Payment Cuts, Nursing Facility Clinician Affiliations Part of CMS’ CY2022 Physician Fee Schedule Final Rule
On November 3, 2021, the Centers for Medicare & Medicaid Services (CMS) released its final rule that includes updates on policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues. The rule finalizes approximately 4%-5% cuts to nursing home codes. With the budget neutrality adjustment to account for changes in relative value units (RVUs), as required by law, and expiration of the 3.75% temporary CY2021 payment increase provided by the Consolidated Appropriations Act, 2021 (CAA), the CY2022 PFS conversion factor is $33.59, a decrease of $1.30 from the CY2021 PFS conversion factor of $34.89. See the table below for the specifics on the nursing home codes:
|
Code |
Total 2022 |
2022 Payment Rate |
Total 2021 |
2021 Payment Rate |
Percentage Change |
|
RVUs |
(CF=33.5983) |
RVUs |
(CF=34.8931) |
2020-2021 |
|
|
99304 |
2.57 |
$86.35 |
2.59 |
$90.37 |
-4.45% |
|
99305 |
3.71 |
$124.65 |
3.73 |
$130.15 |
-4.23% |
|
99306 |
4.76 |
$159.93 |
4.81 |
$167.84 |
-4.71% |
|
99307 |
1.26 |
$42.33 |
1.27 |
$44.31 |
-4.47% |
|
99308 |
1.99 |
$66.86 |
2.01 |
$70.14 |
-4.67% |
|
99309 |
2.62 |
$88.03 |
2.64 |
$92.12 |
-4% |
|
99310 |
3.86 |
$129.69 |
3.9 |
$136.08 |
-4.70% |
|
99315 |
2.09 |
$70.22 |
2.12 |
$73.97 |
-5.07% |
|
99316 |
2.99 |
$100.46 |
3.03 |
$105.73 |
-4.98% |
|
99318 |
2.75 |
$92.40 |
2.78 |
$97.00 |
-4.75% |
|
%= (new-old)/old |
Given that these cuts are based on statutory requirements for budget neutrality, AMDA anticipated that they would be finalized. However, we are disappointed and are against any cuts to nursing home services during a pandemic that has affected clinicians and patients in this setting at a disproportionate rate. We continue to work in a large coalition of specialty societies to urge Congress to take immediate action to avert these cuts and ensure continued access to vital clinical services for the vulnerable population in our nation’s nursing homes. To send a letter to Congress urging them to pass legislation to avert these cuts please go here.
Other provisions included in the final rule:
Attending Physician Affiliations with Nursing Facilities
For several years, the Society has been advocating for CMS to provide more transparency around clinicians who practice in the nursing home setting. The Society has directly asked CMS to establish a medical director registry or list so that the public and federal agencies can quickly and easily contact all medical directors during emergencies. With this rule, CMS took a major step forward in achieving one of Society’s top advocacy priorities. While CMS is not yet establishing such a list, they state that they are not doing so yet due to lack of the agency’s ability to collect such information. However, CMS has finalized a proposal that will now list attending physician “affiliations” with nursing facilities under the care compare website. CMS will use Medicare billing data to establish a nursing facility “affiliation.” This is a major step forward in identifying clinicians in this space and we applaud CMS for taking this step. We also look forward to continuing our work with CMS to figure out ways to collect medical director information so that it can be added to the care compare website. The exact language in the rule reads:
“We currently do not have a mechanism or source of data for verifying medical director or other healthcare administrative roles in SNFs or other types of care settings. Rather, if the clinician has filed a claim, it is because that clinician is actively treating patients and furnishing healthcare services, even if they also have an administrative role. We would not have information to report for a medical director or other healthcare administrator unless they have filed a claim. We understand the commenters concern and will explore alternative data sources that are found to be reliable. ...In response to questions regarding how we plan to obtain and verify facility affiliation, we plan to determine additional facility affiliations by using claims data in the same way we determine the hospital affiliations currently on clinician profile pages. This analysis includes reviewing claims for clinicians practicing at a given facility caring for at least three different Medicare patients on three different dates of service in the preceding 6 months, as documented in Medicare claims.”
Split (or Shared) E/M visits
A split (or shared) visit refers to an E/M visit performed (split or shared) by both a physician and a NPP who are in the same practice group. The Medicare statute provides a higher PFS payment rate for services furnished by physicians than those same services furnished by NPPs. For visits in the non-facility (e.g., office) setting, when an E/M visit is performed in part by a physician and an NPP, the physician is permitted to bill for the visit as long as the visit meets the conditions for services furnished “incident to” a physician’s professional services.
CMS defines a split (or shared) visit as an E/M visit in the facility setting, for which “incident to” payment is not available, and that is performed in part by both a physician and a non-physician practitioner (NPP). Only the physician or NPP who performs the substantive portion of the split (or shared) visit would bill for the visit. CMS defines “substantive portion” as more than half of the total time spent by the physician and NPP. CMS also modified its existing policy and now will allow either physicians or NPPs to bill for split (or shared) visits for both new and established patients, for critical care and certain skilled nursing facility/nursing facility (SNF/NF) E/M visits. The split visit 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 also notes that Medicare does not pay for partial E/M visits. CMS requires a modifier to be utilized to designate these split (or shared) visits in claims data.
