Summary: Proposed Calendar Year 2023 Physician Fee Schedule

Summary: Proposed Calendar Year 2023 Physician Fee Schedule

On July 7, 2022, CMS issued the Calendar Year 2023 (CY2023) Physician Fee Schedule (PFS) proposed rule, which makes payment and policy changes under Medicare Part B.

CMS is proposing to add some services to the Medicare Telehealth Services List on a Category 3 basis through the end of 2023, some of which had not been previously added to the Medicare Telehealth List during the COVID-19 public health emergency (PHE), but will be added on a subregulatory basis.

In addition, CMS is proposing that Medicare telehealth services furnished on or before the 151st day after the end of the PHE, in alignment with the extensions of telehealth-related flexibilities in the Consolidated Appropriations Act (CAA), 2022, will continue to be processed for payment as Medicare telehealth claims when accompanied with the modifier “95”. CMS is also proposing that physicians and practitioners can continue to report the place of service code that would have been reported had the service been furnished in-person during the 151-day period after the end of the PHE, as finalized on an interim basis in the March 31 IFC (85 FR 19233).

Below is a summary of key payment and policy change proposals within the proposed rule. Specific information that CMS is requesting comments on are also included below. Comments are due September 6, 2022.

See here for a press release, general fact sheet, fact sheet on the Medicare Shared Services Program, fact sheet on the Quality Payment Program, and blog on behavioral health changes that accompanied the proposed rule.

1. Provisions of the Proposed Rule for the PFS
2. Payment for Medicare Telehealth Services Under Section 1834(m) of the Act
3. Payment for Medicare Telehealth Services Under Section 1834(m) of the Act

