by Kem Tolliver, CMPE, CPC, CMOM
Feb 28th, 2023
As we walk (or run depending on your enthusiasm for leaving 2022 behind); we are presented with the rules that will govern much of the healthcare industry’s regulatory compliance standards and reimbursement guidelines. These rules are published in the Center for Medicare and Medicaid (CMS) Annual Final Rule - which was released on November 18, 2022 for the 2023 calendar year.
The rule making process starts with the “Proposed Rule,” followed by a 60-day public comment period. Hopefully you have at some point, commented and advocated on behalf of your specialty or healthcare organization. “CMS uses public comments to inform its proposed and final decisions, and responds in detail to all public comments received on a proposed decision when issuing a final decision memorandum.” https://www.cms.gov/Medicare/Coverage/InfoExchange/publiccomments
The value of participating during the comment period allows a proactive approach to providing evidence relative to the impact that CMS’ legislation will have on Medicare Beneficiaries and Participating Providers. Follow this link to learn more about the public comment submission process: https://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking.
Since most commercial insurance payers follow the lead of CMS, it’s critical to understand the direction CMS sets for the industry as others follow suit. Most healthcare organizations rely on the standards set by CMS for internal policy development, understanding regulations and optimal care delivery.
The highlights selected for your reading pleasure have been chosen based on the widespread impact expected on healthcare organizations. This is not an exhaustive itemization of the entire Final Rule; however, those brave (or bored) souls who wish to read the entire Final Rule may do so by navigating to the Federal Register / Vol. 87, No. 222, November 18, 2022/Rules and Regulations: 69404: https://www.govinfo.gov/content/pkg/FR-2022-11-18/pdf/2022-23873.pdf. Everyone else, who may have other things to do – continue reading to avoid cracking open the beforementioned 1297 paged document.
Let’s get into it and examine the top 5 takeaways from the CMS 2023 Final Rule.
- Conversion Factor
The conversion factor (CF) is a rate that is included in the formula used to pay participating providers for services to Medicare beneficiaries through the Medicare Physician Fee Schedule (MPFS). In CY 2022 the CF was set at $34.61, it is decreasing in 2023 to $33.89. Prepare your internal fee schedule and charge description master for this adjustment. Again, commercial payers appraise CMS’s payment policies so be prepared for potential adjustments.
- MIPS Program
MIPS Value Pathways (MVPs) which prioritizes specialty-based MIPS reporting. There were revisions to the seven inaugural programs; all of which focus on prevention such as Optimizing Chronic Disease Management. Reporting period 2022 was the last year for the additional exceptional performance adjustment. Expect to see greater focus on encouraging Advanced APM participation. Reminder that 2021 scores will be used for 2023 MIPS payments.
The Public Health Emergency (PHE) was extended which keeps the polices within the 1135 Waiver that allow for telehealth services to be reimbursed in expanded geographic locations, originating sites inclusive of a patient’s home and the continuation of audio only services. CMS will accept the use of modifier -95 along with a place of service identifier for approved in-person service locations. PT, OT, SLP and Audiologists may continue providing telehealth services. Each of these provisions will remain effective for 151 days after the end of the PHE. Evaluation and Management telehealth services have not been given the green light for permanent reimbursement.
- Evaluation and Management (E/M) Services
Grab your wallet and purchase your CPT and HCPCS coding books. New definitions and descriptors to include those for time will be in place. E/M coding guidelines have been updated – and it’s possible that you may not find them in your EMR so, get your coding manuscripts to access this vital information. For split/shared services, determining the substantive visit portion will be based on: MDM, History, Physical Exam or spending more than half of total encounter time.
- Refunds for Discarded Single Dose Drugs
In an effort to eliminate pharmaceutical waste, CMS will require manufacturers of certain single-dose container or single-use package drugs to refund CMS the amount of the discarded drug that exceeds a certain percentage. There will be enforcement and dispute resolution processes in place as well as definitions of “refundable single-dose containers or single-use packages.
There are so many updates in store for us in 2023 to include but certainly not limited to: The expansion of Behavioral Health via telemedicine, preventive vaccine administration, and Opioid Treatment Program guidelines.
Now is the time to be proactive about how you consume and act upon this information to create sustainability within your organization. Sharing is caring, so give others a helping hand by looping them into updates that they need to know. Good luck in 2023!