Physician Fee Schedule Final Rule for Calendar Year 2023

2023 conversion factor

$33.8872 (updated 1/5/2023)

• CMS continues to state it doesn’t have the authority to extend telehealth in all geographic locations after the PHE ends. Congress passed a law requiring Medicare to continue to pay for telehealth for 151 days after the PHE ends. This doesn’t require commercial payers to do the same.
• CMS tells us not to use POS 02 and POS 10 during the PHE. Continue to report the place of service that would have been reported if the patient was seen in person.

CMS is adopting most of the E/M CPT changes for 2023.

• However, when a patient is admitted from another site of service, CPT in 2023 now says to report both the first service (ED or office or nursing facility) and the initial hospital care code. CMS will not pay for both.
• CMS will continue its 8-24 hour policy for observation care.

Prolonged care coding is a mess.

• Not only are there two sets of codes: CPT and HCPCS codes, the time threshold for using them is different. Office visits have time ranges. For office visits, CPT allows us to use prolonged care when 15 minutes more than the lower of the time range. CMS requires the HCPCS code and only allows it when 15 minutes more than the higher of the time range.
• For inpatient, observation, and nursing facility prolonged care, CPT uses the times in the CPT book as the base for adding prolonged care. CMS is using the times in their internal time file and requires HCPCS codes.
• There is no CPT prolonged care code for home or residence services. CMS developed a HCPCS code.
• Need the details? Search for prolonged care in the search box for an article about this.

Split/shared visits

• Bill the service under the provider number of the practitioner who provided the substantive portion of the service.
• The substantive portion of the service may be determined by either who spent >50% of the time or the practitioner who documented in its entirety history, exam or MDM. Since history and exam are not key components, it is difficult to know what the “entirety” is.
• CMS had said that they would only use time in 2023, but they are allowing another “transition” year.

Critical care

• CMS is no longer applying the mid point rule to critical care for add-on code 99292. In order to use it, the full 30 minutes must be spent.

Screening for colorectal cancer

• This can now begin at age 45.
• If a patient has a positive screening stool test and is sent for colonoscopy, the colonoscopy can be reported and paid as screening, not diagnostic.

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Physician Fee Schedule Final Rule Archives (old news)

2022 Final Rule

2022 conversion factor—$34.6062

• Conversion factor decreased 3.75% from 2021 to 2022
• CMS posts complicated shared services rules for services performed in a facility
• Critical care updates
• CMS is developing a modifier for split/shared services and a new modifier for unrelated critical care by the surgeon in a global period, but did not release these modifiers in the Final Rule

Two new modifiers for 2021

FS  Split (or shared) Evaluation and Management service

• Use this for shared or split services between a physician and non-physician practitioner, including critical care

FT Unrelated Evaluation and Management (E/M) visit during a postoperative period, or on the same day as a procedure or another e/m visit. (report when an E/M visit is furnished within the global period but is unrelated, or when one or more additional E/M visits furnished on the same day are unrelated

• Use this for critical care performed by a surgeon during a global period. The critical care must be unrelated to the procedure/surgery done.
• The Final Rule also says the intensivist can use modifier FT (in addition to modifier 55) if there is a full transfer of care from the surgeon to the intensivist. Modifier 55 is for post operative management. It seems unlikely that a surgeon would fully transfer care to an intensivist for post op management.

November 6, 2021

CMS was right on time in releasing the 2022 Physician Fee Schedule Final Rule. It dropped November 2, 2021.

CMS stuck with their proposed conversion factor of $33.5983, a 3.75% decrease from last year and for anesthesia, the conversion factor is $20.9343, a 2.39% decrease. Last year, Congress stepped in the final hours of December and boosted the conversion factor. Certainly, the professional societies are advocating this, but who knows.

Shared or split services

Most of us were waiting to see what CMS was going to do about shared services for E/M services performed in an outpatient department, inpatient, or ED setting. CMS added nursing facility to the allowed setting for shared services. Shared services are E/M services performed jointly between a physician and a non-physician practitioner (NPP). Shared services are currently allowed in an office setting only if they service also meets incident-to requirements.

Starting in 2022, shared services will no longer be allowed in place of service office, even if they meet incident-to rules.