• Requests to Add Services to the Medicare Telehealth Services List for CY 2023
  • CMS found that none of the requests received by the February 10th submission deadline met Category 1 or Category 2 criteria for permanent addition to the Medicare telehealth services list. As a reminder, Category 1 are services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the Medicare Telehealth Services list, and the criterion for adding services under Category 2 is that there is evidence of clinical benefit if provided as telehealth.
  • CMS also assessed the appropriateness of adding the proposed services to the Medicare Telehealth Services List on a Category 3 basis instead. CMS is not proposing changes to the length of time the services included on the temporary Category 3 basis. Category 3 will continue to be included through the end of CY 2023. In the event the PHE extends into CY 2023, CMS may consider revising this policy.
  • CMS is proposing to add some services to the Medicare Telehealth Services List on a Category 3 basis through the end of 2023, some of which CMS had not previously added to the Medicare Telehealth List during the PHE, but will be added on a subregulatory basis as provided in § 410.78(f) of its regulations. CMS has received information from interested parties suggesting potential clinical benefit for some of these services. For other services, CMS believes there is sufficient evidence of potential clinical benefit to warrant allowing additional time for interested parties to gather data to support their possible inclusion.
  • CMS is proposing to continue to allow certain telehealth services that would otherwise not be available via telehealth after the expiration of the PHE to remain on the Medicare Telehealth Services List for 151 days after the expiration of the PHE, as per the Consolidated Appropriations Act, 2022 (CAA, 2022) (Pub. L. 117-103, March 15, 2022).
  • CMS is proposing that CPT codes 97150, 97530, and 97542 (the set of therapy services that are currently on the Medicare Telehealth Services List on a temporary basis for the PHE), should be added to the Medicare Telehealth Services List through the end of CY 2023 on a temporary, Category 3 basis. This will allow CMS time to gather additional data that could support the inclusion on a more permanent basis. CMS also believes keeping these services through the end of CY 2023 would preserve access to care and promote health equity, and based on information provided by interested parties, internal review, may safely be furnished as telehealth outside of the circumstances of the PHE through the end of CY 2023.
  • CMS is encouraging commenters to supply additional information in support of adding other requested therapy services, namely CPT codes 97537, 97763, 90901, and 98960-98962, to the Medicare Telehealth Services List on a permanent basis, including information regarding the safety and appropriateness of furnishing these services via telehealth. Including these services on the Medicare Telehealth Services List during the PHE and through CY 2023 would allow additional time for the development of evidence for CMS to consider when evaluating these services for potential permanent addition to the Medicare Telehealth Services List on a Category 1 or 2 basis.
  • As noted in the CY 2021 PFS final rule (85 FR 84535), CMS will assign the Telephone E/M visit codes (CPT codes 99441, 99442, and 99443) a “bundled” status after the end of the PHE and the 151-day extension period. CMS will post the RUC-recommended RVUs for these codes in accordance with the usual practice.
  • CMS is seeking comment on whether GI Tract Imaging, CPT code 91110 and Ambulatory Continuous Glucose Monitoring, CPT code 95251 would meet the criteria for inclusion on the Medicare Telehealth Services List either for the PHE, as Category 3 services, or permanently on a Category 1 or 2 basis as whether they are inherently non-face-to-face services, and therefore, may not fit within the scope of services that could be furnished as Medicare telehealth services. CMS is also seeking comment on whether these services would involve an in-person service when furnished without the use of telecommunications system.
  • CMS is proposing to add CPT codes 95970, 95983, and 95984 to the Medicare Telehealth Services List on a Category 3 basis. CMS is concerned about CPT codes 95970, 95983, and 95984, which describes general brain nerve neurostimulation, about whether the full scope of service elements could be furnished via two-way, audio-video communication technology, particularly since it is unclear whether the connection between the implanted device and the analysis/calibration equipment can be done remotely. CMS is also soliciting comment on their concerns regarding patient safety and whether these services are appropriate for inclusion on the Medicare Telehealth Services List outside the circumstances of the PHE.
