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CMS Issues CY 2022 Physician Fee Schedule Final Rule

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The Centers for Medicare & Medicaid Services (CMS) issued its calendar year (CY) 2022 physician fee schedule (PFS) final rule on Nov. 2.

Despite opposition from CHA, CMS adopted a conversion factor of $33.59, a decrease of $1.30 compared to CY 2021. This reflects a statutory update of 0%, the expiration of the 3.75% payment increase for CY 2021 included in the Consolidated Appropriations Act (CAA) of 2021, and a budget neutrality adjustment to account for changes in relative value units.

Additional key provisions of the rule are summarized below.

  • Telehealth Services Under the PFS: CMS finalized its proposal to allow certain services added to the Medicare telehealth list to remain on the list to the end of Dec. 31, 2023, creating a glide path to evaluate whether the services should be permanently added following the COVID-19 public health emergency (PHE).  
  • Telehealth for Mental Health Services Under Section 123 of the CAA: CMS implements Section 123 of the CAA, which removes geographic restrictions and adds the home of the beneficiary as a permissible originating site for telehealth services furnished for the purposes of diagnosis, evaluation, or treatment of a mental health disorder. The CAA requires that an in-person, non-telehealth service to be provided by a provider furnishing mental health telehealth services within six months prior to the initial telehealth service. In a change from the proposed rule, CMS finalizes that an in-person, non-telehealth visit must be furnished at least every 12 months — rather than every six months — for these services. CMS will also allow exceptions to the in-person visit requirement based on beneficiary circumstances (with the reason documented in the patient’s medical record). In addition, CMS finalizes its proposal to allow audio-only interactive telecommunications system for these services when the beneficiary is not capable of using, or does not consent to, the use of two-way, audio/video technology. CMS also finalizes the use of a claims modifier for those circumstances.  
  • Evaluation and Management (E/M) Visits: CMS finalizes several policies related to split (or shared) E/M visits, critical care services, and services furnished by teaching physicians involving residents. 
  • Therapy Services: CMS is implementing section 53107 of the Bipartisan Budget Act of 2018, which requires the agency to identify and pay 85% of the otherwise applicable Part B payment amount for physical therapy and occupational therapy services furnished in whole or in part by physical therapist assistants and occupational therapy assistants, for dates of service on and after Jan. 1, 2022. In the final rule, CMS clarifies the definition of the de minimis standard for determining when a service is furnished in whole or in part by physical therapist assistants or occupational therapy assistants.  
  • Appropriate Use Criteria (AUC): CMS finalizes a delay in the payment penalty phase of the AUC program to the later of Jan. 1, 2023, or the Jan. 1 that follows the declared end of the public health emergency for COVID-19. Previously, the payment penalty phase of the AUC program was set to begin Jan. 1, 2022. 
  • Beneficiary Coinsurance for Colorectal Screening When an Additional Procedure Is Performed: The final rule implements section 122 of the CAA which, over time, reduces the amount of coinsurance a Medicare beneficiary will pay when a screening colonoscopy includes a procedure. For services furnished on or after Jan. 1, 2022, the coinsurance amount paid for planned colorectal cancer screening tests that require additional related procedures will be 20% for CY 2022, 15% for CYs 2023 through 2026, 10% for CYs 2027 through 2029, and 0% beginning CY 2030 or the lesser of the actual charge for the service or the amount determined under the fee schedule that applies to the test.  
  • Physician Assistant Services: CMS implements section 403 of Division CC of the CAA, which authorizes Medicare to make direct payment to physician assistants for professional services they furnish under Part B beginning Jan. 1, 2022.  
  • Opioid Treatment Programs – Telehealth: CMS finalizes its proposal to allow opioid treatment programs to furnish counseling and therapy services via audio-only interaction (such as telephone calls) after the conclusion of the COVID-19 public health emergency in cases where audio/video communication is not available to the beneficiary. In addition, CMS has issued a separate interim final rule freezing the payment rate for methadone to opioid treatment programs in CY 2022 at the CY 2021 rate, averting a significant decrease in the payment amount. 
  • Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) Telehealth Mental Health Services: CMS finalizes its proposal to allow RHCs and FQHCs to report and receive payment for mental health visits furnished via real-time telecommunication technology in the same way they currently do when visits take place in-person, including audio-only visits when the beneficiary is not capable of, or does not consent to, the use of video technology.  
  • RHC Payment Limit Per Visit: The final rule continues the implementation of Section 130 of the CAA, which limits the growth rate for the all-inclusive rate for provider-based RHCs.    
  • Concurrent Billing for Chronic and Transitional Care Management Services for RHCs and FQHCs: CMS finalizes its proposal to allow RHCs and FQHCs to bill for transitional and other care management services furnished for the same beneficiary during the same service period, provided all requirements for billing each code are met.  
  • Vaccine Administration Services: CMS finalizes payment rates of $30 per dose for the administration of the influenza, pneumococcal, and hepatitis B virus vaccines. In addition, CMS will maintain the current payment rate of $40 per dose for the administration of the COVID-19 vaccines through the end of the calendar year in which the ongoing PHE ends. CMS will also continue the additional payment of $35.50 for COVID-19 vaccine administration in the home under certain circumstances through the end of the calendar year in which the PHE ends. 
  • COVID-19 Monoclonal Antibody Products: CMS will continue to pay for COVID-19 monoclonal antibodies under the Medicare Part B vaccine benefit through the end of the calendar year in which the PHE ends. During this interim time, CMS will maintain the $450 payment rate for administering a COVID-19 monoclonal antibody therapy in a health care setting, as well as the payment rate of $750 for administering a COVID-19 monoclonal antibody therapy in the home. 
  • Pulmonary Rehabilitation Coverage: CMS finalizes its proposal to expand coverage of outpatient pulmonary rehabilitation services, paid under Medicare Part B, to beneficiaries who have had confirmed or suspected COVID-19 and experience persistent symptoms that include respiratory dysfunction for at least four weeks. 
  • Medicare Shared Savings Program (MSSP): The rule adopts several changes to the MSSP. These include:  
    • Extending the availability of the CMS web interface collection type for three years, through performance year (PY) 2024, to provider a longer transition for accountable care organizations (ACOs) reporting electronic clinical quality measure/merit-based incentive payment system clinical quality measure all-payer quality measures   
    • Freezing the quality performance standard for PY 2023 by providing one additional year before increasing the quality performance standard ACOs must meet to be eligible to share in savings  
    • Revising the methodology for calculating repayment mechanism amounts for risk-based ACOs to reduce the percentage used in the existing amount by 50%  
    • Revising the definition of primary care services that are used for purposes of beneficiary assignment  
  • Quality Payment Program: The rule includes annual updates to the Quality Payment Program. A summary of these updated policies is available in this fact sheet.