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CMS updates its claims processing guidance to add policies from 2022 MPFS final rule

On December 2, 2021, the Centers for Medicare and Medicaid Services (CMS) issued a new transmittal (Change Request 12519) to provide a summary of new policies addressed in the CY 2022 Medicare Physician Fee Schedule (MPFS) final rule. Some pertinent changes to Medicare payment policies are described below.

Medicare Telehealth Services

CMS decided against adding any new Category 1 and Category 2, Healthcare Common Procedure Coding System (HCPCS) codes to the list of telehealth services. Codes that were added to the telehealth services list on a Category 3 temporary basis during the public health emergency (PHE) will remain in place through the end of 2023.

For telehealth services provided on or after January 1 of each subsequent calendar year, the telehealth originating site facility fee (set initially in CY 2001 at $20) is increased by the percentage increase in the Medicare Economic Index (MEI). The MEI increase for 2022 is 2.1% bringing the CY 2022 payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) to be 80 percent of the lesser of the actual charge, or $27.59 (The Medicare beneficiary is responsible for any unmet deductible amount and Medicare coinsurance).

The transmittal lists the codes that have been added to the Medicare telehealth services list here

Physician Assistant Services

Changes here were in response to provisions of the Consolidated Appropriations Act, 2021 (CAA) that authorizes the Medicare Part B program to make direct payment to physician assistants (PAs) for their professional services. Previously only the PA’s employer or independent contractor could bill for PA services. Effective January 1, 2022, Medicare Part B payments at 85% of the MPFS amount can be made directly to a PA who bills the program for their professional services. PAs have the option to reassign payment for their professional services and (to the extent permitted by state law) to incorporate with other PAs and bill the Medicare program for PA services.                            

Teaching Physician Services

Beginning in 2022, CMS has made a technical clarification to provide that when teaching physicians bill their time as an office/outpatient evaluation and management (E/M) visit that involves the care of residents, Medicare payment can be made to teaching physicians. However, this payment to teaching physicians under the MPFS includes only the total time that the physician is present during such a visit, not the resident’s time.                  

For primary care services, CMS finalized a proposed policy to allow selection of medical decision making (MDM) as the sole E/M visit level indicator for office/outpatient E/M visits and the total time.            

Split (or Shared) Evaluation and Management (E/M) Visits

Beginning in 2022, CMS has revised its longstanding policies for split (or shared) E/M visits by establishing the following:                   

  • Split (or shared) E/M visits are defined as E/M visits provided in the facility setting by a physician and a non-physician practitioner (NPP) in the same group.
  • By 2023, the practitioner who provides the substantive portion of the split or shared visit, which will be defined for 2023 as more than half of the total time spent, will bill for the visit. For 2022, however, the substantive portion of the visit can be defined as history, physical exam, medical decision-making, or more than half of the total time. The exception is critical care, where the substantive portion is defined as more than half of the total time.                        
  • Split (or shared) visits can be reported for new as well as established patients and for initial and subsequent visits, as well as for prolonged services.                        
  • A new modifier must be on the claim to identify these services. CMS states that the use of the modifier will inform policy and help ensure program integrity.                        
  • Documentation in the medical record must identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the medical record.          

These revised policies will be codified in new regulations at 42 CFR 415.140.

Critical Care Services

The term critical care is defined in the Current Procedural Terminology (CPT) Codebook (99291 and 99292) as a critical illness or injury, or as an illness or injury that acutely impairs one or more vital organ systems such that there is a high probability of imminent or life-threatening deterioration in the patient's condition. Critical care services are defined as a physician's direct delivery of medical care for a critically ill or critically injured patient. It involves decision making of high complexity to assess, manipulate, and support patients with vital organ system failure and/or to prevent further life-threatening deterioration of the patient's condition

When medically necessary, critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty, and critical care services can be furnished as split (or shared) visits. These services are furnished in critical care settings. The billing practitioner would report CPT code 99291 for the first segment of critical care services and would use CPT code 99292 thereafter for additional 30-minute increments.

Critical care may be paid on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty, if the practitioner documents that the E/M visit was provided prior to the critical care service at a time when the patient did not require critical care, the visit was medically necessary, and the services are separate and distinct, with no duplicative elements from the critical care service provided later in the day. Practitioners must report modifier - 25 on the claim when reporting these critical care services.

Critical care services may be separately paid in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases). CMS will introduce a new modifier that will be required on such claims to identify that the critical care is unrelated to the procedure. 

Appropriate Use Criteria

Finally, while not addressed in this transmittal, it should be noted that in the CY 2022 final MPFS rule CMS delayed the payment penalty phase of the appropriate use criteria (AUC) program to the latter of January 1, 2023, or the January 1 that follows the declared end of the PHE for COVID-19. CMS indicated that the flexible effective date was intended to take into account the impact that the PHE for COVID-19 has had and may continue to have. Previously, the payment penalty phase of the AUC program was set to begin on January 1, 2022.

This Change Request (CR) provides a summary of the policies in the CY 2022 Medicare Physician Fee Schedule (MPFS) Final Rule and announces the Telehealth Originating Site Facility Fee payment amount.

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health care & life sciences, medicare, 2022 mpfs rule, payment policies

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