Medicare payment policy changes established under the CMS CY 2023 Medicare Physician Fee Schedule (“MPFS”) Final Rule, issued on November 1, 2022, become effective January 1, 2023. Below is a high-level summary of significant changes established for 2023.
Evaluation and Management (E/M) Visits
Over the past several years, CMS engaged in efforts with the American Medical Association (“AMA”) and other interested parties to update coding and payment for evaluation and management (“E/M”) visits, with the goal of reducing administrative burden. CMS finalized most of the changes in coding and documentation approved by the AMA CPT Editorial Panel for “Other E/M Visits” (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services and cognitive impairment assessment). This revised framework includes CPT code definition changes, including without limitation:
- New descriptor times;
- Revised interpretive guidelines for levels of medical decision-making;
- Choice between medical decision making or time to select code levels; and
- Elimination of the use of history and physical exam to determine the code level (requiring instead a medically appropriate history and physical exam).
CMS also finalized its creation of Medicare-specific coding for payment of “Other E/M” prolonged services in an effort to maintain consistency with new coding and payment structure for these services. These services will be reported with three separate Medicare-specific G codes.
Split/Shared E/M Visits
Longstanding CMS policy has been that, for split or shared visits in an institutional setting, the physician can bill for the services if he/she performs a substantive portion of the encounter. CMS has chosen to extend its phase-in approach of defining “substantive portion” as more than half the time of the visit to CY 2024. Accordingly, consistent with CY 2022, clinicians who furnish split or shared visits will continue to have a choice of history, physical exam, medical decision-making or more than half the total practitioner time spent to fulfill the “substantive portion” requirement. However, despite pushback from the industry, CMS continues to support its movement towards the time-based approach, and providers should expect to see this change in 2024.
CMS updated the Telehealth Originating Site Facility Fee for CY 2023 and is also implementing a number of policies related to Medicare telehealth services in an effort to smoothly transition from changes made during the Public Health Emergency (“PHE”). CMS will make several services that are currently only temporarily available as telehealth services for the duration of the PHE available at least through CY 2023. This will allow additional time for the collection of data that may support the inclusion of these services as permanent additions to the Medicare Telehealth Services List. The following policies will remain in place for the duration of the PHE:
- Allowing telehealth services to be furnished in any U.S. geographic area and originating site setting including the beneficiary’s home;
- Allowing certain services to be furnished via audio-only telecommunications systems; and
- Allowing physical therapists, occupational therapists, speech-language pathologists and audiologists to furnish telehealth services.
Outside the circumstances of the PHE, direct supervision requires the immediate availability of the supervising physician or other practitioner, but the professional need not be present in the same room during the service. However, temporary PHE flexibilities have expanded the definition of direct supervision to allow the supervising professional to be immediately available through virtual presence using real-time audio/video technology rather than physical presence. As of now, CMS does not have plans to make this flexibility to the definition of direct supervision permanent; however, CMS did solicit comments regarding whether this change should be made beyond the PHE.
The CY 2023 Final Rule included language from the Consolidated Appropriations Act (“CAA”) of 2022 that extended telehealth flexibilities for a period of 151 days following the end of the PHE. However, this time period is expected to be extended based on language in the current year-end Omnibus Bill.
Behavioral Health Services
In an effort to increase access to behavioral health services for Medicare beneficiaries, CMS has added an exception to the direct supervision requirement under 42 CFR 410.26 to allow behavioral health services to be provided on an incident-to basis under the general supervision of a physician or non-physician practitioner (“NPP”) when these services or supplies are furnished by auxiliary personnel, such as licensed professional counselors and licensed marriage and family therapists. Additionally, the physician or NPP supervising the auxiliary personnel does not need to be the same clinician who is treating the patient more broadly.
Opioid Treatment Programs
CMS revised its pricing methodology for methadone and will base the payment amount for the drug component of HCPCS codes G2067 and G2078 for CY 2023 and subsequent years on the payment amount for methadone in CY 2021 as a base and adjust this amount annually to account for inflation using the Product Price Index (“PPI”) for Pharmaceuticals for Human Use (Prescription) category. CMS also modified its payment rates for the non-drug component of the bundled payments for these episodes of care to base the rate for individual therapy on a crosswalk to a code describing a 45-minute session, rather than the current crosswalk to a code describing a 30-minute session.
CMS is finalizing its proposal to permit the use of audio-only communication technology to initiate treatment with buprenorphine in cases where audio-video technology is not available to the beneficiary. Additionally, CMS is allowing periodic assessments to be furnished audio-only when video is not available for the duration of CY 2023 when certain regulatory requirements (namely, those of the Substance Abuse and Mental Health Services Administration (“SAMHSA”) and the Drug Enforcement Administration (“DEA”) are met. Finally, CMS clarified that Opioid Treatment Programs can bill for medically necessary services provided via mobile units, so long as services are performed in accordance with SAMHSA and DEA guidance.