Last week, the Centers for Medicare & Medicaid Services (CMS) released the CY 2022 Medicare Physician Fee Schedule Proposed Rule. The rates for nursing home services (99304-99318) will see between a 3-5% decrease. With the proposed budget neutrality adjustment to account for changes in RVUs (required by law), and expiration of the 3.75% payment increase provided for CY 2021 by the Consolidated Appropriations Act, 2021 (CAA), the proposed CY 2022 PFS conversion factor is $33.58, a decrease of $1.31 from the CY 2021 PFS conversion factor of $34.89. The PFS conversion factor reflects the statutory update of 0.00% and the adjustment necessary to account for changes in relative value units and expenditures that would result from our proposed policies. The table below highlights the RVUs and percentage of change for the codes.
Nursing Facility Codes 2022 Proposed Rates
|
Code |
Total 2022 |
2022 Payment Rate |
Total 2021 |
2021 Payment Rate |
Percentage Change |
|
RVUs |
(CF=33.5848) |
RVUs |
(CF=34.8931) |
2020-2021 |
|
|
99304 |
2.59 |
$86.98 |
2.59 |
$90.37 |
-3.75% |
|
99305 |
3.72 |
$124.94 |
3.73 |
$130.15 |
-4.01% |
|
99306 |
4.76 |
$159.86 |
4.81 |
$167.84 |
-4.75% |
|
99307 |
1.29 |
$43.32 |
1.27 |
$44.31 |
-2.23% |
|
99308 |
2 |
$67.17 |
2.01 |
$70.14 |
-4.23% |
|
99309 |
2.65 |
$89.00 |
2.64 |
$92.12 |
-3% |
|
99310 |
3.91 |
$131.32 |
3.9 |
$136.08 |
-3.50% |
|
99315 |
2.09 |
$70.19 |
2.12 |
$73.97 |
-5.11% |
|
99316 |
2.99 |
$100.42 |
3.03 |
$105.73 |
-5.02% |
|
99318 |
2.75 |
$92.36 |
2.78 |
$97.00 |
-4.79% |
|
%= (new-old)/old |
Other proposals in the rule include:
Telehealth Services
- Nursing facility services initial visit codes (99304-06)—Remain temporarily on list of Medicare telehealth services list through the end of the Public Health Emergency (PHE). Once PHE ends, they will NOT be extended.
- Domiciliary or rest home (99324-28)—Temporarily on list of Medicare telehealth services list through the end of the PHE. Once the PHE ends, they will NOT be extended.
- Nursing facility subsequent care codes (99307-99310)—Permanently on list of Medicare telehealth services, During the PHE, the telehealth frequency limitation has been eliminated for these codes. However, once the PHE ends, the practitioner will again be restricted to billing the 99307-99310 codes to once per 14 days as was finalized in the CY2021 physician fee schedule.
CMS would like more time to collect more information regarding utilization of these services during the pandemic and provide stakeholders the opportunity to continue to develop support for the permanent addition of appropriate services to the telehealth list through CMS’ regular consideration process, which includes notice-and-comment rulemaking. CMS will facilitate the submission of requests to add nursing facility services to the permanent list of telehealth services in the CY 2023 PFS for consideration in the CY 2024 PFS rule.
Split (or Shared) E/M visits
CMS is proposing to modify its policy to allow physicians and NPPs to bill for split (or shared) visits for both new and established patients, and for critical care and certain Skilled Nursing Facility/Nursing Facility (SNF/NF) E/M visits. CMS is proposing these modifications to the current policy and conditions of payment for split (or shared) visits to account for changes that have occurred in medical practice patterns, including the evolving role of NPPs as part of the medical team.
CMS did note that under its current policy, no E/M services can be furnished and billed as split (or shared) visits in the SNF setting per the Conditions of Participation in 42 CFR 483.30 regarding the SNF/NF visits that are required to be performed in their entirety by a physician. That regulation requires that certain SNF/NF visits must be furnished directly and solely by a physician. If finalized, their split visit proposal would not apply to the SNF/NF visits that are required to be performed in their entirety by a physician; any SNF/NF visit that is required to be performed in its entirety by a physician cannot and would not be able to be billed as a split (or shared) visit. However, for other visits to which the regulation at § 483.30 does not apply, there is no requirement for a physician to directly and solely perform the visit. CMS proposes that those visits could be furnished and billed as split (or shared) visits.
Updates to Physician Self-Referral Regulations
CMS is proposing to revise the regulation to include as a potential indirect compensation arrangement any unbroken chain of financial relationships in which the compensation arrangement closest to the physician (or immediate family member of the physician) involves compensation for anything other than services that he or she personally performs. This would include arrangements for the rental of office space or equipment that meet the other conditions of the regulation at § 411.354(c)(2), which would be subject to, among other requirements, the prohibition on percentage-based and unit-based (often referred to as “per click”) compensation formulas at § 411.357(p)(1)(ii) in the exception for indirect compensation arrangements (or the requirements of another applicable exception).
