Reviewing the 2022 Proposed Medicare Physician Fee Schedule Rule

Radiology stakeholders are still working to understand and absorb the potential impacts of the 2022 Medicare Physician Fee Schedule (PFS) proposed rule released by the Centers for Medicare & Medicaid Services (CMS) on Tuesday, July 13, 2021, as the final rule approaches. Radiology will once again experience a threat to payments after an excruciatingly trying year for many facilities and providers. On the upshot, the American College of Radiology (ACR) and other stakeholders are “pleased with CMS’s proposal to move forward with the appropriate use criteria (AUC) program.” As usual, the proposed rule outlines potential updates to a variety of policies and provisions that dictate payment for many services included in the Quality Payment Program (QPP), the Merit-Based Incentives Payment System (MIPS), and Advanced Alternative Payment Models (APMs). Keep in mind that these policies are proposed and will not be set in stone until the release of the final rule. Here, we highlight some but not all of the impacts the rulemaking could have on radiology.

Projected Conversion Factor Grinds Reimbursement

According to CMS, “the rule is one of several proposed rules that reflect a broader Administration- wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation.” Yet for radiology, the policies continue to target reimbursement time and time again with lasting consequences.

For 2022, the conversion factor will yield a slight decrease. If finalized, the proposed PFS changes could see an impact of a two percent decrease to radiology. However, a more consequential aggregate decrease of nine percent for interventional radiology is expected. Watch out for a two percent decrease for nuclear medicine. Meanwhile, radiation oncology and radiation therapy centers will likely experience a five percent decrease. In its evaluation, CMS estimated a 2022 conversion factor of $33.5848, a slight decrease from the present factor of 34.8931 in 2021. Changes in RVUs along with redistributive goals and impacts of the proposed clinical labor pricing update, along with the “phase-in implementation of the previously finalized updates to supply and equipment pricing,” help account for the decrease. Note that the Consolidated Appropriations Act, 2021 (P.L.116-260) contained a 3.75 percent adjustment to the 2021 conversion factor. This staved off alarming payment cuts for radiology that racked up a projected 10 percent cut and reduced it to four percent. However, the ACR warns, “If Congress does not intervene, the percent decreases mentioned above could be greater for CY 2022 for many physicians including Interventional Radiology and Radiation Oncology.”

Flexibility Through Extreme and Uncontrollable Circumstances

With case numbers rising, and the healthcare system still feeling the toll of the pandemic, the national public health emergency (PHE) is projected to last through 2021 and will continue to rock the operations of clinicians and healthcare professionals. With this projection,

CMS is enabling several groups to qualify and apply for Extreme and Uncontrollable Circumstances (EUC) “to reweight one or more performance categories for PY 2021.” These groups are expected to include:

• Individual clinicians

• Clinician groups

• Virtual groups

Understand that should a clinician, clinical group, or virtual group provide a EUC application while also submitting performance category data, the data is expected to outweigh and overrule the EUC application.

Virtual Direct Supervision and PHE Flexibilities Face Expiration

Some of the supervision flexibilities that benefited many services may be coming to an end depending on decisions from CMS. In the proposed rule according to the ACR, CMS is requesting 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.”

CMS is also inquiring to know if physicians and practitioners project whether they will continue to use the flexibilities following the end of the PHE and whether these changes should be a permanent policy. Some controversy existed amongst stakeholders during 2020 and 2021 as to whether the flexibilities should continue due to concerns surrounding the quality of care and services.

2022 Updated MIPS Category Weighting

For 2022, CMS proposed weights of the following:

• Quality – 30%,

• Cost – 30%,

• PI – 25%,

• and IAs – 15%.

Following the policies set forth in the 2020 MPFS final rule, expect to see a lowered weight for the Quality category down to 30% in 2022 and subsequent years. Note that with Cost rising to 30% in 2022, percentages will likely be constant for MIPs program future years. Category reweighting will continue to be an option for those physicians that cannot provide data for one or more performance categories. The ACR acknowledges that “in most cases, the weight of these categories will continue to be redistributed to the Quality category.”

2022 MIPS Performance Threshold and Incentive Payment Changes

As some may remember, CMS was granted latitude to establish a performance threshold for three years following the policies in the Bipartisan Budget Act of 2018. This helps with a gradual transition to the statutorily mandated performance threshold. This mandated performance threshold is founded upon the mean or median of final scores from a respective previous period. Starting in 2022, expect to see the performance

threshold rise up to 75 points, reflecting the 2017 performance data mean. Watch out for an exceptional performance threshold locked in at 89 points. This reflects the 25^th percentile of final scores over the performance threshold from 2017. In addition, note that the agency finalized the payment adjustment of +/- 9% for performance years 2020 and future years. Understand that no changes are in the works for the MIPS adjustment.

AUC/Clinical Decision Support CDS Gets Greenlight

The proposed rule plans to advance with the appropriate use criteria (AUC) program for advanced diagnostic imaging services. This AUC program is a requirement of policy provisions included within the Patient Access to Medicare Act of 2014. Starting on January 1, 2023, plan for the potential of monetary penalties. The initial delay came after a solid understanding by CMS that monumental challenges exist for hospitals and medical practices over the course of the PHE, while realizing the prior investment allocated by many practices in AUC systems.

According to the ACR, “When fully implemented, the AUC program will be a valuable tool to ensure that Medicare patients receive the right imaging at the right time.” The ACR also notes that “the proposed rule also includes several potential solutions to claims processing issues that have delayed the program’s implementation. These solutions appear to be a step in the right direction, however, the ACR will review the proposals in detail in the coming weeks and will provide feedback to CMS during the comment period.”

Further Sources to Explore:

https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-schedule-proposed-rule

https://public-inspection.federalregister.gov/2021-14973.pdf

https://www.acr.org/-/media/ACR/NOINDEX/Advocacy/2022-MFS-PR-Preliminary-Summary.pdf