct, with no duplicative elements from the critical care service provided later in the day.”

d. Global Surgical Period: When the critical care services you provide are not related to a performed surgical procedure, Medicare will reimburse you separately even within the global surgical period.
e. Pre- and/or postoperative critically ill patients: You can receive reimbursement for critical care services in addition to a procedure during the following situations:

i. The patient must meet the definition of critical care,
ii. The care of the patient must require the “full attention of the physician,” and
iii. The critical care service provided “is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases).”

f. Transfer of Care: Reimbursement will also be authorized when a patient’s care is “fully transferred from the surgeon to an intensivist (and the critical care is unrelated).” Your claim must include the appropriate modifiers, and your documentation must clearly indicate a transfer of care to be eligible for reimbursement.

7. Teaching Physician Services: Medicare physician fee schedule.

a. Primary Care Exception: In specific primary care centers owned by teaching hospitals, the teaching physician will be authorized to bill for specified services separately provided by the resident (even when the teaching physician is not physically present). The only additional stipulation is that the teaching physician must review the care provided.
b. E/M Services: When residents are involved in providing E/M services, only the “time spent by the teaching physician in qualifying activities, including time that the teaching physician was present with the resident performing those activities, can be included for purposes of visit level selection.
c. Primary Care Exception: You may not utilize time to select your E/M level when the primary care exception applies. In these instances, you are only allowed to use medical decision-making when choosing the E/M level.

Note: If you want to read the entire rule, you can access the Federal Register posting of the official announcement of the 2022 Medicare Physician Fee Schedule (PFS) changes and review CMS’ overview online. Also, keep an eye out for the posting of Healthcare Training Leaders upcoming online training that will help you incorporate these new changes accurately the first time.


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