CMS Releases Physician Fee Schedule Final Rule

November 4, 2022
Policy Snapshot

Last week, the Centers for Medicare & Medicaid Services (CMS) released the CY 2023 Physician Fee Schedule (PFS) Final Rule, which included an overall cut to the payments rates; however, nursing facility codes valuation was increased.

With the budget neutrality adjustments, which are required by law to ensure payment rates for individual services don’t result in changes to estimated Medicare spending, the required statutory update to the conversion factor for CY 2023 is 0%, and the expiration of the 3% supplemental increase to PFS payments for CY 2022; that means the final CY 2023 PFS conversion factor is $33.06, a decrease of $1.55 to the CY 2022 PFS conversion factor of $34.61, approximately a 4.5% cut.

As part of the ongoing updates to E/M visit codes and related coding guidelines that are intended to reduce administrative burden, the AMA CPT Editorial Panel approved revised coding and updated guidelines for Other E/M visits, effective January 1, 2023. Similar to the approach CMS finalized in the CY 2021 PFS final rule for office/outpatient E/M visit coding and documentation, CMS finalized and adopted most of these AMA CPT changes in coding and documentation for Other E/M visits (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment) effective January 1, 2023. This revised coding and documentation framework includes CPT code definition changes (revisions to the Other E/M code descriptors), including:

  • New descriptor times (where relevant)
  • Revised interpretive guidelines for levels of medical decision-making
  • Choice of medical decision-making or time to select code level (except for a few areas like emergency department visits and cognitive impairment assessments, which are not timed services)
  • Eliminated use of history and exam to determine code level (instead there would be a requirement for a medically appropriate history and exam)

Nursing Facility Visits (Codes 99304-99318)

CMS finalized changes in coding and values for the proposed revised Nursing Facility Visits E/M code set. This code set is effective beginning in CY 2023, and the proposed values will go into effect with those codes as of January 1, 2023. CMS finalized when total time on the date of encounter is used to select the appropriate level of a nursing facility visit service code, both the face-to-face and non-face-to-face time personally spent by the physician (or other qualified health-care professional that is reporting the office visit) assessing and managing the patient are summed to select the appropriate code to bill.

Additionally, the codes have new descriptor times, assigned for when time is used to select visit level. (CMS notes that they are not adopting the CPT Codebook instructions regarding the application of prolonged codes to CPT codes 99306 and 99310; see additional discussion under the subsection “Prolonged Codes for NF Care.”)

Finalized Billing Policies:

  • Initial comprehensive assessment required under 42 CFR 483.30(c)(4) will be billed as an initial NF visit (CPT code 99304 through 99306). A practitioner may bill the most appropriate initial nursing facility care code (CPT codes 99304 through 99306) or subsequent nursing facility care code (CPT codes 99307 through 99310), if the practitioner furnishes services that meet the code descriptor requirements, even if the service is furnished prior to the initial comprehensive assessment.
  • A given practitioner cannot bill an initial NF visit and another E/M visit (such as an O/O visit or ED visit) on the same date of service, for the same patient. However, the time the practitioner spends furnishing a visit in another setting can be counted toward reporting prolonged NF services, if requirements for reporting prolonged NF serves are met.
  • CMS is adopting the CPT instruction for reporting initial nursing facility care, which provides that transitions between SNF level of care and nursing facility level of care do not constitute a new stay.
  • An initial service is one that occurs when the patient has not received any professional services from the physician or other qualified health-care professional or another physician or other qualified health-care professional of the exact same specialty who belongs to the same group during the stay. A subsequent service is one that occurs when the patient has received any professional services from the physician or other qualified health-care professional or another physician or other qualified health-care professional of the exact same specialty who belongs to the same group during the stay.
  • CPT codes 99315 and 99316 (Discharge Management) are reported for a face-to-face visit with the patient provided by the physician or the qualified NPP, which is required in order to report the SNF/NF discharge day management service. The NF discharge day management visit shall be reported for the date of the actual visit by the physician or qualified NPP, even if the patient is discharged from the facility on a different calendar date. (Refer to Medicare Claims Processing Manual, IOM 100-04, Chapter 12, 30.6.13.I.) Additionally, a physician or qualified NPP may report CPT codes 99315 or 99316 for a patient who has expired only if the physician or qualified NPP personally performed the death pronouncement.
  • Prolonged services will not be reportable in conjunction with CPT codes 99315 and 99316 (NF discharge day management).

