Health Reform WK-EDGE Physician fee schedule proposed rule to improve access to, equity in health care
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Monday, August 2, 2021

Physician fee schedule proposed rule to improve access to, equity in health care

By Susan L. Smith, JD, MA

CMS proposes changes to thePhysician Fee Schedule for calendar year 2022, Part B payment policies, Medicare Shared Savings Program requirements; provider enrollment updates, provider and supplier prepayment and post-payment medical review to improve health equity and patient access.

CMS has issued an extensive proposed rule updating the physician fee schedule (PFS) for calendar year (CY) 2022 as well as other policies and programs. The updates include Part B payment policies, Medicare provider enrollment policies, the Quality Payment Program (QPP) and prepayment and postpayment medical review activities. CMS also proposed changes to Medicare coverage of opioid use disorder services furnished by opioid treatment programs, the Medicare Shared Savings Program (MSSP), and requirements for electronic prescribing for controlled substances for a covered Part D drug under a prescription drug plan or a Medicare Advantage Prescription Drug (MA-PD) plan. Finally, CMS updated the Medicare Ground Ambulance Data Collection System; and proposed changes to the Medicare Diabetes Prevention Program (MDPP) as well as amendments to the physician self-referral law regulations (Proposed rule, 86 FR 39104, July 23, 2021).

Payment provision. Payment provisions include:

  • Conversion factor. The proposed conversion factor for CY 2022 is $35.58, a decrease of $1.31 from the CY 2021 that was $34.89.
  • Evaluation and Management. The proposals take into account changes to evaluation and management visit codes, which were made in January 2021, to refine current policies related to split (or shared) E/M visits, critical care services, and services furnished by teaching physicians involving residents as well as requiring reporting of a modifier on the claim to ensure program integrity.
  • Critical care services. Proposals include using the American Medical Association Current Procedural Terminology language as the definition of critical care visits; allowing critical care services to be provided concurrently to the same patient on the same day by more than one specialty; and critical care services can not be reported during the same time period as procedure with a global surgical procedure.
  • Teaching physician services. CMS is proposing to clarify that the time when the teaching physician was present can be included when determining E/M visit level.
  • Telehealth services. CMS is proposing to extend certain services added during the COVID-19 public health emergency to the end of December 31, 2023; require an in-person visit by a physician or practitioner furnishing the services within six months prior to the telehealth services; and require interactive audio-visual services rather than telehealth unless the circumstances do not allow for audio-visual communication for mental health services.
  • Therapy services. CMS is proposing to use new modifiers to identify and make payment at 85 percent of the applicable payment for services provided by physical and occupational therapy assistants beginning January 1, 2022. In addition, CMS would revisit to determine the de minimis standard would continue in situation in which physical or occupational therapy assistants work in whole or in part with physical or occupational therapist.
  • Physician assistants. Under the proposed rule, physician assistants would be able to bill Medicare directly for their services.
  • Beneficiary co-insurance for additional services during colorectal screening tests. CMS has proposed that beginning CY 2022, the coinsurance amount paid by beneficiaries for planned colorectal screening tests that require additional procedures furnished in the same clinical encounter will gradually be reduced each calendar year and will be zero percent beginning January 1, 2030.
  • Opioid treatment. The proposed rule would allow opioid treatment programs (OTPs) to furnish counseling and therapy services through audio-only interaction after the conclusion of the COVID-19 public health emergency when audio-visual communication is not available to the beneficiary. OTPs would be required to use a service-level modifier for audio-only services and document the rationale for the service being audio-only in the medical record to facilitate program integrity activities.

Rural health clinics (RHCs) and federally qualified health plans (FQHCs). To address health equity in rural and vulnerable populations, CMS has proposed the following:

  • Mental health services. Revise current regulatory language to include visits conducted though telecommunication technology and allow payment for such services.
  • Payment limit per visit. Since April 1, 2021, both independent and provider based RHCs have received an increase in their payment limit per-year with a prescribed amount that is to continue for an 8-year period. CMS proposes to establish percentage increase for subsequent years.
  • Attending physician services. Starting January 1, 2022, FQHCs and RHCs would be eligible to receive payment for hospice attending physician services when provided by an FQHC/RHC physician, nurse practitioner, or physician assistant who is employed or working under contract for an FQHC or RHC, but is not employed by a hospice program.

Electronic prescribing of controlled substances. CMS has proposed certain exceptions to the electronic prescribing requirements. These exceptions apply when the prescriber and dispensing pharmacy are the same entity; for prescribers who issue 100 or fewer controlled substance prescription for Part D drugs per calendar year; and for prescribers who are in a geographic area of a natural disaster or who are granted a waiver based on extraordinary circumstances.

Additional proposed rules. Other proposals include requiring certain manufacturers to report drug pricing information for Part B for their covered outpatient drugs to be payable and a proposed methodology for drugs and biologicals that many be included in future Office of Inspector General reports. CMS also proposed to allow independent laboratories to be paid for specimen collections from beneficiaries who are homebound or inpatients not in a hospital for COVID-19 testing and to pay for pulmonary rehabilitation services for beneficiaries who were hospitalized for COVID-19 and experience persistent symptoms.

CMS is soliciting comments for its proposals as well as comments on payment for vaccine administration services and tribal FQHC payment considerations. Comments must be received no later than 5 p.m. on September 13, 2021.

FederalRegisterIssuances: ProposedRules AgencyNews MedicarePartANews MedicarePartBNews MedicarePartCNews MedicarePartDNews PreventiveCareNews ProviderPaymentNews ProgramIntegrityNews

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