7 takeaways from the 2023 Medicare Physician Fee Schedule Final Rule
Medicare finalizes its annual physician fee update with several changes affecting optometry, yet physicians’ attention remains largely focused on sizable payment reductions looming.
On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) published its final rule that includes updates and policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, come Jan. 1, 2023. Broadly, the PFS reflects the administration’s effort to promote accessibility, quality, affordability, empowerment and innovation, while specifically, outlines policy changes that affect billing and coding, reimbursements and participants in the Merit-based Incentive Payment System (MIPS).
While the 2023 PFS final rule contains much of the feedback and recommendations shared by optometry’s advocates during a public comments period in July, the AOA continues to review and evaluate the final rule’s effect on optometry. Notably, the final rule heaps urgency in the waning days of this congressional session to avert ballooning cuts to Medicare physician payments slated for 2023.
Below, the AOA provides doctors of optometry seven takeaways from the 2023 Medicare PFS Final Rule.
Conversion factor decrease and reimbursement.The 2023 PFS finalized a $1.55 decrease in the conversion factor, resulting in a calendar year (CY) 2023 conversion factor of $33.06. This conversion factor also reflects the expiration of the temporary, offsetting 3% increase in payments for CY 2022 provided by the Protecting Medicare and American Farmers from Sequester Cuts Act, as well as the statutorily required budget neutrality adjustment to account for changes in payment rates.
The AOA had recommended that CMS engage specialty societies to discuss options for reducing regulatory burdens that drive up costs and to identify other options for doctors to mitigate the intense financial pressures that practices are facing.
In addition to the conversion factor decrease, further cuts could be coming to Medicare physicians’ pay in 2023 as automatic budget controls were tripped by Congress’ emergency COVID-19 spending. Already, reimbursements are reduced 2.75% due to the expiration of an AOA-backed fix that saw two 1% Medicare sequester cuts take effect in 2022.
Moreover, an at least 8% cut mandated by the federal Pay-As-You-Go statute, in addition to the expiring 3% PFS increase, could significantly affect doctors’ pay in 2023. Read more about how doctors can help advocate for immediate and lasting Medicare payment reform.
RUC value changes for ophthalmic procedures.The CMS accepted both the Relative Value Scale Update Committee (RUC)-recommended practice expense and work values for the orthoptics CPT code 92065, as well as the RUC-recommended practice expense and work values for the anterior segment imaging CPT code 99287.
Alternatively, the CMS rejected the RUC-recommended—and AOA endorsed—work value of 0.14 for the dark eye adaptation CPT code 92284. The CMS noted the code is typically reported with an evaluation and management (E/M) code and shared that the agency believes the technology has led to greater efficiencies in the service, necessitating a reduction in the work Relative Value Unit. The AOA anticipates that this reduction in work value will impact reimbursement significantly, with an average decrease of $12. The AOA will continue to work with the CMS to ensure reimbursement reflects the physician work involved.
Cataract surgery in the office setting.In the CMS’ proposed rule, the agency noted it had received requests to establish non-facility values for the cataract surgery codes and vitrectomy codes, as it had been suggested these procedures could be performed in the non-facility office setting safely and effectively. The AOA encouraged CMS to evaluate outcomes data on the success of surgeries in this setting before moving forward with a valuation.
In the final rule, the CMS expressed concerns about these services provided in non-facility settings and agreed to further evaluate before establishing any values.
Strategies for improving global surgical package valuation.In the CMS’ proposed rule, the AOA encouraged a continued reliance on the RUC process to assess the number of pre- and post-surgical visits included in a surgical package. The AOA noted that CMS should continue to use the information obtained through the work of the RUC Relativity Assessment Workgroup, which identifies potentially misvalued services with global periods. Additionally, the AOA said such efforts are better spent assessing specific codes of concern rather than making broad assumptions regarding the global surgery packages overall.
In the final rule, the CMS agreed to examine whether this specific model of postoperative care is still necessary or relevant for all procedures.
Payment for Medicare telehealth services.The CMS noted it will remove CPT codes 92002 and 92004 from the Medicare Telehealth Services List after 151 days following an end to the public health emergency (PHE) declaration, whereas CPT codes 92012 and 92014 will be included on the Medicare Telehealth Services list through the end of 2023.
MIPS registry active engagement.The CMS agreed with the AOA on the need to postpone requiring that MIPS-eligible clinicians spend one performance period at the Preproduction and Validation level of active engagement per measure, and that they should progress to the Validated Data Production level in the next performance period for which they report a particular measure. The CMS will delay this change until 2024.
MIPS specialty measure set.The CMS agreed with the AOA on adding “Optometry” to the title of the Ophthalmology specialty set to create a combined new specialty set, titled, “Ophthalmology/Optometry.”
Lastly, the CMS estimates that doctors of optometry will have total allowed charges of over $1.3 billion, whereas estimated allowed charges for 2022 amounted to $1.1 billion.
Contact Your Members of Congress
Congress needs to know that the statutory cuts threatening Medicare physicians’ pay are unacceptable. Access the AOA’s Action Center to connect directly with the aid of a pre-populated message expressing these concerns.
Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2023, the AOA continues to press for Congress to act on reforms that would give doctors of optometry an annual, permanent inflationary Medicare payment tied to the Medicare Economic Index.
The federal government and private payers are heavily scrutinizing the use of modifier -25. When used appropriately, it can help to ensure that patients receive appropriate treatment and that doctors of optometry are reimbursed appropriately for their service. If you believe a claim that includes modifier -25 was inappropriately denied, follow appropriate criteria when appealing.