Valuation of NF Codes:

For codes 99304-99310, CMS is finalizing the RUC-recommended work RVUs for all the NF codes.

CODE

Descriptor

Current Work RVU

New Final Work RVU

% Change

99304

Initial Nursing Facility Care (25 minutes)

1.64

1.50

-2.44

99305

Initial Nursing Facility Care (35 minutes)

2.35

2.5

+6.38

99306

Initial Nursing Facility Care (45 minutes)

3.06

3.5

+14.4

99307

Subsequent Nursing Facility (10 minutes)

0.76

0.70

-7.9

99308

Subsequent Nursing Facility (15 minutes)

1.16

1.3

+12.1

99309

Subsequent Nursing Facility (30 minutes)

1.55

1.92

+23.9

99310

Subsequent Nursing Facility (45 minutes)

2.35

2.8

+19.1

99315

Nursing facility discharge day (30 mins or less)

1.28

1.5

+14.9

99316

Nursing facility discharge day (More than 30 mins)

1.9

2.5

+31.6

G0317

Prolonged Nursing Facility (beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes with or without patient contact

NEW

0.61

 

CMS noted that even though they are finalizing the RUC recommendations, they recommend that the CPT Editorial Panel reconsider the descriptor time for several of the codes in the NF family and apply a more consistent approach to descriptor times within and across families.

Prolonged Services:

CMS finalized that prolonged nursing facility services by a physician or NPP would be reportable under a new G Code, G0317, which would be used when the total time (in the time file) is exceeded by 15 or more minutes to account for the additional time spent.

Prolonged services HCPCS codes GXXX2 and GXXX3, which are being finalized as G0317 (Prolonged nursing facility evaluation and management service(s) beyond the total time for the primary service (when the primary service has been selected using time on the date of the primary service); each additional 15 minutes by the physician or qualified health-care professional, with or without direct patient contact (list separately in addition to CPT codes 99306, 99310 for nursing facility evaluation and management services). (Do not report G0317 on the same date of service as other prolonged services for evaluation and management 99358, 99359, 993X0). (Do not report G0317 for any time unit less than 15 minutes)

The practitioner would include any prolonged service time spent within the surveyed timeframe, which includes the day before the visit, the day of the visit, and up to and including 3 days after the visit (please see summary table below).

TABLE: Proposed Time Thresholds to Report Other E/M Prolonged Services (NF Codes only)

Primary E/M Service

Prolonged Code*

Time Threshold to Report Prolonged

Count physician/NPP time spent within this time period (surveyed timeframe)

Initial Nursing Facility Visit (99306)

G0317

95 Minutes

1 day before visit + date of visit + 3 days after

Subsequent Nursing Facility Visit (99310)

G0317

85 Minutes

1 day before visit + date of visit + 3 days after

Prolonged physician or NPP NF services would be reportable when the total time (in the physician time file) is exceeded by 15 or more minutes which would be once 95 minutes are spent for initial NF visits, and once 85 minutes are spent for subsequent NF visits, and for each additional 15 minutes furnished thereafter. Consistent with CPT coding guidance, there would not be any frequency limitation; therefore, CMS is proposing that physicians and NPPs would be able to bill G0317 for each additional 15-minute increment of time beyond the total time for CPT codes 99306 and 99310.

Since G0317 includes time without direct patient contact, there would no longer be a need to use CPT codes 99358 and 99359 (prolonged E/M visit without direct patient contact) in conjunction with NF visits. Therefore, CMS is changing the payment status for CPT codes 99358 and 99359 to “I” (Not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services). This is consistent with CMS final policy for O/O E/M visits, where prolonged time can no longer be reported using CPT codes 99358 and 99359.

Prolonged services will not be reportable in conjunction with CPT codes 99315 and 99316 (NF discharge day management).

Deletion of 99318: In February 2021, the CPT Editorial Panel deleted CPT code 99318, the annual nursing facility assessment code, and revised the remaining nursing facility code to better align with the principles included in the E/M office visit services by documenting and selecting level of service based on total time or medical decision-making. CMS finalized the deletion of 99318.

