The Federal Register published the Calendar Year 2022 Medicare Physician Fee Schedule final rule on November 19, 2021. The MPFS final rule establishes payment and relative value unit assignments for services provided by physicians and other Medicare suppliers. In addition, the MPFS includes payment policies for specific services and specific types of suppliers. Following is a brief discussion of key elements in the MPFS final rule for 2022. 

Conversion Factor

Each year, the MPFS updates the Conversion Factor (the amount that is multiplied by the service’s relative value units to determine the baseline price of the service). The update generally takes into account any changes to RVUs established for services and any services added to or deleted from the MPFS. Because CMS is required to make MPFS payments budget-neutral year over year, the Conversion Factor update is frequently negative. That was the case this year, as the conversion factor announced in the MPFS Final Rule was $33.59 – a decrease of $1.30 from CY2021. However, Congress subsequently enacted legislation to mitigate the negative adjustment, and consequently, CMS announced on December 15, 2021 that the CY 2022 Conversion Factor would be $34.6062, a reduction of approximately $0.29 from the CY2021 rate.

Evaluation and Management Codes.

CMS made several changes to payment policy for certain evaluation and management services

Split/Shared Services.

Split/shared services occur when a physician and a non-physician practitioner both provide portions of the same service to a patient in a facility setting. Unlike “incident to” services in the office setting, split/shared services historically were required to involve a face-to-face interaction with the patient from both the physician and the NPP to allow billing under the physician’s billing number and payment at the physician rate. CMS has established a new methodology by stating that only the practitioner who performs the “substantive portion” of the visit, which is defined in 2022 as the history, the physical examination, the medical decision-making, or at least one-half of the total time spent with the patient (except for critical care codes, which may only be determined by time). For CY2023, the “substantive portion” will be determined solely by time. This change is likely to mean that many split/ shared services that were previously billed under the physician’s number will now be billed under the NPP’s number and paid at 85% of the full fee schedule rate.

Critical Care Services.

CMS refined its longstanding policies regarding critical care services.

• CMS established that critical care services may be provided concurrently by more than one provider representing more than one specialty when medically necessary.

• Critical care services may be furnished as split/shared visits.

• Critical care services may also be provided on the same day as other E/M visits, if the other E/M visit is provided before the need for critical care arose and that the services were not duplicative. In this situation, practitioners must report a -25 modifier with the critical care service.

• Critical care services may also be paid separately in addition to surgical services if the critical services are above and beyond and unrelated to the specific surgical procedure

Teaching Physician Services

Teaching physicians have historically been able to bill for off/outpatient E/M visits in which a resident participates based either on time or on medical decision-making if the teaching physician is present for the key or critical portion of the service. CMS clarified that when using time to select the appropriate code, only the teaching physician’s time may be counted. Under the so-called “primary care exception,” which allows teaching physicians in certain primary care centers to bill for residents’ primary care services even when the physician is not present, the teaching physician must bill based on medical decision-making and may not bill based on time

Telehealth Services.

• Certain services that were added to the telehealth list for the COVID-19 public health emergency (PHE) will remain on the list until December 31, 2023.

• As required under the Consolidated Appropriations Act, 2021 (CAA), CMS will pay for telehealth services provided for the diagnosis, evaluation or treatment of a mental health disorder where the patient’s home is the “originating site” for purposes of telehealth billing.

• CMS also amended its definition of “interactive telecommunications system” to include audio-only technology for mental health disorders where the practitioner has both audio and video capability but the patient either lacks video capability or declines to use video capability. A new modifier will be required for audio-only services.

• Substance use disorders will be included in mental health services for purposes of the telehealth services described above

Therapy Services.

CMS has completed its implementation of payment at 85% of fee schedule for therapy services provided by physical therapy assistants and occupational therapy assistants under the supervision of a physical therapist or occupational therapist, respectively.

Billing for Physician Assistant Services.

CMS implemented the requirements of Section 403 of the CAA authorizing direct payment to physician assistants for their services. Previously, payment could only be made to the employer of a physician assistant for services provided by that physician assistant.

Vaccine Administration

• CMS will reimburse $30 per dose for administration of the influenza, pneumococcal and hepatitis B vaccines.

• CMS will maintain the current rate of $40 per dose for administration of COVID-19 vaccines through the end of the calendar year in which the current PHE ends.

• CMS will pay an additional $35.50 for home administration of COVID-19 vaccines through the end of the calendar year in which the current PHE ends.

• CMS will pay $450 for COVID-19 monoclonal antibodies in a health care setting, and $750 in the home setting, through the end of the calendar year in which the PHE ends. Thereafter, monoclonal antibodies will be paid according to existing payment policy for biologicals

Medicare Shared Savings Program.

• CMS extended the transition to e-reporting of clinical quality measures by extending the availability of the CMS web portal through performance year (PY) 2024.

• CMS also delayed the increase in the quality performance standard that ACOs must meet to be eligible to share in savings until PY 2024.

• CMS eased the repayment mechanism requirements for ACOs that have accepted performance-based risk to facilitate more ACOs entering into two-sided risk.

• CMS reduced some of the paperwork requirements related to applications to participate in the Shared Savings Program.

• Finally, CMS revised the definition of primary care services to be used for beneficiary assignment beginning with PY 2022.

Other changes.

• The Final Rule includes clarifying regulations related to practitioners that may provide medical nutrition therapy (MNT) services.

• CMS implemented Section 122 of the CAA to reduce the coinsurance obligation for beneficiaries whose colorectal screenings become diagnostic services (for example, when a polyp must be removed).

• RHCs and FQHCs may now provide mental health services by telehealth.

• CMS implemented the requirements of Section 130 of the CAA to increase the per-visit payment limit for RHCs.

• CMS finalized the limited circumstances under which it would waive the requirement for prescribers to use e-prescribing for controlled substances.