Medicare Physician Fee Schedule (MPFS) Final Rule for CY 2022

Medicare Physician Fee Schedule Final Rule for CY 2022

CMS released a final rule for the Medicare Physician Fee Schedule (MPFS) on November 2, 2021. It takes effect on January 1, 2022.

The rule includes a notice of the CY 2022 PFS conversion factor of $33.59, a decrease of $1.30 from the CY 2021 conversion factor. This adjustment is necessary to account for changes in relative value units and expenditures included in the finalized policies and to maintain budget neutrality.

CMS released a fact sheet that details this and other changes to the Medicare physician fee schedule for 2022. We discuss some of the highlights below.

Evaluation and Management (E/M) Visits

CMS has updated its rules on E/M services. This includes details on the policies for split or shared E/M visits for physicians and non-physician practitioners (NPPs). These changes reflect the evolving role of NPPs as members of the health care team, as well as clarifying conditions for payment for the E/M services. The practitioner who provides the substantive portion of the service shall be responsible for billing the visit. For 2022, the substantive portion of the visit can be history, physical exam, medical decision making, or more than half the total time (other than critical care). By 2023, CMS will define the substantive portion of the visit as more than half the total time spent.

In addition, split or shared services can be reported for both new and established patients and for initial and subsequent visits as well as prolonged services. CMS will require a modifier on these claims to identify the split/shared services. Furthermore, documentation must identify the two individuals who completed the visit. The individual providing the substantive portion must sign and date the medical record.

The rule also includes additional information on payment for critical care services. CMS will allow for payment of these services during the postoperative period for conditions unrelated to the surgical procedure. The rule also includes clarification of provisions for office/other outpatient services furnished by a resident in a teaching setting.

Telehealth Services

CMS finalized that certain services added to the Medicare telehealth services during the COVID-19 PHE will remain on the list through December 31, 2023. Prior to this announcement, CMS had scheduled the provisions to expire on either December 31, 2021, or the end of the PHE. CMS also extended certain cardiac and intensive cardiac rehabilitation codes. This will allow sufficient time for CMS to determine if these services should remain permanently on the Medicare telehealth services list, as well as reduce uncertainty of the timing for the potential removal of these services from the list. CMS shall adopt coding and payment for a longer virtual check-in service on a permanent basis.

CMS shall also amend the definition of interactive communication. The new definition will allow for audio-only communications services for mental health treatment telehealth for established patients in their homes under certain circumstances. CMS established limits or these mental health services. Namely, the rule applies for cases where the practitioner has the capability to provide the two-way audio/video communication, but the beneficiary either does not have the capability for these types of communications, or chooses not to use the technology and instead uses audio-only communication. CMS will require a new modifier for the audio-only service.

We’ve discussed previously the coding procedure for telehealth and other services that were impacted by the COVID-19 PHE. You can find out more about that here.

Additional Medicare Physician Fee Schedule 2022 Updates

The two additional modifiers related to Telehealth Services, specifically telehealth mental services, are: FQ = A telehealth service was furnished using real-time audio-only communication technology; and FR = A supervising practitioner was present through a real-time two-way, audio/video communication technology (Updated 1/21/22).

The 2022 MPFS also establishes code Q3014 Medicare Telehealth Originating Site Facility Fee with the MEI adjustment as $27.59. Intensive Cardiac Rehabilitation (ICR) codes G0422 and G0423, and Cardiac Rehabilitation (CR) codes 93797 and 93798, have been assigned as Category III codes on the 2022 PFS List of Telehealth Services (CMS, 2022). They will be available up through December 31, 2023.

CMS notes a change in the POS code 02 and 10 in the healthcare insurance industry. However, CMS telehealth claims will continue to recognize the previous POS 02 code as “Telehealth: The location where health services and health related services are provided or received, through a telecommunication system (Effective January 1, 2017)” (CMS). Currently, any POS reference to the “Telehealth and the Patient’s Home” will be disregarded. For instructions, refer to CR 12427 NEW/MODIFICATIONS TO THE PLACE OF SERVICE (POS) CODES FOR TELEHEALTH.

Vaccine Administration Services

CMS will pay $30 a dose for administration of influenza, pneumococcal and hepatitis B virus vaccines. This is in addition to continuing the $40 payment per dose for COVID-19 vaccinations. This payment rate will remain through the calendar year in which the PHE ends; after this point, the payment rate will align with that of administration of other Part B vaccines. CMS will extend the additional $35.50 payment for COVID-19 vaccine administration in the home in certain circumstances through the end of the calendar year in which the PHE ends. This deadline will also apply for the $450 rate for administering a COVID-19 monoclonal antibody in a health care setting. CMS is also including the $750 rate for this therapy provided in the home in the rule.

We already put out an article on how to do medical coding for COVID-19 vaccines. You can find all the information you need here.

Other Provisions

Many more details are included in the 2400+ page final rule. Other provisions cover services provided by occupational and physical therapy assistants identified with a new modifier, as well as direct payment for physician assistant services for selected services, payment for Part B drugs, and more. The rule will be published in the November 19, 2021 Federal Register. A review of the entire text can be located here.