  • CMS is soliciting comments on patient safety concerns regarding emotional/behavior assessment, psychological, or neuropsychological testing and evaluation services. These services are currently on the Medicare Telehealth Services List temporarily for the duration of the PHE. CMS believes that there is likely to be clinical benefit when furnished via telehealth, and therefore, they meet the criteria for temporary inclusion on a Category 3 basis. However, CMS is concerned regarding whether, outside the circumstances of the PHE, the full scope of service elements can occur in a manner that does not jeopardize quality of care, whether this patient population could be fully assessed via interactive audio-video technology, and whether these services could be conducted in a way that maintains the safety of the beneficiary.
• Other Services Proposed for Addition to the Medicare Telehealth Services List
  • CMS is proposing to add a number of services to the list on a Category 3 basis that are currently included on the Medicare Telehealth Services List temporarily during the PHE. These services would be included on the Medicare Telehealth Services List through 2023 to allow CMS to evaluate data that may support their permanent addition to the list on a Category 1 or Category 2 basis.
    • The services proposed for inclusion to the Medicare Telehealth Services List on a Category 3 basis includes CPT codes 90875, 92012, 92014, 92014, 92507, 94005, 96105, 96110, 96112, 96113, 96127, 96170, 96171, 97129, 97130, and 99473.
  • CMS is soliciting comments regarding how widespread the availability of remote audiology testing technology is, and whether interested parties believe these services can be furnished in a way that does not jeopardize patient safety or quality of care when these services are furnished remotely. CMS believes that, in circumstances in which such equipment is available at the originating site, these services can be furnished in a way in which all of the elements of the services are met and that there is likely to be a clinical benefit when these services are furnished via telehealth. Therefore, CMS is proposing to add these services to the Medicare Telehealth Services List on a Category 3 basis, which would allow these services to be available via telehealth through the end of CY 2023.
  • CMS is proposing to create codes to describe prolonged services associated with certain types of E/M services. CMS believes these proposed G codes would be sufficiently similar to psychiatric diagnostic procedures or O/O visits currently on the Medicare Telehealth Services List to qualify for inclusion on the list on a Category 1 basis. Therefore, CMS is proposing to add proposed HCPCS codes GXXX1, GXXX2, and GXXX3 to the Medicare Telehealth Services List on a Category 1 basis.
  • Table 8 outlines services that CMS is proposing for addition to the Medicare Telehealth Services List on a Category 3 basis. Table 9 lists the services that CMS is proposing for permanent addition to the Medicare Telehealth Services List on a Category 1 basis. See appendix for both tables.
• Services Proposed for Removal from the Medicare Telehealth Services List After 151 Days Following the End of the PHE
  • As noted in the CY 2022 PFS final rule (86 FR 65054), at the conclusion of the PHE for COVID-19, the associated waivers and interim policies will expire, payment for Medicare telehealth services will once again be limited by the requirements of section 1834(m) of the Act, and CMS will return to the policies established through the regular notice-and-comment rulemaking process, through which CMS established Medicare Telehealth Services List.
  • CMS is proposing to continue to include on the Medicare Telehealth Services List the services that are currently set to be removed from the list when the PHE ends (that is, those not currently added to the list on a Category 1, 2, or 3 basis) for an additional 151 days after the PHE ends. Table 10 (appendix) lists those services that are temporarily available for the PHE, which CMS is proposing to retain on the Medicare Telehealth Services List for an additional 151 days following the end of the PHE. These services will no longer be available on the Medicare Telehealth Services List on the 152nd day after the end of the PHE, payment for Medicare telehealth services will once again be limited by the requirements of section 1834(m) of the Act, as aforementioned, and telehealth claims for these codes will be denied. CMS is proposing to align those services that had been planned to stop being available as Medicare telehealth at the end of the PHE with the 151-day extensions of flexibilities enacted in the CAA, 2022 in order to simplify the process of when flexibilities will end and to minimize possible errors.