Telehealth Services
CMS finalized several policies related to telehealth. While many current codes that were added to the telehealth list during the pandemic will remain on what CMS terms as Category 3 basis—meaning they will continue to study these codes and determine whether they should permanently stay or not—this was not the case for nursing facility codes. CMS finalized the following polices in that regard:
- Nursing facility services initial visit codes (99304-06) remain temporarily on the Medicare telehealth services list through the end of the Public Health Emergency (PHE). Once the PHE ends, they will NOT be extended. CMS states that once the PHE is over, these services must remain in-person.
- Domiciliary or rest home (99324-28) are temporarily on the 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 are permanently on the 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.
|
LIST OF MEDICARE TELEHEALTH SERVICES effective January 1, 2022-updated November 1, 2021 |
||
|
99304 |
Nursing facility care init. |
Temporary Addition for the PHE for the COVID-19 Pandemic |
|
99305 |
Nursing facility care init. |
Temporary Addition for the PHE for the COVID-19 Pandemic |
|
99306 |
Nursing facility care init. |
Temporary Addition for the PHE for the COVID-19 Pandemic |
|
99307 |
Nursing fac. care subseq. |
After PHE-billable once per 14 days |
|
99308 |
Nursing fac. care subseq. |
After PHE-billable once per 14 days |
|
99309 |
Nursing fac. care subseq. |
After PHE-billable once per 14 days |
|
99310 |
Nursing fac. care subseq. |
After PHE-billable once per 14 days |
|
99315 |
Nursing fac. discharge day |
Available up through December 31, 2023 |
|
99316 |
Nursing fac. discharge day |
Available up through December 31, 2023 |
The Society opposes these policies. As stated in our comment letter on the proposed rule, we believe nursing facility codes, like many others in the healthcare system, should remain on the list on a Category 3 basis with no frequency limitations so that we can determine how to effectively utilize them moving forward. Taking away a valuable tool that has worked to reduce hospitalizations and according to studies has done no harm to PALTC patients is counterproductive. Given the current workforce crisis in PALTC, we need to be using every tool available and provide clinicians the flexibility to use these tools in order to best care for their patients.
Electronic Prescribing of Controlled Substances (EPCS)
The SUPPORT Act required that Medicare Part D prescriptions for controlled substances be prescribed electronically starting on January 1, 2021, and also required that the Drug Enforcement Administration (DEA) modify the biometric component of the multifactor authentication requirements within its EPCS standards. The DEA has not yet revised these standards. CMS is also required to specify circumstances when the EPCS requirement may be waived, establish exceptions to the requirement, and determine penalties for non-compliance.
CMS continues to encourage EPCS adoption and notes that EPCS increased from 38% of prescriptions in 2019 to 70% in 2021. The final rule pushes back the deadline for EPCS compliance until no earlier than January 1, 2023. For patients in long-term care facilities, the compliance deadline will be 2025. CMS also finalized that the threshold prescribers would need to meet for compliance is 70% of their Part D controlled substances being e-prescribed. CMS also finalized exceptions and waivers from the requirement, for example, for those who issue 100 or fewer Part D controlled substance prescriptions annually, those in disaster areas, as well as those who request and receive from CMS a waiver due to circumstances that prevent EPCS such as lack of broadband access. CMS also finalized its proposed policy that prescribers not in compliance by the deadline will be sent a letter advising of the need to comply, but no penalties will be imposed.
Quality Payment Program
CMS continues to make changes to the Quality Payment Program (QPP). The biggest change in this program in some time is that CMS finalized its proposal to move toward Merit Based Incentive Payment System (MIPS) Value Pathways (MVPs). The goal of the MVP is to streamline the currently fragmented reporting requirements that are burdensome to clinical practices. CMS’ goal is to move toward this type of reporting by 2027. There are several MVPs finalized in the rule; however, they do not currently impact PALTC directly. The Society will continue to work with CMS to establish appropriate quality measures and reporting requirements as it moves toward the MVPs paradigm.
For 2022, CMS has finalized several changes to MIPS. The CY2022 performance categories will be adjusted as follows
- 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
The minimum performance threshold will be raised to 75%, meaning many practices will have to take meaningful steps to participate in the program.
We anticipate that there will be continued hardship exemptions due to the COVID-19 pandemic as well as other uncontrollable circumstances. For example, for PALTC, many quality measures in the promoting interoperability category remain unattainable or not applicable.
The Society will provide more information as we analyze the rule further. We will also continue to advocate with CMS to ensure this program better represents quality of care in PALTC rather than a mere “check-the-box” program that is burdensome to PALTC clinicians.
The text of the final rule can be found here.
Link to the Physician Fee Schedule fact sheet.