CMS releases 2023 Medicare PFS proposed rule, seeks comments
Medicare physicians face continued uncertainty over statutory reductions as the proposed 2023 Physician Fee Schedule (PFS) outlines a flat payment update, while the AOA prepares comments on a range of policy changes affecting optometry next year.
On July 7, the Centers for Medicare & Medicaid Services (CMS) published its 2023 PFS proposed rule to announce and solicit public comments on policy changes for Medicare payments taking effect on or after Jan. 1, 2023. While the proposed PFS reflects a broader administration-wide strategy for accessibility, quality, affordability and innovation in a more equitable health care system, the policy proposals do include specific changes that would impact optometry, if finalized.
Therefore, the AOA will submit public comments on behalf of the profession for the below policy changes, as well as continue to advocate for Congress to avert an impending fiscal cliff that could see nearly 15% cuts to Medicare physician payments in 2023.
Conversion factor decrease
The 2023 PFS proposes a $1.52 decrease in the conversion factor, resulting in a calendar year (CY) 2023 conversion factor of $33.08. This represents a decrease of $1.52 to the 2022 conversion factor of $34.61.
The CMS explains the decreased conversion factor because of budget neutrality adjustments that require a statutory update of 0% to the CY 2023 conversion factor, as well as the expiration of the offsetting 3% increase in PFS payments for CY 2022. The latter was a provision the AOA fought for and won inclusion in the Protecting Medicare and American Farmers from Sequester Cuts Act at the end of 2021 to temporarily extend increased physician reimbursement due to pandemic-related expenses.
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.
Still outstanding are sizable reductions due to a ballooning scorecard mandated under the federal Pay-As-You-Go statute, now at least 8%, and the offsetting 3% PFS increase set to expire at year’s end that could affect doctors’ pay in 2023 without Congressional intervention. Congress needs to know that these impending cuts are unacceptable and any efforts to find a workable solution must fully value the care provided by doctors of optometry. Lawmakers also need to hear that simply stopping the cuts is not enough and that Congress must continue working with the AOA and other physician organizations to develop and enact lasting Medicare payment reform this year that ensures positive payment updates instead of annual threats of cuts.
Contact your lawmakers via the AOA Action Center. Reach out directly with the aid of a pre-populated message expressing concern over the statutory reductions to Medicare physicians’ pay. Or text “PAYMENT” to 855.465.5124 to access the Action Center on your mobile device.
Audiology, dental service changes
Significantly, the CMS proposes two policy changes that would have the effect of expanding beneficiaries’ access to audiology services, as well as clarifying coverage for select dental care services.
As for the former, the CMS proposes allowing beneficiaries to have direct access, where appropriate, to an audiologist without a physician referral by creating a new HCPCS code for audiologists to use when billing for audiology services they already provide that are defined by other codes. The services encompassed by the new HCPCS code would allow beneficiaries to receive care or examinations for the purposes of hearing aids. Whereas in the latter case, the CMS proposes covering some additional dental care only when a clinical scenario presents where dental services may be inextricably linked to the clinical success of other covered medical services.
The AOA notes that both policy changes reflect conversations broached during Congress’ 2021 efforts to expand traditional Medicare benefits to include new hearing, dental and vision coverage. Throughout that year-long process, the AOA repeatedly made clear to lawmakers that any proposal for vision coverage expansion must meet the AOA’s specific core principles or risk being an unworkable benefit for patients and their doctors. Specifically, the AOA successfully beat back vision discount plan attempts to highjack and wrest control of the new refraction and materials benefit lawmakers had envisioned.
“It’s notable that the fee schedule did not include any proposals that would have devalued eye health care services and potentially restricted patient access to doctors of optometry,” says William T. Reynolds, O.D., AOA Advocacy Committee chair. “The AOA continues to stand firm against misguided proposals that impose anti-doctor and anti-patient mandates on optometry practices.”
RUC value changes for ophthalmic procedures
The CMS indicates it will accept 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 rejects the RUC-recommended work value of 0.14 for the dark eye adaptation CPT code 92284. The CMS believes the work value was inaccurate as the procedure is usually completed during an evaluation and management (E/M) visit. Instead, the CMS proposed a physician work value of 0.00 for CPT code 92284, which is comparable to other “ophthalmic screening tests,” such as 99172. The AOA intends to fully address this issue as part of the public comment period on the 2023 PFS.
Cataract surgery in the office setting
The CMS reports it has received a request to establish non-facility values for the cataract surgery codes and vitrectomy codes, and it’s been suggested that these procedures can be properly performed in the non-facility office safely and effectively. Such is the case; the CMS seeks feedback on whether to pursue development of valuation of the cataract and vitrectomy codes in the non-facility setting.
MIPS registry engagement, specialty measure set
Within the 2023 PFS, the CMS proposes changes to the Merit-based Incentive Payment System (MIPS) program, including a registry participation requirement and adding “optometry” to the ophthalmology specialty set.
While CMS previously allowed doctors to meet their Promoting Interoperability (PI) requirement on registry engagement by simply enrolling with a registry, the CMS now proposes requiring doctors to demonstrate that they are moving toward full production of data to a registry from one year to the next. This proposal does create a challenge for some doctors of optometry and the AOA believes the sudden change is inconsistent with the lack of progress that has been achieved in sending data across a myriad of EHRs to registries.
Additionally, the CMS proposed adding “optometry” to the title of the ophthalmology specialty set to create a combined new specialty set: Ophthalmology/Optometry. While specialty measure sets are not required to be reported by MIPS-participating doctors, they can be helpful for doctors to more easily identify measures that can be reported.
The CMS proposes keeping CPT 92002 and 92004 on the Medicare Telehealth Covered Services List through 2023; however, the agency does not intend to permanently include these codes on the telehealth covered services list.
Further, the CMS indicates it does not plan to keep the telephone E/M codes on the Medicare Telehealth Services List after the end of the public health emergency (PHE) and the 151-day post-PHE extension period. The CMS plans to assign these telephone E/M visit codes (99441, 99442 and 99443) a “bundled” status after the end of the PHE and the 151-day extension period, and the CMS will post the RUC-recommended values for these codes.
2023 total allowed charges
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.
There will be a 60-day public comment period on this proposed rule that closes on Sept. 6, 2022. To share input or feedback into the AOA’s public comments for the proposed 2023 PFS, please contact firstname.lastname@example.org.
Have input or feedback? Contact the AOA
Your feedback and comments can help shape the AOA’s advocacy and public comments into the 2023 Medicare PFS. Send an email with your input to email@example.com.
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.