• Implementation of Telehealth Provisions of the Consolidation Appropriations Acts, 2021 and 2022
  • CMS is proposing to implement provisions of section 1834(m) of the Act (including the amendments made by the CAA, 2021) and provisions of the CAA, 2022 that extend certain Medicare telehealth flexibilities adopted during the PHE for 151 days after the end of the PHE.
  • In-Person Requirement for Behavioral Health. Section 304(a) of the CAA, 2022 amended section 1834(m)(7)(B)(i) of the Act to delay the requirement for an in-person visit with a physician or practitioner within six months prior to an initial mental health telehealth service, and again at subsequent intervals as the Secretary determines appropriate. In light of this amendment, the in-person requirements for telehealth services furnished for purposes of diagnosis, evaluation, or treatment of a mental health disorder will again be effective on the 152nd day after the PHE ends. In addition, section 304(b) and (c) of the CAA, 2022 modified sections 1834(y) and 1834(o)(4) of the Act, respectively, to similarly delay in-person visit requirements for mental health visits furnished by Rural Health Clinics and Federally Qualified Health Centers via telecommunications technology.
    • Therefore, CMS proposes to update its regulations to recognize the delay of the in-person requirements for mental health visits furnished by RHCs and FQHCs through telecommunication technology under Medicare until the 152nd day after the PHE for COVID-19.
  • Audio-Only Telehealth. CMS is proposing to continue to make payment for services included on the Medicare Telehealth Services List as of March 15, 2022 that are furnished via an audio-only telecommunications system for the 151-day period beginning on the first day after the end of the PHE. CMS read section 305 of the CAA, 2022 to require that we continue to make payment for services furnished via audio-only telecommunications systems (each described by a HCPCS code, including their successor codes) for the 151-day period after the end of the PHE. These services include certain behavioral health, counseling, and educational services.
  • Given that the end date of the PHE is not yet known and could occur before the rulemaking process for the CY 2023 PFS is complete, and that the changes made by these provisions are very specific and concise, CMS is providing notice that they intend to issue program instructions or other subregulatory guidance to effectuate the changes described above, other than the proposed revisions to § 410.78, in the near future. CMS believes this approach will serve to ensure a smooth transition after the end of the PHE for COVID-19.
• Use of Modifiers for Medicare Telehealth Services Following the End of the PHE for COVID-19
  • CMS proposes that Medicare telehealth services furnished on or before the 151st day after the end of the PHE, in alignment with the extensions of telehealth-related flexibilities in the CAA, 2022, will continue to be processed for payment as Medicare telehealth claims when accompanied with the modifier “95”.
  • CMS further proposes that physicians and practitioners can continue to report the place of service code that would have been reported had the service been furnished in-person during the 151-day period after the end of the PHE, as finalized on an interim basis in the March 31 IFC (85 FR 19233). Medicare telehealth services performed with dates of service occurring on or after the 152nd day after the end of the PHE will revert to pre-PHE rules and will no longer require modifier “95” to be appended to the claim, but the appropriate place of service (POS) indicator will need to be included on the claim to be processed for payment as Medicare telehealth claims in order to properly identify the place where the service was furnished.
  • CMS proposes that, beginning January 1, 2023, a physician or other qualified health care practitioner billing for telehealth services furnished using audio-only communications technology shall append CPT modifier “93” to Medicare telehealth claims (for those services for which the use of audio-only technology is permitted under § 410.78(a)(3)), to identify them as having been furnished using audio-only technology. CMS believes that using modifier “93”, which is a CPT modifier, will simplify billing, as this modifier is used by payers outside of Medicare.

