On Nov. 1, the Centers for Medicare & Medicaid Services (CMS) released the 2023 Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP) final rule. Along with the rule, the CMS also released a Physician Fee Schedule fact sheet, a Medicare Shared Savings Program fact sheet, and a Quality Payment Program fact sheet.
The rule includes updates to payment rates for physicians and other health care professionals for 2023, extends telehealth waivers and flexibilities, adopts evaluation and management (E/M) coding and payment changes, promotes coverage of behavioral health services, makes significant changes to the Shared Savings Program, revises policies for the 2023 performance year of the QPP, and includes many other provisions.
Notably, the 2023 conversion factor would be reduced by 4.47%, from $34.61 in calendar year (CY) 2022 to $33.06 for CY 2023. This is primarily due to the expiration of the 3% payment increase provided for in CY 2022 by Congress and changes to E/M Current Procedural Terminology (CPT) codes. The AAMC and other stakeholders are advocating that Congress take action to stop these payment cuts, implement an inflationary update for physicians, and waive the 4% pay-as-you-go sequester [refer to Washington Highlights, Oct. 7].
The rule also delays implementation of the definition of “substantive portion” of a split (shared) service as being more than half of the total time for one year until Jan. 1, 2024. The rule adopts significant changes to several E/M code families (hospital, emergency medicine, nursing facility, and home visits) that were recommend by the American Medical Association’s CPT Editorial Panel and Resource-Based Relative Value Scale Update Committee.
The rule implements policies in the Consolidated Appropriations Act of 2022 (P.L. 117-103) which extend certain flexibilities in place during the COVID-19 public health emergency (PHE) for 151 days after the PHE ends, including permitting telehealth services to be furnished in any geographic area including the patient’s home, permitting audio-only technology, and allowing physical therapists, occupational therapists, speech-language pathologists, and audiologists to furnish telehealth services.
In light of the increased needs for mental health services, the rule creates a new general behavioral health integration service personally performed by clinical psychologists or clinical social workers to account for monthly care integration when those practitioners are serving as the focal point of care integration. It also allows licensed professional counselors, marriage and family therapists, and other behavioral health practitioners to provide services under general (rather than direct) supervision. In addition, the rule creates new codes to allow payment for chronic pain management.
The CMS made numerous changes to the Medicare Shared Savings Program (MSSP) to incentivize participation. These include allowing advanced payments to certain Accountable Care Organizations (ACOs) that are low revenue and serve underserved populations, giving more time to transition to downside risk for certain organizations, and making adjustments to benchmarks to reduce the effect of ACO performance on historical benchmarks and increase options for ACOs caring for high-risk populations. It also updates the MSSP quality measurement policies, including a new health equity adjustment for ACOs serving higher proportions of underserved or dually eligible beneficiaries.
For the QPP, the agency added five new Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPs) and revises the seven established MVPs for a total of 12 MVPs starting in performance year 2023. The CMS finalized refinements to the MIPS subgroup reporting process. Subgroup reporting will be voluntary for CY 2023, 2024, and 2025 performance periods, and multispecialty groups will be required to participate as subgroups when reporting MVPs in the 2026 performance period.
Finally, the rule includes changes to scoring and requirements under the Promoting Interoperability performance category. For the 2023 performance year, eligible clinicians will no longer be able to earn the 5% Advanced Alternative Payment Model (APM) bonus payment or the MIPS exceptional performance bonus unless Congress passes legislation extending these bonuses. The AAMC and other organizations have been advocating for Congress to extend the APM bonus payment and the exceptional performance pool funding [refer to Washington Highlights, Sept. 28].