Shared services will be allowed for nursing facility services, except for those services that are mandated to be done by a physician.Only a physician may bill the initial nursing facility visits 99304-99306 in a skilled nursing facility or nursing facility.  (There is an exception to this in a nursing facility who is not employed by the facility). Sometimes, the PA/NP sees the patient at an earlier date than the physician, who comes and does the admission. In that case, the PA/NP bills a subsequent visit, even though the initial has not been billed. This is a Medicare rule.

Critical care may be billed as a shared visit between a physician and NPP, but must be reported by the practitioner who provides >50% of the time.

I wrote about shared or split visits (or share/split as the AMA labels them) for 2022 in more detail here.

Critical care

CMS had two proposals related to critical care. The first, mentioned above, is that a physician and NPP in a group may share critical care services. This is a change from their current policy. I’m going to call their new policy a win/lose situation.  Yes, you can add together the time of the physician and NPP (win) but you must bill it under the practitioner who has spent the most time (lose, if it’s an NPP, because it’s paid at 85% of the physician fee schedule.)

CMS has significantly changed its policies regarding critical care, and I will update CodingIntel’s critical care guide, webinar, quick video and the two articles about the topic.  But, here is the overview:

CMS is adopting CPT’s definitions and prefatory language for critical care services. Although CPT^® uses the term qualified health care professional, CMS continues to use the term non-physician practitioners. Both are describing advance practice registered nurses, clinical nurse specialists and physician assistants who are qualified to perform critical care in their state and organization. CMS says it is adopting the same list of bundled procedures as in the CPT book (old news, the same list was in their withdrawn manual portions.)

For services that cross midnight, CMS says it will follow the CPT^® rule in the introduction section that if the service is continuous past midnight, it does not reset at midnight and create a new hour. If there is a disruption, then when the service resumes after midnight, it starts a new hour.

CMS will now allow physicians/NPPs of different specialties to both provide critical care during the same time period. Their withdrawn manual section only allowed one practitioner to be paid for critical care at any one time.

Prior to 1/1/2022, one physician or NPP must have met the entire 74 minute time frame to bill 99291 before a second practitioner in the same group could report 99292 for an additional 30 minutes. So, if one pulmonologist spent 30 minutes and the second 50 minutes, the times could not be added together to report 99291 and 99292. Now, two practitioners of the same specialty can add together their time to meet 99291, and additional units of 99292.

Critical care may be shared between physicians and NPPs of the same specialty. Add together the time spent by each. Bill under the provider number of the practitioner who spent “a substantive portion” of the time, greater than 50%.

CMS will continue to allow an E/M service to be performed on the same day as critical care, if the E/M service occurred before the patient was critically ill, the patient later became ill later on the same calendar day. They removed the restriction that did not allow an ED visit and critical care to be billed on the same day by the same physician.

CMS will continue to allow surgeons to bill post-operative critical care that is unrelated to the surgery that was performed.

Check back to our critical care page for updates to all of the resources.

RHCs and FQHCs

Rural Health Centers (RHCs) are pain an All Inclusive Rate (AIR) for medically necessary medical and mental health services and qualified preventive services on the same day (with a few exceptions). Federally Qualified Health Centers (FQHCs) are paid using the Prospective Payment System (PPS rate) for qualified visits.

Beginning January 1, 2022, a patient on hospice may elect as their attending physician a practitioner from an RHC or FQHC. A patient who is currently enrolled in hospice may change the attending designation after January 1.

CMS is allowing TCM and CCM to be done in the same calendar month, following their rules from prior years for other physician practices.

After the public health emergency ends, telehealth and audio only telehealth will be continue to be allowed for mental health services.  This is because of the CARES Act passed in March, 2020.  I’ll update the article on telehealth and update the articles on behavioral health care with these new rules. They extend to RHCs and FQHCs.

Teaching physician rules

The ten pages of the rule related to billing for E/M services performed under the teaching physician rules didn’t provide any dramatic changes. CMS said:

• If using time to select an E/M service only the attending’s time (not the resident’s time) maybe included. This isn’t a change, but CMS clarified it is face-to-face time of the attending with the patient, and cannot include non-face-to-face activities or teaching.
• A commenter wanted CMS to use “provider-neutral” language instead of “teaching physician services” in order to include NPs and PAs who might spend time with residents. CMS said these clinicians are not included in the statutory definition of “physician.”
• For the primary care exception, only medical decision making can be used to select the level of E/M service.

