CMS’ 2022 Medicare PFS decreases conversion factor, sets new policy goals
Medicare physicians’ payments still hang in the balance without Congressional action as the 2022 Physician Fee Schedule (PFS) finalizes cuts and other program changes that affect optometry in the new year.
On Nov. 2, the Centers for Medicare & Medicaid Services (CMS) published a final rule that updates policy changes for Medicare payments under the PFS for the calendar year (CY) 2022, reflecting a broader administration-wide strategy for accessibility, quality, affordability, empowerment and innovation, the agency says. The final rule, taking effect Jan. 1, 2022, does reflect the AOA’s advocacy during the rulemaking process on a range of issues, spanning updates to billing and coding, Merit-based Incentive Payment System (MIPS) categories, the much-maligned, rate-setting and conversion factor, and much more.
Conversion factor, payment decreases
In July, CMS issued its proposed policy changes with a conversion factor decrease of $1.30 over the CY 2021 conversion factor, bringing the CY 2022 conversion factor to $33.59. The decrease is on account of the budget neutrality adjustment for changes in relative value units (RVUs) and expiration of the temporary, 3.75% payment increase provided for in the Consolidated Appropriations Act 2021 to offset scheduled PFS cuts.
Such is the case, Medicare physicians now stand to see a nearly 10% decrease in 2022 reimbursement due to a perfect storm of payment reductions—the original 3.75% PFS cut, a 2% cut for Medicare sequestration and a 4% Statutory Pay-As-You-Go (PAYGO) cut triggered by federal pandemic spending.
While the AOA raised concerns with the conversion factor and potential impact on reimbursement during the PFS rulemaking, ultimately, it’s Congress that has the power to address this issue and CMS noted the agency is bound by statute to make these adjustments.
The AOA and optometry’s advocates are calling on Congress to waive the Statutory PAYGO implications, as well as extend the temporary 3.75% payment adjustment through at least 2022. As recently as Oct. 14, a U.S. House-led letter to congressional leaders had urged an immediate remedy for these impending cuts. But more support is needed to ensure congressional action to prevent these cuts, and here’s how:
- Visit the AOA’s Action Center to urge your members of Congress to immediately address all three Medicare payment cuts now targeting physicians. Or text “PAYMENT” to 855.465.5124 to access the Action Center.
Communication Technology-Based Services (CTBS)
The AOA supported—and CMS finalized—a proposal to permanently establish separate coding and payment for the longer virtual check-in service described by Healthcare Common Procedure Coding System (HCPCS) code G2252. The CMS agreed to work with the Current Procedural Terminology (CPT) and Specialty Society Relative Value Scale Update Committee (RUC) to value the service, using the value of CPT code 99442 as a crosswalk to the G code with national pricing for 99442 at $92.82.
Evaluation and management (E/M) visits
Beginning in 2023, the CMS will implement a policy wherein the physician or practitioner who spent more than half the total time will bill for the primary E/M visit and the prolonged service code(s) when the service is furnished as a split (shared) visit, if all other requirements to bill for the services are met. The physician and non-physician practitioner will add their time together, and whomever furnished more than half of the total time, including prolonged time, will report both the primary service code and the prolonged services add-on code(s), assuming the time threshold for reporting prolonged services is met. Notably, this is only for E/M services performed in a facility setting and not a physician’s office.
Telehealth eye exam
As the CMS continues to evaluate the inclusion of telehealth services that were temporarily added during the COVID-19 public health emergency, the agency finalized certain services added to the Medicare telehealth services list through Dec. 31, 2023. The AOA raised concerns with the inclusion of the eye exam codes on the telehealth covered services list, yet CMS did not address these codes. However, it did note that all services on the current telehealth covered services list would remain until 2023.
Medicare Diabetes Prevention Program (MDPP) expanded model
The CMS announced steps to improve its MDPP expanded model permitting local suppliers to provide Centers for Disease Control and Prevention (CDC)-approved curriculum for training in dietary change, increase physical activity and weight-loss strategies. The AOA supported bringing the MDPP expanded model into full alignment with the CDC’s National DPP, including:
- Eligibility to participate
- A screening standard FPG range (100-125 mg/dl)
- The use of A1c test results to establish a diagnosis of prediabetes
- Same choices of delivery modality, including online and distance-learning modalities
The CMS agreed to waive the Medicare enrollment fee for all organizations that apply to enroll as an MDPP supplier on or after Jan. 1, 2022. Additionally, the CMS shortened the MDPP services period to the one-year model instead of the current two-year model, making delivery of MDPP services more sustainable, reduce the administrative burden and costs to suppliers, and improve patient access by making it easier for local suppliers to participate and reach their communities. Finally, the CMS notes it will restructure payments, so MDPP suppliers receive larger payments for participants who reach milestones for attendance.
Quality Payment Program (QPP) changes
The final rule also proposed several changes to QPP measures that the AOA provided feedback on during rulemaking, including:
- MIPS Value Pathways (MVPs). The CMS agreed with the AOA and delayed MVPs until 2023, beginning with an initial set of MVPs.
- Quality measure benchmarks. Instead of using benchmarks for the CY 2022 performance period/2024 MIPS payment year based on the actual data submitted during the CY 2022 performance period, the CMS agreed with the AOA and opted to use data from the CY 2020 performance period/2022 MIPS payment year and will allow clinicians advanced notice of performance targets to aid in measure selection and help clinicians to work toward improvement on quality measures.
- Promoting Interoperability (PI) category. While the AOA advocated for an exemption for the new objective requiring an annual self-assessment of the high priority practices listed in the Office of the National Coordinator for Health IT (ONC’s) SAFER Guides, the CMS noted this measure will be required—just not scored—in the CY 2022 performance period/CY 2024 MIPS payment year.
- Quality Measure Reporting via Claims: The Age-Related Macular Degeneration (AMD): Dilated Macular Examination quality measure (measure 14) will no longer be allowed to be reported via Part B claims in 2022.
Diabetes eye exam quality measure revision
Significantly, the CMS finalized a change to the measure numerator for the diabetes eye exam quality measure. This revision opens the possibility of artificial intelligence interpretation of fundus photography results. While the AOA raised concerns with this approach, the CMS suggested the AOA work with the quality measure developer to further refine the measure. The AOA continues to advocate on this issue.
2022 total allowed charges
Lastly, the CMS estimates that doctors of optometry will have total allowed charges of $1.38 billion in 2022, as compared to $1.33 billion in 2020 and $1.30 billion in 2019.
Changes in coding and reimbursements worth knowing. Meanwhile, with the clock winding down on 2024, 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.