2023 Proposed Medicare Physician Fee Schedule

CMS has released the 2023 Proposed Physician Fee Schedule.  The proposed rule is more than 2,000 pages and contains numerous, important rule changes including:

  • Decrease in the conversion factor to $33.0775 from $34.6062
  • Adoption of the 2023 E/M changes for emergency department, hospital inpatient/observation, nursing and residential facilities, with certain exceptions:
    • CMS is creating new prolonged service codes which differ from CPT similar to their changes for prolonged services in the outpatient/office setting
    • CMS is not adopting the AMA guidelines for initial and subsequent services.  The 2023 CPT rules contain coding guidance for services rendered by subspecialists.  However, CMS does not recognize subspecialties and defines an initial service as one that occurs when a patient has not received any professional services from the physician or other qualified health care professional or another physician or qualified health care professional of the same specialty who belongs to the same group practice during the stay
    • CMS is not adopting the AMA guidelines for time based service coding.  Many CPT codes are reported based on the time spent as defined in the code descriptor.  The AMA’s general policy has been that a billable unit of service may be reported once the midpoint of time is achieved.  For example, if a CPT code descriptor is 30 minutes, the provider may report the code if at least 15 minutes have been spent.  CMS indicated last year with respect to critical care, that the full 30 minutes must be spent in order to report the service.  In the 2023 proposed rule, they have further clarified they expect the full time as defined in a CPT descriptor to be met in order to report the service. 
    • CMS is not adopting the AMA guidelines that allow services rendered in an office, emergency department or nursing facility on the same day the patient is admitted to inpatient or observation status to be separately reported with modifier 25.  CMS restated their policy that all services rendered by a physician (or another physician/qualified provider in the same group)  related to the admission are considered included in the admission when performed on the same day.
  • Delay to the split/shared visit rules which would have required time to be the substantive portion for all split/shared services beginning on January 1, 2023.  Instead, with the exception of critical care, providers will continue to have the option to to use history, exam or MDM as the substantive portion until January 1, 2024.
  • Modification of supervision requirements to allow certain behavioral health services to be rendered “incident to” under general supervision rather than direct supervision
  • Creation of new chronic pain management codes
  • Continued evaluation/expansion of telehealth services
  • Updates to MIPS 

We recommend you read the entire Proposed Rule in order to identify all of the changes applicable to your practice.  We will be providing more detailed analysis in the upcoming days.

The Proposed Rule is available here: https://public-inspection.federalregister.gov/2022-14562.pdf

The fact sheet is available here: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule

HBE’s team of coding and compliance experts is available to assist you with external reviews of your documentation, coding and reimbursement as well as providing customized education and training for your staff. We are also available to provide assistance with conducting risk assessments, internal investigations and policy and procedure development.

DISCLAIMER:  This newsletter contains only summary information and highlights; it should be read in conjunction with the full article or document provided as a link.  Any advice or recommendations are general and specific questions should be directed to professional counsel.

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