2. Other Non-Face-to-Face Services Involving Communications Technology Under the PFS
3. Expiration of PHE Flexibilities for Direct Supervision Requirements

• CMS changed the definition of “direct supervision” during the PHE for COVID-19 (85 FR 19245 through 19246) as it pertains to supervision of diagnostic tests, physicians’ services, and some hospital outpatient services, to allow the supervising professional to be immediately available through virtual presence using real-time audio/video technology, instead of requiring their physical presence.
• CMS is seeking information on whether the flexibility to meet the immediate availability requirement for direct supervision through the use of real-time, audio/video technology should potentially be made permanent.
• CMS is seeking comment regarding the possibility of permanently allowing immediate availability for direct supervision through virtual presence using real-time, audio/video technology for only a subset of services, as CMS recognizes that it may be inappropriate to allow direct supervision without physical presence for some services due to potential concerns over patient safety.

1. Non-Face-to-Face Services/Remote Therapeutic Monitoring (RTM) Services

• From CY2022 – CMS has heard two concerns related to the clinical labor in the direct PE for the two RTM treatment management codes, CPT codes 98980 and 98981.
• For CY 2023 CMS is proposing to create four new HCPCS G codes with one pair of codes aimed at increasing patient access to remote therapeutic monitoring services and the second pair aimed at reducing physician and NPP supervisory burden.
• CMS considered requests from interested parties to develop a generic device code for RTM and decided to wait to develop a generic RTM device code and instead will seek comment to inform any new coding relating to devices.
  • CMS seeks comment about RTM devices that are used to deliver services that meet the “reasonable and necessary” standard under section 1862(a)(1)(A) of the Act.
  • CMS seeks information related to the types of data collected using RTM devices, how the data that are collected solve specific health conditions and what those health conditions are, the costs associated with RTM devices that are available to collect RTM data, how long the typical episode of care by condition type might last, and the potential number of beneficiaries for whom an RTM device might be used by the health condition type.
• Proposal to develop two HCPCS G codes that allow certain qualified nonphysician health care professionals to furnish RTM services
  • As a means of increasing beneficiary access to RTM services, as well as more clearly defining the services of RTM for qualified nonphysician healthcare practitioners whose Medicare benefit category does not include services provided incident to their own services, CMS is proposing two codes that would expressly facilitate RTM services furnished by qualified nonphysician healthcare professionals who cannot bill under Medicare Part B for services furnished incident to their professional services. These codes would not include “incident to” activities in the practice expense (PE). Neither of the two proposed new codes include clinical labor inputs in the direct PE. CMS is proposing to make the current CPT codes 98980 and 98981 codes non-payable by Medicare.
• Proposed HCPCS G Codes:
  • GRTM3 (Remote therapeutic monitoring treatment assessment services, first 20 minutes furnished personally/directly by a nonphysician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the month).
  • GRTM4 (Remote therapeutic monitoring treatment assessment services, additional 20 minutes furnished personally/directly by a nonphysician qualified health care professional over a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month (List separately in addition to code for primary procedure))
• CMS is proposing a work RVU of 0.62 for the base code, HCPCS code GRTM3, which is the RUC-recommended work RVU established for CPT code 98980 in the CY 2022 PFS final rule. Similarly, for the add-on code, HCPCS code GRTM4, CMS is proposing a work RVU of 0.61, which is the RUC-recommended value established for CPT code 98981. CMS is proposing to remove the clinical labor inputs in the direct PE for both codes, which will facilitate the use of these codes by qualified nonphysician healthcare practitioners who cannot bill under Medicare Part B for services furnished incident to their professional services. See Table 28: Summary of Proposed HCPCS G Codes for Remote Therapeutic Monitoring Services for more detailed information about the codes.
• All the RTM codes including proposed HCPCS codes GRTM3 and GRTM4 would be designated as “sometimes therapy” codes, which means that the services could be billed outside a therapy plan of care by physicians and certain NPPs. When the services described by proposed HCPCS codes GRTM3 and GRTM4 are furnished by PTs, OTs, or SLPs, the services would always need to be furnished under a therapy plan of care. CMS reminds readers that RTM services that relate to devices specific to therapy services should always be furnished under a therapy plan of care regardless of who provides them. See the Medicare Benefit Policy Manual Chapter 15, Section 230 for more information about the practice of PT, OT, and SLP.
• Proposal to Develop two HCPCS G Codes Allowing General Supervision of Auxiliary Personnel – CMS is proposing to create two HCPCS G codes, one base code and one add-on code, that include clinical labor activities (that is, incident to services such as communicating with the patient, resolving technology concerns, reviewing data, updating and modifying care plans, and addressing lack of patient improvement) that can be furnished by auxiliary personnel under general supervision.
  • These two new G codes, GRTM1 and GRTM2, will include physician work and direct PE inputs as currently described in CPT codes 98980 and 98981 but will allow general supervision of the clinical labor found in the direct PE inputs. See Table 28: Summary of Proposed HCPCS G Codes for Remote Therapeutic Monitoring Services for more detailed information about the codes and use of the codes.
    • Proposed HCPCS G Codes:
      • HCPCS code GRTM1 (Remote therapeutic monitoring treatment management services, physician or NPP professional time over a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes of evaluation and management services).
      • HCPCS code GRTM2 (Remote therapeutic monitoring treatment management services, physician or NPP professional time over a calendar month requiring at least one interactive communication with the patient/caregiver over a calendar month; each additional 20 minutes of evaluation and management services during the calendar month (List separately in additional to code for primary procedure).
    • CMS is proposing a work RVU of 0.62 for HCPCS code GRTM1, which reflects the work RVU for CPT code 98980 finalized in the CY 2022 PFS final rule. For HCPCS code GRTM2, CMS is proposing a work RVU of 0.61, which is the RUC-recommended value finalized for the similar CPT code 98981. CMS is proposing the direct PE inputs associated with CPT codes 98980 and 98981 without refinement for HCPCS codes GRTM1 and GRTM2, respectively. CMS is proposing to make the current CPT codes 98980 and 98981 codes non-payable by Medicare.

1. Valuation of Specific Codes

(33) Chronic Pain Management and Treatment (CPM) Bundles (HCPCS GYYY1, and GYYY2)

In the CY 2022 PFS proposed rule (86 FR 39104, 39179 – 39181), CMS explored refinements to the PFS that would appropriately value chronic pain management and treatment (CPM) by soliciting comment on CPM for the purpose of future rulemaking. In CMS’ solicitation, they described Federal efforts for more than a decade to effectively address pain management as a response to the nation’s overdose crisis, such as the National Pain Strategy and the HHS Pain Management Best Practices Inter-Agency Task Force (PMTF) Report.

