CMS Increases 2023 Cuts in Final Physician Fee Schedule, Finalizes Behavioral Health Reforms and Changes to Medicare Shared Savings Program (CMS-1770-F)

On November 1, the Centers for Medicare & Medicaid Services (CMS) issued the final calendar year (CY) 2023 Physician Fee Schedule, which proposes policies for physician payment and other outpatient services covered under Medicare Part B. The official CMS press release is available here. CMS has provided a rule overview fact sheet and a Medicare Shared Savings Program proposal fact sheet. This rule finalizes the following:

Decreases the conversion factor for 2023 by 4.48 percent from the conversion factor for 2022,
Delays rebasing and revising Medicare Economic Index (MEI) cost share weights,
Refines current Evaluation and Management visit policies,
Includes significant changes to the Medicare Shared Savings Program,
Includes Medicare behavioral health reforms,
Updates the Quality Payment Program, including changes to the Merit-based Incentive Payment System Value Pathways (MVPs),
Maintains telehealth services added during the public health emergency (PHE) through 2023,
Revises the provider and supplier Medicare enrollment requirements,
Updates vaccine administration payment,
Clarifies policies regarding covid-19 vaccine and monoclonal antibody products,
Codifies existing clinical laboratory fee schedule specimen collection and travel allowance payment policies, and
Adds four new remote therapeutic monitoring “G” codes.

The provisions of the final rule are effective January 1, 2023. The final rule has not been published in the Federal Register at this time.

CMS FINALIZES DECREASED CONVERSION FACTOR, REBASES AND REVISES MEDICARE ECONOMIC INDEX COST SHARE WEIGHTS

Physicians and other health professionals are paid under Medicare Part B for services that include office visits, surgical procedures, and other diagnostic and therapeutic efforts. To determine payment, Medicare uses a physician fee schedule (PFS) that is based on the relative resources typically used to furnish the service. These relative value units (RVUs) are applied to each service for physician work, practice expense (PE), and malpractice.

CMS multiplies these RVUs by a “conversion factor” to determine the Medicare payment amounts for each physician service. For 2023, CMS is finalizing decreasing the conversion factor by 4.48 percent, which reflects the finalized unadjusted 2022 conversion factor of $33.60 multiplied by an RVU budget neutrality adjustment of – 1.60 percent. Specifically, CMS finalizes a conversion factor of $33.06, which is a decrease of $1.55 from the 2022 conversion factor of $34.61.[1] This means that each physician service will be paid over 4 percent less in 2023 than it was in 2022, except for services where CMS proposes changes to the RVUs or otherwise specifically proposes payment increases.

The Protecting Medicare and American Farmers from Sequester Cuts Act (PMA)[2] provided a 1-year 3.0 percent increase to the conversion factor that increased the 2022 finalized conversion factor from $33.60 to $34.61. CMS notes that the PMA required this increase not to be taken into account in determining the PFS payment rates for subsequent years. Therefore, the 2023 conversion factor was calculated as though the 3.0 percent increase for the 2022 conversion factor had never been applied.

TABLE 1. Physician Fee Schedule Conversion Factor (CF) Comparison[3]

2022 Finalized CF	PMA Adjusted CF	2023 Finalized CF[4]
33.5983	34.6062	33.06

Overall, providers are facing significant reductions in Medicare payments, including a 2 percent sequestration cut[5]that restarted on July 1, 2022 following a moratorium during the Covid-19 pandemic, and is scheduled to continue through fiscal year 2031.[6] Sequestration[7] is a budget enforcement tool that reduces federal spending when budget goals are not met.[8]

CMS Delays Rebasing and Revising Medicare Economic Index Cost Share Weights

CMS will delay its proposal to rebase and revise Medicare Economic Index (MEI) cost share weights from a 2006-base year to a 2017-base year to reflect more recent market conditions. In this final rule, CMS confirms that will not use the rebased and revised MEI weights in PFS ratesetting and 2023 geographic practice cost index (GPCI). CMS will maintain current use of 2006-based MEI cost share weights for CY 2023 GPCIs.

The CMS Office of the Actuary developed the MEI, which consists of an index that measures market price changes of inputs used to provide physician services. CMS has historically used MEI cost weights to update geographic practice cost index (GPCI) weights to weigh four components of the GPCI PE, including employee compensation, office rent, purchased services, and medical equipment, supplies and other miscellaneous expenses.

The MEI was last updated in 2014. In its proposed rule, CMS proposed to primarily rebase the MEI from data provided by the U.S. Census Bureau’s 2017 Services Annual Survey (SAS), supplemented by other various data services. CMS reiterated in this final rule that 2017 SAS data is the most recently available complete data due to concerns about the COVID-19 pandemic’s impact on more recent data.

