The Centers for Medicare and Medicaid Services (CMS) released a an update to the Medicare Physician Fee Schedule and Quality Payment Program for calendar year 2023 (Proposed Rule). The Advocacy Council submitted comments in response to the Proposed Rule. This article summarizes key proposals concerning the Medicare Physician Fee Schedule that would impact allergy practices.
Overall, the 2023 reimbursement rates for allergy services will decrease under the Proposed Rule. The Advocacy Council developed a spreadsheet that compares the 2022 reimbursement and Relative Value Units (RVUs) for allergy codes to the ones proposed for 2023. (Note – these amounts do not account for geographic adjustments). For more information about proposed changes to the Quality Payment Program, please refer to our recent Insider Article 2023 Proposed MIPS Changes – ACAAI Member.
Cuts to Physician Reimbursement
Due to the expiration of the statutory increase in Medicare physician fee schedule payments for 2022, as well as the budget neutrality requirement imposed on the Medicare Physician Fee Schedule, CMS is proposing to reduce the conversion factor to $33.0775, a decrease of $1.53 (4.42%). The proposed cut to the conversion factor, in addition to other structural cuts, would materially impact reimbursement to providers across the Medicare program, including allergists.
Note: Certain codes, including Current Procedural Terminology (CPT) code 95165, would decrease by more than 4.42% due to other factors in addition to the conversion factor adjustment.
In our comments, we expressed concern that the proposed cuts to provider payment will place an additional financial strain on practitioners. We urged CMS to work with Congress to mitigate or eliminate the effects of these cuts and identify longer term “fixes” to this annual issue. Specifically, Congress should:
- Extend the 3% temporary increase in the Medicare physician fee schedule.
- Waive the 4% PAYGO sequester.
- Provide an inflation-based update.
- Provide relief to counter the 1.5% budget neutrality cut for 2023.
When a physician uses clinical staff to aid in the furnishing of a service, Medicare rules generally require that the physician be immediately available on site. This is known as direct supervision. In response to the COVID-19 public health emergency (PHE), CMS temporarily relaxed this direct supervision requirement, allowing the supervising physician (or other supervising practitioner) to be immediately available through virtual presence via real-time audio and video technology, until the end of the calendar year in which the COVID-19 PHE ends. This applies to both “incident-to” services (e.g., allergy injections) and diagnostic tests (e.g., allergy skin tests). The Advocacy Council urged CMS to permanently adopt this policy so that allergists can continue to satisfy the direct supervision requirement through the use of real-time audio and video technology. This would facilitate greater efficiencies in the workforce and reduce the potential spread of COVID-19.
Remote Therapeutic Monitoring (RTM) Services
RTM services represent the review and monitoring of data related to signs, symptoms, and functions of a therapeutic response. These include respiratory system status, therapy adherence, and therapy response. One technology used by some allergists consists of Bluetooth sensors that are attached to a patient’s inhalers and an app that tracks frequency of inhaler use. This can provide the clinician and the patient with a better understanding of the patient’s asthma triggers and avoidance measures. Another technology is a device that allows for in-home spirometry testing.
Unlike remote physiological monitoring (RPM) services, which can be provided under general physician supervision (i.e., provided by a physician’s clinical staff without the physician being in the office or on-site), a physician (or nonphysician practitioner) must directly supervise the clinical staff who are furnishing the treatment management of the RTM service. This creates a significant obstacle to providing RTM services and makes it practically impossible to have the service provided by third-party vendors.
For 2023, CMS is proposing to create four new Healthcare Common Procedure Coding System (HCPCS) G codes, including HCPCS codes GRTM1 and GRTM2, which include clinical labor activities that can be furnished by auxiliary personnel under general supervision. The Advocacy Council is concerned that the creation of the two HCPCS G codes may cause confusion and requested that CMS simply allow for general supervision of RTM CPT codes 98980 and 98981. These codes describe RTM treatment management services, requiring at least one interactive communication with the patient or caregiver during the calendar month, provided by a physician or other qualified health care professional.
Many of the telehealth services CMS implemented during the COVID-19 PHE were only implemented on a temporary basis. Following the expiration of the PHE, the statutory and regulatory restrictions on payment for Medicare telehealth services will apply once again. This means that, in most cases, payment will only be made for the previously approved Medicare telehealth services furnished by certain types of physicians and practitioners to patients located in specified types of medical settings (originating sites) – mostly in rural areas – and only when the service is furnished using audio and video equipment permitting two-way, real-time interactive communication between the patient and furnishing practitioner.
However, CMS is proposing to implement provisions of the Consolidated Appropriations Act of 2022, which would extend certain flexibilities for an additional 151 days after the end of the PHE. Under this proposal, Medicare telehealth services furnished on or before the 151st day after the end of the PHE will continue to be processed for payment as Medicare telehealth claims when accompanied with the modifier “95.” During this timeframe, physicians and practitioners can continue to report the place of service (POS) code that would have been reported had the service been furnished in-person.
Medicare telehealth services performed on dates of service occurring on or after the 152nd day after the end of the PHE will revert to pre-PHE rules and will no longer require modifier “95” to be appended to the claim. For Medicare telehealth services furnished on or after the 152nd day after the end of the PHE, the POS indicators would be:
- POS 02 –Telehealth Provided Other than in Patient’s Home.
- POS 10 –Telehealth Provided in Patient’s Home.
CMS also proposes that, beginning Jan. 1, 2023, a physician or other qualified health care practitioner billing for telehealth services furnished using audio-only communications technology must append modifier “93” to Medicare telehealth claims. CMS had received requests to add certain telephone E/M services (CPT codes 99441, 99442, and 99443) to the Medicare Telehealth Services List after the end of the PHE. However, because audio-only telephone E/M services are “inherently non-face-to-face services” and are not analogous to in-person care, CMS is not proposing to permanently add these services to the Medicare telehealth services list after the end of the PHE and the 151-day extension period.
Supervising practitioners would continue to be required to append the “FR” modifier on any applicable telehealth claim when required to be present through an interactive real-time, audio and video telecommunications link, as reflected in each service’s requirement.
The Advocacy Council encouraged the agency to continue working under its current authority and with Congress to ensure that telehealth is available long-term.
Read more about the 2023 Medicare Physician Fee Schedule proposed rule.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.