2023 Payment Rates

The below table shows the predicted payment rates given the finalized changes. The 2023 Medicare conversion factor would be reduced by about 4.6% from $34.6062 to $33.0607. This is largely a result of the expiration of a 3% increase to the conversion factor at the end of CY 2022 as required by law. The additional approximate 1.6% decrease is the result of budget neutrality requirements that stem from the revised E/M changes.

Code

Total 2023

2023 Payment Rate

Total 2022

2022 Payment Rate

Percentage Change

RVUs

(CF=33.0775)

RVUs

(CF=34.6062)

2022-2023

99304

2.38

$78.68

2.57

$88.94

-11.53%

99305

3.91

$129.27

3.72

$128.74

0.41%

99306

5.35

$176.87

4.76

$164.73

7.37%

99307

1.19

$39.34

1.27

$43.95

-10.44%

99308

2.18

$72.07

1.98

$68.52

5.18%

99309

3.13

$103.48

2.65

$91.71

13%

99310

4.49

$148.4

3.87

$133.93

10.84%

99315

2.39

$79.02

2.08

$71.98

9.77%

99316

3.81

$126.96

2.99

$103.47

21.73%

Telehealth

CMS will retain nursing facility initial visit codes on the Medicare Telehealth Services List for an additional 151 days following the end of the public health emergency (PHE). The services listed in the below table will no longer be available on the Medicare Telehealth Services List on the 152nd day after the end of the PHE. On the 152nd day after the end of the PHE, payment for Medicare telehealth services will once again be limited by the requirements of section 1834(m) of the Act and telehealth claims for these codes will be denied.

Nursing Facility Services to be Removed from the Medicare Telehealth Services After 151 Days Following the End of the PHE

HCPCS

Short Descriptor

99304

Nursing facility care initial

99305

Nursing facility care initial

99306

Nursing facility care initial

Services Proposed for Permanent Addition to the Medicare Telehealth Services List on a Category 1 Basis

HCPCS

Short Description

G0316

Prolonged inpatient or observation services by physician or other QHP

G0317

Prolonged nursing facility services by physician or other QHP

G0318

Prolonged home or residence services by physician of other QHP

A list of the services that involve audio-only interaction but are included on the Medicare Telehealth Services List for the duration of the PHE is available on the CMS website.

Split (or Shared) E/M Visits

CMS is finalizing its proposed policy to delay implementation of the definition of the substantive portion as more than half of the total practitioner time until January 1, 2024. CMS feels that by delaying implementation of this aspect of its policy it would also allow for the changes in the coding and payment policies for other E/M visits to take effect for CY 2023 and allows for a one-year transition for providers to get accustomed to the new changes and adopt their workflow in practice.

Therefore, for CY 2023, as in CY 2022, the substantive portion of a visit may be met by any of the following elements:  

  • History
  • Performing a physical exam
  • Making a medical decision
  • Spending time (more than half of the total time spent by the practitioner who bills the visit)

MVPs

CMS is finalizing updates to the Quality Payment Program and Medicare Shared Saving Program for 2023. It also includes a timeline for implementation of the new voluntary Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs). Highlights include: 

  • The addition of five new MVPs for 2023, bringing the total MVPs to 12. The proposed new MVPs include Advancing Cancer Care; Optimal Care for Kidney Health; Optimal Care for Patients with Episodic Neurological Conditions; Supportive Care for Neurodegenerative Conditions; and Promoting Wellness.
     

APM Policies

CMS is finalizing several policies for Advanced APMs. For example, it is permanently establishing the 8% minimum Generally Applicable Nominal Risk standard for Advanced APMs, which is currently set to expire in 2024. CMS also previously finalized a policy to set a limit of 50 on the number of clinicians in an organization that participate in an Advanced APM through a Medical Home Model, using the Medical Home Model nominal financial risk criteria. At that time, CMS described the way in which they would identify APM Entities that meet this standard as looking for “APM Entities that participate in Medical Home Models and that have 50 or fewer eligible clinicians in the organization through which the entity is owned and operated.” CMS defined organizational size as measured based on the size of the “parent organization” rather than the size of the APM Entity itself. CMS finalized a policy to apply the 50 eligible clinician limit to the APM Entity participating in the Medical Home Model based on the TIN/NPIs on the APM Entity’s participation list and conforming changes to our Other Payer Advanced APM policies in these areas.