For purposes of updating payments outside of the PFS ratesetting, CMS is finalizing the proposed 2017-based MEI cost share weights as proposed for all cost categories in the MEI except for the compensation cost category weights where CMS revised the methodology based on public comments.

CMS FINALIZES REFINEMENTS TO CURRENT EVALUATION AND MANAGEMENT VISIT POLICIES

CMS is finalizing its proposal to adopt AMA CPT^®[9] changes in the coding and documentation for Other Evaluation and Management (E/M) visits. As part of a process to reduce administrative burden, the AMA CPT Editorial Panel approved coding and updated guidelines for Other (E/M) visits that go into effect on January 1, 2023. The Other E/M visits CMS is adopting include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment, effective January 1, 2023. Evaluation and management (E/M) visits make up approximately 40 percent of all allowable charges under the PFS.

CMS is finalizing a revised coding and documentation framework that will include CPT code definition changes (revisions to the Other E/M code descriptors), including:

New descriptor times (where relevant);
Updated guidelines for levels of medical decision making;
Choice of medical decision making or time to select code level (except for a few families like emergency department visits and cognitive impairment assessment, because they are not timed services); and
Eliminated use of history and exam to decide code level. There will instead be a requirement for a medically appropriate history and exam.

Additionally, CMS is finalizing its proposal to maintain the current billing policies that apply to E/Ms while CMS considers potential further revisions in future rulemaking. The Agency is also finalizing the creation of Medicare-specific coding payment of Other E/M prolonged services. Prolonged E/M will be reported under one of the three HCPCS codes G0316- G0318.

CMS Finalizes Delay Split (Or Shared) E/M Visits Policy

A split (or shared) E/M visit is one that is performed by both a physician and a NPP that are a part of the same group practice. In the 2022 PFS, CMS finalized a policy for split (or shared) E/M visits, specifically the definition of substantive portion of a visit as more than half of the total time spent. For 2023, CMS finalizes that it will delay the split (or shared) visits policy for a year until 2024.

This means that in 2023, as in 2022, physicians who provide split (or shared) visits will have the choice of history, physical exam, or medical decision making, or more than half of the total practitioner time spent to define the substantive portion, instead of using total time to determine the substantive portion.

CMS FINALIZES POLICIES TO ADVANCE HEALTHY EQUITY IN THE MEDICARE SHARED SAVINGS PROGRAM

Over 11 million Medicare fee-for-service (FFS) beneficiaries receive care from a healthcare provider in a Shared Savings Program Accountable Care Organization (ACO).[10] The Shared Savings Program is the largest value-based purchasing program in the U.S. Eligible healthcare providers and hospitals can participate in the program by starting or joining an ACO. In the Shared Savings Program, an ACO agrees to be held accountable for the quality, cost, and experience of care for assigned fee-for-service (FFS) beneficiaries.

The Shared Savings Program has different participation options (tracks) that allow ACOs to take on various levels of risk, including a BASIC track glide path from one sided risk that increases to more risk and the ENHANCED track, which encompasses maximum risk.

Based on stakeholder feedback[11] and continuing recent efforts to advance health equity, CMS is finalizing the following changes:

Providing advanced shared savings payments (referred to as advance investment payments) to low revenue ACOs that are inexperienced with performance-based risk initiatives, that are new to Shared Savings Program (that is, not a renewing ACO or a re-entering ACO), and that provide care to underserved populations;
Supporting organizations new to accountable care by providing greater flexibility in the progression to performance-based risk, allowing organizations additional time to redesign their care processes to be successful under risk arrangements;
Reducing the impact of ACO’s performance on their benchmarks;
Modifications to benchmarking methodology to reduce bias in regional expenditure calculations that benefit ACOs electing prospective assignment;
Opportunities for some low revenue ACOs participating in the BASIC track to share in savings even if they do not meet the minimum savings rate (MSR). This will allow for investments in care redesign and quality improvement activities among less capitalized ACOs;
Transitioning ACOs to all payer quality measure reporting and implementing a health equity adjustment;
Eliminating the requirement for an ACO to submit marketing materials to CMS for review and approval prior to disseminating materials to beneficiaries and ACO participants;
Streamlining the skilled nursing facility (SNF) 3-day rule waiver application review process; and
Reducing the frequency with which beneficiary information notices are provided to beneficiaries from annually to a minimum of once per agreement period.

CMS is also finalizing as proposed the initial application cycle for ACOs to apply to enter an agreement period to participate under the modified participation options, which will occur during 2023 for a January 1, 2024 start date. CMS notes that more information on how to apply will be available via the Shared Savings Program’s website during Spring 2023.