Electronic Prescribing of Controlled Substances
CMS proposes to extend the compliance deadline for Part D controlled substance prescriptions written for beneficiaries in long-term care (LTC) facilities, excluding beneficiaries who are residents of nursing facilities and whose care is provided under Part A of the benefit, from January 1, 2022, to January 1, 2025. The intent of this extension is to strike a balance between being responsive to stakeholder concerns surrounding the increased implementation barriers faced by LTC facilities, while at the same time helping ensure that these facilities eventually implement electronic prescribing of controlled substances (EPCS).
Section 2003 of the SUPPORT Act requires EPCS for schedule II, III, IV, and V controlled substances covered through Medicare Part D. The statute provides the secretary with discretion on whether to grant waivers or exceptions to the EPCS requirement and specifies several types of exceptions that may be considered. It also gives the secretary authority to enforce non-compliance with the requirement and to specify appropriate penalties for non-compliance through rulemaking. In December 2020, CMS implemented the first phase of this mandate by naming the standard that prescribers must use for EPCS transmissions and delaying compliance actions until January 1, 2022.
In the PFS proposed rule, CMS is proposing to implement the second phase of this mandate by proposing certain exceptions to the EPCS requirement. The proposed exceptions would apply:
- Where the prescriber and dispensing pharmacy are the same entity
- For prescribers who issue 100 or fewer controlled substance prescriptions for Part D drugs per calendar year
- For prescribers who are in the geographic area of a natural disaster, or who are granted a waiver based on extraordinary circumstances, such as an influx of patients due to a pandemic
Vaccine Administration Services: Medicare Payments for Administering Preventive Vaccines
CMS is seeking feedback on how it should update the payment rate for administration of preventive vaccines (influenza, pneumococcal, HBV, and COVID-19) under Medicare Part B. The goal is to inform the development of more accurate rates for these services. More specifically, CMS is seeking information on:
- The different types of health care providers who furnish vaccines and how have those providers changed since the start of the pandemic
- How the costs of furnishing flu, pneumococcal, and hepatitis B vaccines compare to the costs of furnishing COVID-19 vaccines, and how costs may vary for different types of health care providers
- How the COVID-19 PHE may have impacted costs, and whether health care providers envision these costs to continue
CMS is also seeking stakeholder input on two other issues. First, input on the preliminary policy to pay $35 add-on for certain vulnerable beneficiaries when they receive a COVID-19 vaccine at home. CMS is interested in stakeholder input on what qualifies as the “home” and how it can balance ensuring program integrity with beneficiary access. CMS had previously established that SNSs and NFs were not to be considered “home.”
Second, as the market for COVID-19 monoclonal antibody products matures, CMS is also seeking comments on whether it should treat these products the same way CMS treats other physician-administered drugs and biologicals under Medicare Part B.
Quality Payment Program
For CY 2022, performance category percentages are:
- 30% for the quality performance category
- 30% for the cost performance category
- 15% for the improvement activities performance category
- 25% for the Promoting Interoperability performance category.
If an eligible clinician participates in an Advanced APM and achieves Qualifying APM Participant (QP) status, he or she is excluded from the MIPS reporting requirements and payment adjustment. Those that are qualifying APM participants (QPs) for the year receive a 5% lump sum incentive payment during the corresponding payment year through CY 2024, or a differential payment update under the PFS for payment years beginning in 2026.
Participation in the Quality Payment Program rose in the third year. CMS saw 99.99% of eligible clinicians participate in MIPS in 2019, with 954,614 MIPS eligible clinicians receiving a payment adjustment, which exceeded CMS’ 2018 participation rates. In addition, 97.6% of eligible clinicians participating in MIPS received a positive payment adjustment for 2021 based on 2019 performance year results. For performance in Advanced APMs for the 2019 QP Performance Period, 195,564 eligible clinicians earned Qualifying APM Participant (QP) status while another 27,995 eligible clinicians earned partial QP status.
CMS is issuing a request for information (RFI) on addressing the Advancing to Digital Quality Measurement and the Use of Fast Healthcare Interoperability Resources (FHIR) in Physician Quality Programs as well as a RFI to address Closing the Health Equity Gap in CMS Clinician Quality Programs.
CMS is proposing several MIPS Value Pathways (MVPs) proposals, including:
- To define who can report MVPs, through the term MVP Participant
- A delay to the CY 2023 MIPS performance period/CY 2025 MIPS payment year:
- MVP implementation and subgroup reporting timelines. Beginning in the CY 2025 MIPS performance period/CY 2027 MIPS payment year, multispecialty groups would be required to form subgroups in order to report MVPs.
- An introductory set of 7 MVPs to be available beginning with the 2023 performance period.
- MVP reporting requirements that account for the four MIPS performance categories.
- During the CY 2023 and CY 2024 performance periods, voluntary subgroup reporting within MIPS limited to reporting through MVPs or the APP.
The Society will continue to review the proposed Physician Fee Schedule and comment as needed.
Access the Notice of Proposed Rule Making for the 2022 Medicare Physician Payment Schedule.
Read CMS’ press release on the NPRM is available here.
Review the fact sheet summarizing the NPRM.