Through solicitation of comments, the CCM/CCCM/PCM code family now includes five sets of codes, each set with a base code and an add-on code. The sets vary by the degree of complexity of care (that is, CCM, CCCM, or PCM), who directly performs the services (that is, clinical staff, or the physician or NPP), and the time spent furnishing the services. The RUC-recommended values for work RVUs and direct PE inputs for these codes in CY 2022 were derived from a recent RUC specialty society survey.

• CMS is seeking comments regarding how best the initial visit and subsequent visits should be conducted (for example, in-person, via telehealth, or the use of a telecommunications system, and any implications for additional or different coding).
• CMS will also consider whether to add the CPM codes to the Medicare Telehealth Services List, based on our review of any information provided through the public comments and CMS analysis of how these new services may be appropriately furnished to Medicare beneficiaries.
• CMS is also asking for comment regarding whether there are components of the proposed CPM services that do not necessarily require face-to-face interaction with the billing practitioner, such as care that could be provided by auxiliary staff incident to the billing practitioner’s services.

(30) Cognitive Behavioral Therapy Monitoring (CPT Code 989X6).

See the Remote Therapeutic Monitoring (RTM) section II.I. of this proposed rule for a review of new device code, CPT code 989X6.

VII. Regulatory Impact Analysis

1. Extension of Certain Medicare Telehealth Flexibilities, Under Section 1834(m) of the Act, as Amended by the Consolidated Appropriations Act, 2022

As discussed in section II.D.1.e of this proposed rule, CMS is proposing to implement sections 301, 302, 304, and 305, of the Consolidated Appropriations Act, 2022, which extended the geographic restrictions (section 301), extended the temporary expansion of practitioner types who are eligible to furnish Medicare telehealth (section 302), delayed the in-person requirements under Medicare for mental health services furnished through telehealth under the PFS (section 304), and extended audio-only flexibilities for certain telehealth services that would otherwise not be available via telehealth (section 305) after the expiration of the PHE to remain on the Medicare Telehealth Services List for a 151-day period beginning on the first day after the end of the public health emergency (PHE) for COVID-19.

This proposal is necessary to fulfill the statutory requirement to implement this extension until the 152nd day after the end of the PHE for COVID-19.

1. Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

As discussed in section III.C.3 of this proposed rule, CMS implements sections 303 and 304 of the Consolidated Appropriations Act, 2022. Section 303 of the CAA, 2022 amended section 1834(m)(8) of the Act to temporarily continue payment for telehealth services furnished by FQHCs and RHCs for the 151-day period beginning on the first day after the end of the COVID-19 PHE using the methodology established for telehealth services furnished by FQHCs and RHCs during the PHE, which, in accordance with section 1834(m)(8)(B) of the Act, is based on payment rates that are similar to the national average payment rates for comparable telehealth services under the PFS.

Section 304 of the CAA, 2022 delays the in-person requirements under Medicare for mental health services furnished through telehealth under the PFS and for mental health visits furnished by RHCs and FQHCs via telecommunications technology for a 151-day period beginning on the first day after the end of the public health emergency (PHE) for COVID-19. These proposals are necessary to fulfill these statutory requirements.

CMS also discusses implementation of sections 301 and 305 of the CAA, 2022 that would apply to telehealth services (those that are not mental health visits) furnished by RHCs and FQHCs. That is, section 301 of the CAA, 2022 extended the geographic restrictions and section 305 of the CAA, 2022 extended audio-only flexibilities for certain telehealth services that would otherwise not be available via telehealth.

Alliance – CY2023 Physician Fee Schedule Proposed Rule – Summary of Telehealth Provisions