Physician Final Rule 2021 (old news)

Conversion factor for 2021 released–updated

January 6, 2021

In a typical year, the conversion factor is released in the physician fee schedule, and that’s that. This year, Congress passed a stimulus bill/continuing resolution in early December that mandated changes to the conversion factor. These are described in the next section. The important news is that on January 5, CMS released the calendar year 2021 conversion factor and it is $34.89. This is a decrease from the 2020 rate, but an increase of about 7.7% from the factor released in CMS’s final rule.

Combined with the increase in RVUs and payments for office and outpatient codes 99202–99215, groups that receive most of their revenue from office visits will see their Medicare revenue increase. And, surgical and procedural specialties will see less of a decrease than anticipated.

This comes from Congress adding $3 billion to Part B payments in 2021, and from prohibiting implementation of payment for the add-on code G2211, for inherent complexity.

Breaking news 12/22/20: health care changes in the stimulus bill

The stimulus bill/continuing resolution that Congress signed in the dead of night on Dec. 21, the shortest day of the year, includes health care provisions that change policy in the 2021 Physician Fee Schedule Final Rule.

• Implementation of add-on code G2211 for inherent complexity is delayed for three years
• The money that would have gone to primary care and medical specialties for G2211 will now be spread across all specialties, all services and will increase the conversion factor
• RVUs for office/outpatient codes will remain at the increased level that CMS published for 2021
• There is $3 billion dollars in additional funding to support a 3.75% payment increase
• The President signed the bill on Dec. 27th.

Overview of the 2021 calendar year Physician Fee Schedule Final Rule

• The Final Rule included a significant decrease in the conversion factor; with the passage of the stimulus bill/continuing resolution on Dec. 22, Congress is mandating an increase, partially based on delaying implementation of G2211, and partially by increasing funds for Part B payments
• Confirmation about teaching physician rules updated earlier in the year

CMS released the Final Rule for calendar year 2021 late December 1^st. If you’re reading this, you probably have already heard the main point.  The Dec 22 law  As expected, CMS confirmed their agreement with the 2021 AMA definitions and rules for codes 99202—99215.

With the increase in payments for office visits, CMS is also increasing payments for certain other services which have office visits as a component, or whose values were based on its similarity to a specific E/M service. This includes some ESRD monthly payments, maternity care, transitional care management, wellness visits, psychiatric collaborative care management, and assessment of cognitive impairment. CMS did not increase the value of services with 10 or 90 day global periods, which also include office visits.

Delayed for three years by Congress: HCPCS code G2211: add-on code for office visits

G2211 “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).”

This replaces the HCPCS placeholder code GPC1X that CMS talked about in prior rules, and we now have a definition and instructions on when to use it. CMS believes that even with the increase in RVUs for office visit codes, that the payments still do not reflect the complexity and expense associated with caring for patients in a primary care practice and certain other specialties. The increased payment is for the resources associated with:

“a comprehensive, longitudinal, and continuous relationship with the patient and involves delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape.”[1]

CMS is not restricting its use to primary care, and specialists who care for a patient with a particular disease over a long period of time may also use it. It should not be used by professionals:

“whose relationship with the patient is of a discrete, routine, or time-limited nature, such as a mole removal or referral to a physician for removal of a mole; for treatment of a simple virus; for counseling related to seasonal allergies, initial onset gastroesophageal reflux disease; treatment for a fracture; and where comorbidities are either not present or not addressed, and/or and when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for subsequent, ongoing medical care for that particular patient with consistency and continuity over time.”[2]

Based on that description, it would appear that the code would not have wide use in urgent care

Learn more about HCPCS code G2211 in this article.

