CMS Rule Proposals Herald Numerous Key Changes for Providers

Physicians and their organizations can expect to see significant changes to the PFS, QPP, and OPPS regulations.

The Centers for Medicare & Medicaid Services (CMS) issued key proposed rules related to Medicare payment for the 2022 calendar year (CY) recently. These rules propose important payment rates and policies for the Part B Physician Fee Schedule (PFS) and Quality Payment Program (QPP), and for outpatient facilities under the Outpatient Prospective Payment System (OPPS).

As a reminder, payments under the fee schedule are based on the relative value units (RVUs) applied to each service for work, practice expenses, and malpractice expenses. These RVUs become payment rates through the application of a conversion factor. Geographic adjusters (geographic practice cost index) are also applied to the total RVUs to account for variation in practice costs by geographic area. Payment rates are calculated to include an overall payment update specified by statute.

In the Part B PFS proposed rule, CMS is proposing a CY 2022 PFS conversion factor of $33.58, a decrease of $1.31 from the CY 2021 PFS conversion factor of $34.89. These changes are based on requirements in the law.

Regarding policy changes, CMS is proposing the following:

  • Refining longstanding policies for split (or shared) evaluation and management (E&M) visits to better reflect the current practice of medicine, the evolving role of non-physician practitioners (NPPs) as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services.
  • Refining policies for critical care services, including allowing such services to be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty, and allowing critical care services to be furnished as split (or shared) visits.
  • Allowing physician assistants (PAs) to bill Medicare directly for their services and reassign payment for their services.
  • Implementing the final part of section 53107 of the Bipartisan Budget Act of 2018, which requires CMS, using new modifiers (CQ and CO), to pay at 85 percent of the otherwise applicable Part B payment amount for physical therapy and occupational therapy services furnished in whole or in part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), for dates of service on and after Jan. 1, 2022.
  • Implementing additional policy changes for telehealth for mental health services and opioid treatment payment policies.

In the OPPS rule, CMS is:

  • Proposing provisions to increase compliance with the hospital price transparency rule, including raising the penalty for non-compliance.
  • Proposing to halt the elimination of the Inpatient-Only (IPO) List, and, after clinical review of the services removed from the IPO in CY 2021, proposing to add the 298 services removed from the IPO in CY 2021 back, beginning in CY 2022.
  • Proposing to reinstate the criteria (which related to patient safety) for adding a procedure to the ASC Covered Procedures List (CPL) that was in place in CY 2020 and prior. CMS is also proposing to remove from the ASC CPL 258 of the 267 procedures that were added in CY 2021.
  • Proposing to update by 2.3 percent OPPS payment rates for hospitals that meet applicable quality reporting requirements.
  • Seeking input on ideas to revise the Hospital OQR and ASCQR programs to make reporting of health disparities based on social risk factors and race and ethnicity more comprehensive and actionable for facilities, providers, and patients.

Programming Note: Listen to Stanley Nachimson report this story live today during Talk Ten Tuesdays at 10 Eastern.

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Stanley Nachimson, MS

Stanley Nachimson, MS is principal of Nachimson Advisors, a health IT consulting firm dedicated to finding innovative uses for health information technology and encouraging its adoption. The firm serves a number of clients, including WEDI, EHNAC, the Cooperative Exchange, the Association of American Medical Colleges, and No World Borders. Stanley is focusing on assisting health care providers and plans with their ICD-10 implementation and is the director of the NCHICA-WEDI Timeline Initiative. He serves on the Board of Advisors for QualEDIx Corporation. Stanley served for over 30 years in the US Department of Health and Human Services in a variety of statistical, management, and health technology positions. His last ten years prior to his 2007 retirement were spent in developing HIPAA policy, regulations, and implementation planning and monitoring, beginning CMS’s work on Personal Health Records and serving as the CMS liaison with several industry organizations, including WEDI and HITSP. He brings a wealth of experience and information regarding the use of standards and technology in the health care industry.

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