On July 13, the Centers for Medicare and Medicaid Services (CMS) released the CY 2022 Proposed Rule for the Medicare Physician Fee Schedule (MPFS), which also includes proposals related to the Quality Payment Program (QPP). The proposed regulations were put on display in the Federal Register on July 13, 2021. Comments are due September 13, 2021, the Academy will submit a comprehensive response to proposals contained in the rule by this date. While AAO-HNS physician leaders and staff are still reviewing the over 1,700-page rule, a high-level analysis identified key proposals impacting the specialty.
The proposed CY 2022 conversion factor is $33.58, a decrease of $1.31 from the CY 2021 PFS conversion factor of $34.89. This reduction includes the sunset of the 3.75% payment update included in the Consolidated Appropriations Act (CAA), 2021. The conversion factor reflects the statutory update of 0 percent and necessary adjustments to account for changes in relative value units and expenditures that would result from the proposed policies.
Estimated Impact to Otolaryngology
In Table 123 of the rule, CMS outlines updates to clinical labor pricing impacting the PE RVUs for all fee schedule services. CMS estimates an overall impact of the PFS proposed changes to be a 1% decrease for otolaryngology. CMS attributes these overall projections to changes in RVUs for specific services resulting from the misvalued code initiative, including RVUs for new and revised codes as well as practice expense updates, including clinical labor inputs and supply costs. The rule’s explanation of these impacts is below.
“The estimated impacts for several specialties, including interventional radiology, vascular surgery, radiation oncology, and oral/maxillofacial surgery reflect decreases in payments relative to payment to other physician specialties which are largely the result of the redistributive effects of the proposed clinical labor pricing update. The services furnished by these specialties involve PE costs that rely primarily on supply or equipment items and therefore are affected negatively by the proposed updates to clinical labor pricing. Since PE is budget neutralized within itself, increased pricing for clinical labor holds a corresponding relative decrease for other components of PE such as supplies and equipment.” p.1181
In light of recent changes to E/M visit codes, as explained in the AMA CPT Codebook, CMS proposes to refine policies, specifically to current policies for split (or shared) E/M visits, critical care services, and services furnished by teaching physicians involving residents. In the rule, CMS seeks to define split E/M visits as in-facility and performed in part by both physician and non-physician practitioners (NPPs) practicing in the same group. The proposal also includes a policy modification to allow physicians and NPPs to bill for split (or shared) visits for both new and established patients, and for critical care.
Additionally, CMS proposes to create a modifier to describe split visits. This modifier would apply only in the circumstance that all elements of the E/M visit are completed by healthcare practitioners in the same group.
If an E/M is billed under total time within a teaching setting, CMS proposes that the billable time is restricted to the time when the teaching physician is present. Under the current Medicare telehealth exceptions, this includes virtual supervision.
Medicare Telehealth Services Under Section 1834(m)
CMS proposes to continue telehealth exceptions currently allowable through the end of 2023, including for speech/hearing therapy (92507/8), pure tone audiometry [threshold]; air and bone (92553), and tympanometry (92567). The full list of exceptions can be found here: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.
The rule outlines that any service currently designated as category 3 will now remain as category 3 through the end of 2023. Originally, those services temporarily designated as category 3 would retain this designation until the end of the PHE. The additional time allotted will allow the agency to evaluate whether services should be moved to category 1 or 2.
Notably, CMS proposes to restrict payment for audio-only telehealth to mental health services.
CMS proposes adjustments to the requirement for in-person visits that must currently be conducted by the provider delivering telehealth services in the 6 months preceding a telehealth visit. CMS is considering changing this requirement so that another physician in the same specialty and subspecialty and in the same practice may conduct this in-person visit if the original physician is unavailable. CMS is also considering either shortening or lengthening the allowable time period (e.g., every 3 months or every 12 months) if it is determined that this would neither present a prohibitively burdensome travel requirement for the patient nor be detrimental to the quality of care.
CMS is seeking comment on the extent to which the flexibility to meet the immediate availability requirement for direct supervision through the use of real-time, audio/video technology is being used during the PHE, and whether physicians and practitioners anticipate relying on this flexibility after the end of the PHE. The agency seeks comment on whether this flexibility should potentially be made permanent.
CMS proposes to permanently adopt virtual check-in, G2252 (virtual check-in, by a physician or other qualified health care professional who can report E/M services, provided to an established patient).
PAs to Bill Directly to Medicare
In the proposed rule, CMS outlines its plans to implement physician assistants’ ability to bill Medicare directly, as nurse practitioners and clinical nurse specialists are currently permitted by Medicare. This change is statutorily based and was passed by Congress in the CCA, 2021 at the end of last year. This does not change the supervision requirements or scope of practice rules for physician assistants.
Valuation of Services
The proposed rule includes Medicare valuation of the following codes impacting the specialty:
- 42XXX Drug Induced Sleep Endoscopy (With dynamic evaluation of velum, pharynx, tongue base, and larynx for evaluation of sleep disordered breathing; flexible, diagnostic)
CMS proposes to accept the RUC recommended work RVU of 1.9.
- 645X1 (Open implantation of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array), 645X2 (Revision or replacement of hypoglossal nerve neurostimulator array and distal respiratory sensor electrode or electrode array, including connection to an existing pulse generator), 645X3 (Removal of hypoglossal nerve neurostimulator array, pulse generator, and distal respiratory sensor electrode or electrode array) Hypoglossal Nerve Stimulator
CMS proposes a reduction of 2 work RVUs from the RUC recommended amounts for each code, reducing the global RVUs for the procedures to 14.5 (from 16.5) for 645X2, 14 (from 16) 645X1, and 12 (from 14) for 645X3.
- 21315 (Closed treatment of nasal bone fracture; without stabilization) and 21320 (Closed treatment of nasal bone fracture; with stabilization) as well as 000-day global period codes from 010-day global period codes
CMS proposes to accept the RUC recommendation to change global period codes from 10 to 0 days. However, due to the change in global period, the agency disagrees with the RUC-recommended work RVUs. CMS instead proposes values of .96 RVUs (from 2.0) for 21315 and 1.59 (from 2.33) for 21320.
- 69714 (Implantation, osseointegrated implant, skull; with percutaneous attachment to external speech processor), 69717 (Revision/replacement (including removal of existing device), osseointegrated implant, skull; with percutaneous attachment to external speech processor), 69X50 (Implantation, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor), 69X51 (Revision/replacement (including removal of existing device), osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor), 69X52 (Removal, osseointegrated implant, skull; with percutaneous attachment to external speech processor), and 69X53 (Removal, osseointegrated implant, skull; with magnetic transcutaneous attachment to external speech processor) Bone Anchored Hearing Aids
CMS proposes to accept the temporary RUC-recommended work RVUs of 8.69 for 69714, 8.80 for 69717, 9.77 for 69X50 and 69X51, 5.93 for 69X52, and 7.13 for 69X53. CMS also proposes to lower the clinical labor time from 108 to 99 minutes for 69714 and 69717.
Appropriate Use Criteria
CMS is proposing to delay the beginning of the payment penalty phase of the Appropriate Use Criteria (AUC) program to no sooner than January 1, 2023, or January 1 following the declared end of the COVID-19 Public Health Emergency. The flexibilities offered by CMS are intended to consider the impact of COVID-19 on providers and their beneficiaries. The current payment penalty phase of the AUC program was slated to begin in 2022.