HCPCS code G2212: prolonged care code for 99205 and 99215

CMS and the American Medical Association (AMA) disagreed about the time threshold to use the new CPT^® prolonged services code 99417. The office and outpatient codes 99202—99205, and 99212—99215 now have time ranges, not a single threshold time. 99417 is for 15 additional minutes beyond the usual time for use only with codes 99205 and 99215. However, when the AMA calculated when to use the add-on code 99417, they started counting at the lower time in the range and CMS started counting at the higher time in the range. Since they couldn’t agree, and the CPT^® books are already on our shelves, CMS developed a HCPCS code for prolonged care of 15 minutes over the maximum threshold time. Like 99417, it may only be reported with 99205 or 99215. Use G2212 and 99205 when 89 minutes were spent caring for the patient on the date of service (practitioner time only, direct care and non-face-to-face time). Use G2212 and 99215 when 69 minutes were spent.

HCPCS codes for virtual communication for clinicians who can’t bill E/M services

G2250, G2251

G2250 (Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment.)

G2251 (Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion).

CMS developed these two new codes that are equivalent to existing HCPCS codes G2012 and G2010, for brief virtual communication and “store and forward” services done by physicians, advance practice registered nurses and physician assistants, clinicians who can bill for E/M services. CMS developed these similar codes G2250 and G2251 for social workers, psychologists, physical therapists (PT), occupational therapists (OT) and speech language pathologists (SLP). They may not be used by audiologists, because CMS believes that they are outside the benefit category for audiologists, and they may not be billed by for medical nutrition therapy.

In addition, HCPCS codes G2061—G2063 are replaced by CPT^® codes 98970—98972. These are on-line assessment codes for use by clinicians without E/M in their scope of practice. For PT, OT, and SLP services these are considered to be sometimes therapy codes and require modifier GO, GP or GN to signify that they are furnished as therapy services under a plan of care.

HCPCS code for virtual check in 11-20 minutes

G2252 (Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.)

This code has similar rules as G0210 and G2012, and is for longer time periods. When phone calls are no longer paid services after the end of the PHE, it could be used for phone calls.

Telehealth update

The rule includes a long section on telehealth, but isn’t likely to make anyone happy. CMS re-iterates its belief that it lacks statutory authority to continue the relaxed telehealth rules when the public health emergency is over. Specifically, during the PHE, CMS relaxed the requirement that the patient be in an underserved area, and must receive the telehealth service at a facility, an originating site. CMS believes that after the PHE ends, Congress must pass a law to allow telehealth to continue in its current form, to patients in any geographic area, from their home.

In multiple places in the rule, CMS confirms that when they say “real-time audio/visual communication” they require the use of both audio and visual technology, not audio only.  This is mentioned in relation to incident to supervision and the teaching physician rules. If you search (excluding audio-only) in the rule, you’ll get quite a few results.

CMS is not proposing to continue paying for audio only calls (phone calls) 99441—99443 after the end of the PHE (the end of the calendar year in which the PHE ends.) These codes will once again have a status indicator of bundled.

If both the patient and practitioner are in the same location, but using video equipment, CMS re-iterated their policy that this should not be reported as telehealth.

Teaching physician rules

CMS is allowing an attending to be present via real-time audio/visual communication in supervising an E/M service provided by a resident. The teaching physician must be present for the key/critical components using audio/visual communication. Phone is insufficient.  Notice what they say about documentation. CMS states that the patient’s medical record:

 “must clearly reflect how and when the teaching physician was present during the key portions of the service, in accordance with our regulations.”[3]

And, they have advice about what to do it the video call with the attending drops.

“We also expect that, if the teaching physician is virtually present and bills for services during which there is a disruption to the virtual connection between the teaching physician and the resident who is with the patient, the encounter would be paused until the connection resumes, or the appointment would be rescheduled.”[4]

CMS confirmed that under the primary care exception, the attending may supervise the service using audio/visual communication during the public health emergency.

The rule is about 2000 pages long, and I’m providing this first look summary. I’ll add information to relevant articles as I’m completing the 2021 site updates.

CMS developed a new prolonged services code: G2212 

Read about it in detail here: Prolonged services in 2021 with 99202–99215: 99417, G2212

 

Source citations

[1] 2021 Calendar Year Physician Fee Schedule Final Rule, page 275

[2] Final Rule, page 279

[3] Final rule, p. 320

[4] Final rule, p. 310

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Previous years

For reference, we have included archives of previous year’s changes below.