CMS FOCUSES ON SUBGROUPS IN MIPS VALUE PATHWAYS

In the annual PFS rulemaking, CMS includes its proposals for the Quality Payment Program (QPP), which includes two tracks: Merit-based Incentive Payment System (MIPS) and Alternative Payment Models (APMs). MIPS includes four performance categories: quality, cost, improvement activities, and promoting interoperability.

In 2020 rulemaking, CMS finalized creation of the MIPS Value Pathways (MVPs), a reporting option for MIPS that the agency believes will provide a more cohesive participation experience by aligning activities from the four MIPS performance categories around a certain specialty, medical condition, or patient population. CMS will move forward with this transition beginning with the 2023 MIPS performance year.

In the 2022 PFS final rule, CMS finalized seven MVPs that would be available for reporting beginning with the 2023 performance period/2025 MIPS payment year:

Advancing Care for Heart Disease;
Optimizing Chronic Disease Management;
Advancing Rheumatology Patient Care;
Improving Care for Lower Extremity Joint Repair;
Adopting Best Practices and Promoting Patient Safety within Emergency Medicine;
Patient Safety and Support of Positive Experiences with Anesthesia; and
Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes.

CMS is finalizing revisions to these seven MVPs and adding five new MVPs:

Advancing Cancer Care;
Optimal Care for Kidney Health;
Optimal Care for Neurological Conditions;
Supportive Care for Cognitive-Based Neurological Conditions; and
Promoting Wellness.

Multispecialty groups that practice in a team-based manner can report MVPs, and each subgroup must include at least one MIPS eligible clinician. CMS believes that subgroup reporting will allow for comprehensive measurement of clinician performance in MIPS because it allows clinicians to form subgroups and report on measures and activities relevant to the scope of care provided. Subgroup reporting will be voluntary for CY 2023, 2024, and 2025 performance periods. Multispecialty groups that choose to report through an MVP will be required to participate as subgroups beginning with the 2026 performance period.

Further, CMS is finalizing policies to encourage participation in Alternative Payment Models (APMs), in line with the Agency’s overall goals. Clinicians participating in an eligible Advanced APM as a Qualifying APM Participant (QP) are excluded from MIPS reporting requirements and payment adjustment. QPs currently receive a 5 percent lump sum incentive payment, which CMS is finalizing to continue through 2024 (the final year in which statute authorizes an APM incentive payment).

CMS is also finalizing a policy to introduce a voluntary reporting option for APM entities to report the promoting interoperability performance category at the APM entity level beginning with the 2023 performance period.

CMS had issued several Requests for Information related to the future of the QPP in the proposed rule and the Agency stated in the final rule that the public comments received in response will be taken into account for future rulemaking.

CMS FINALIZES NUMEROUS MEDICARE TELEHEALTH POLICIES, EXTENDS PHE RELATED FLEXIBILITIES

Services Added as Category 3 Services to Medicare Telehealth Services List through the end of CY 2023

During the COVID-19 PHE, CMS offered increased flexibility for telehealth services to promote Medicare beneficiary access to care. In the CY 2021 PFS final rule, CMS established a subset of “Category 3” codes to designate certain Medicare telehealth services that would be covered temporarily during the PHE. These services are those that will likely provide a clinical benefit when furnished during the PHE, but that there is insufficient evidence to consider permanent inclusion on the list. Not all temporary telehealth service codes are included in Category 3.

In this final rule, CMS finalizes the addition of new services to the Medicare Telehealth Services List^[12] on a Category 3 Basis through the end of CY 2023.[13] These codes encompass services including telephone E/M, therapy, gastrointestinal tract imaging, ambulatory continuous glucose monitoring, electronic analysis of implanted neurostimulator pulse generator/transmitter, and adaptive behavior treatment and behavior identification assessment.

CMS Finalizes Permanent Addition of Category 1 G-codes to the Medicare Telehealth Services List

Category 1 services are defined as services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the Medicare Telehealth Services List. The following codes are added on a Category 1 basis to the Medicare Telehealth Services List and replace existing codes that describe prolonged services (CPT codes 99356 and 99357):

HCPCS	Short Descriptor
G0316	Prolonged inpatient or observation services by physician or other QHP
G0317	Prolonged nursing facility services by physician or other QHP
G0318	Prolonged home or residence services by physician or other QHP
G3002	Chronic pain tx monthly b
G3003	Addition 15m pain mang

Duration of Temporary Telehealth Services Extended

In alignment with the Consolidated Appropriations Act of 2022 (CAA),^[14] the Agency finalized its proposal to extend the duration of time that services are temporarily included on the telehealth services list during the PHE for at least a period of 151 days following the end of the PHE. Also in this final rule, the agency identifies services to be removed from the Medicare Telehealth Service List after 151 days following the end of the PHE.^[15]

Flexibilities for Telehealth Services Extended

CMS will continue to extend the following PHE related telehealth flexibilities for 151 days after the end of the PHE:

Allowing telehealth services to be furnished in any geographic area and in any originating site (including the beneficiary’s home);
Furnishing certain services via audio-only telecommunications;
Allowing qualified health professionals, including physical therapists, occupational therapists, speech language pathologists, and audiologists to furnish telehealth services; and
In person visit requirements for mental health services furnished via telehealth are delayed until 152 days after the end of the PHE.