2020 Physician Fee Schedule Final Rule

Summarized in this handout

2019 Physician Fee Schedule Final Rule

The 2019 Physician Final Rule was released right on time on November 1, 2018. By now, you’ve heard the news that CMS is not implementing its major change to a single blended rate for E/M levels 2-5 in 2019. I won’t repeat what you’ve already read in detail other places, but here are the highlights, and my thoughts.

Things CMS didn’t do:

• CMS did not finalize multiple procedure payment reduction for modifier -25. The proposal was to pay at 50% the lowest valued procedure when two procedures were reported and modifier 25 was on the claim. CMS did not finalize this. Both will continue to be paid at the full allowance. CMS did comment that they believe that there is an overlap in paying for an E/M and some minor procedures, because some of the work overlaps. (Rooming the patient, reviewing the patient’s history, instructions for care) This is good news for many specialties.
• CMS did not finalize a proposal that would allow two visits by physicians of the same specialty in one calendar day.
• And they didn’t change the codes used by Podiatrists. Podiatrists will continue to use E/M codes.

Postponed until 2021

• CMS is not implementing a single payment and single RVU value for levels 2-5 E/M codes. They say they will implement a changed version in 2021, which would pay one fee for level one patients, one fee for levels 2-4 and one fee for level 5 visits. (Varied by new or established patients). They did note that the AMA is working on changes.

“A delayed implementation date for our documentation proposals would also allow the AMA time to develop changes to the CPT^® coding definitions and guidance prior to our implementation, such as changes to MDM or code definitions that we could then consider for adoption.” (page 633 of the rule)

So, although CMS says that these E/M changes are finalized, if the AMA can make changes CMS finds acceptable, it is possible these would not go into effect. The difficulty is getting all of the specialties to agree.

• The two add-on codes for primary care and selected specialty services. CMS has developed the code description for these, and valued them, but is not implementing these until 2021. The rule didn’t say how this would be funded, and keep in mind that these type of changes need to be budget neutral to CMS.  CMS had planned on using the savings from the reduced payments for modifier 25.  CMS did add specialties that could report the inherent complexity E/M code, and say that both the primary care and specialty  codes could be used on the same claim, if a primary care provider was addressing a complex, specialty diagnosis. Let’s not spend too much time on how this would work until closer to 2021. They changed the valuation of these two codes to be the same, rather than having a lower value for the primary care service.
• The new prolonged services HCPCS code (30 minutes) is postponed until 2021.

Finalized proposals

• There is a new CPT^® code for chronic care management performed by the physician, NP or PA, 99491, and CMS is making this a payable code. (Why are the care management codes so difficult to find in the CPT^® book, and why don’t I put a tab on them?)
• CMS is recognizing the four existing and two new inter-professional consultation codes, 99446-99452. These look like a nightmare to me to document and bill, and for not much money.
• Using HCPCS codes, CMS will pay for a brief, virtual check-in (G2012) and for the provider looking at a pre-recorded image or video, “store and forward” (G2010). The wRVUs are low. G2012 could be billed only by clinicians who have E/M in their scope of practice for established patient visits. It could not be a result of an office visit in the past 7 days or result in an office visit in the next 24 hours, or next available appointment. Does a phone call count? Here’s what the rule says.

“We are persuaded by the comments advising us not to be overly prescriptive about the technology that is used, and are finalizing allowing audio-only real-time telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission. We note that telephone calls that involve only clinical staff could not be billed using HCPCS code G2012 since the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.”(Page 111 of the rule)  

As for the pre-recorded picture or video (please, no cat videos) this is a service that is used to determine if an office visit is needed. If it results in an office visit, then it is considered bundled and may not be billed. It may not be billed if the patient was seen in the last 7 days. It is for established patients only.

Changes to E/M: changes to reduce redundancy and provider burden

• The billing provider does not have to personally document the chief complaint or the HPI. Ancillary staff may record this, or it could be recorded on a form by the patient. The billing provider can note that it was reviewed and verified.
• For established patients, the provider does not need to re-enter information already in the record, as long as it is noted as reviewed and unchanged, or reviewed and updated. The provider may choose to focus on what has changed since the last visit, or on pertinent items that have not changed and need not re-record the required elements. The practitioner should still review prior data, update if needed and indicate that this was done.
• Removal of duplicative requirements for notations when services are furnished with a resident.
• For home visits, the medical necessity for the home visit does not need to be stated in the note.

 

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