Telehealth Claims and Billing Practices

CMS finalizes its proposal to continue to allow providers to bill with the place of service (POS) indicators reported for the service, as though it were furnished in person. Claims require the use of modifier “95” to identify them as telehealth services. The agency will continue this billing practice through the end of 2023, or the year in which the PHE ends.

“Direct Supervision” Flexibility to Continue Until At Least End of 2023

In a temporary PHE flexibility, CMS changed the definition of “direct supervision” to allow supervising professionals to be available through virtual presence rather than physical presence for certain services. In the proposed rule, CMS sought comment on this policy, and whether it should be made permanent. Per its previously finalized policy, CMS will continue to permit direct supervision through virtual presence through at least the end of 2023.

CMS Updates Telehealth Originating Site Fee

For 2023, CMS sets the telehealth originating site fee at $28.64 for HCPCS code Q3014 (Telehealth originating site facility fee).

CMS FINALIZES CHANGES TO MEDICARE PROVIDER AND SUPPLIER ENROLLMENT OVERSIGHT

CMS finalizes revisions to the provider and supplier Medicare enrollment process to strengthen program integrity. These finalized changes include:

Allowing revocation based on Office of the Investigator General (OIG) exclusions and felony conviction;
Expanding the number of providers and suppliers subject to the highest level of screening, including skilled nursing facilities (SNFs), which requires fingerprinting all 5 percent or greater owners of those providers and suppliers; and
Adding a new DMEPOS condition of payment requiring DMEPOS suppliers to be in compliance with state licensure requirements[16] at the time an item or service is furnished in order to receive payment.

CMS predicts a slight increase in revocations as a result of the policy to permit revocation based on OIG exclusions and felony convictions.

In addition, CMS is finalizing the requirement that a new ownership or change in ownership will require fingerprinting and a criminal background check if the provider or supplier is in the “high” level of categorical screening. A high level of categorical screening will also apply to prospective providers and suppliers that are enrolled under the same business name or tax identification number as another provider with a high level classification.

CMS is also finalizing moving skilled nursing facilities from the “limited” level to the high level of categorical screening.

Lastly, CMS is finalizing addition of a new condition of payment requiring DMEPOS suppliers to be in compliance with state licensure requirements[17] at the time an item or service is furnished in order to receive payment. This proposal is in response to situations where an unlicensed DMEPOS supplier furnishes items for an extended period and then terminates their enrollment or CMS revokes their enrollment.

CMS TO ANNUALLY UPDATE PAYMENTS FOR PREVENTIVE VACCINE ADMINISTRATION SERVICES AND CONTINUE IN-HOME ADDITIONAL PAYMENT FOR COVID-19 VACCINE ADMINISTRATION

CMS finalized its proposal to annually update the payment amount for the administration of Part B preventive vaccines to reflect changes in cost based upon the increase in the MEI.CMS also will adjust this payment amount to reflect cost differences for the geographic locality using the Geographic Adjustment Factor (GAF). These adjustments will apply to HCPCS codes G0008, G0009, G0010, and CPT codes that describe the service to administer COVID-19 vaccines effective January 1, 2023.

In addition, CMS is finalizing its proposal to maintain in-home additional payment for COVID-19 vaccine administrations for 2023. The 2023 payment is $36.85 which will be geographically adjusted.

CMS CLARIFIES POLICIES REGARDING COVID-19 VACCINE AND MONOCLONAL ANTIBODY PRODUCTS

In light of the distinction between a Public Health Emergency (PHE) declared under section 319 of the Public Health Service Act (PHS Act) and an Emergency Use Authorization (EUA) declaration under section 564 of the Food, Drug, and Cosmetic Act (FD&C Act), and the possibility that they will not terminate at precisely the same time, CMS clarifies that its payment policies for COVID-19 vaccines and COVID-19 monoclonal antibody (mAb) products will continue through the end of the calendar year in which the Emergency Use Authorization (EUA) declaration for drugs and biological products is terminated.

In addition, CMS is finalizing its proposal to permanently cover and pay for covered monoclonal antibody products used as pre-exposure prophylaxis for prevention of COVID-19 under the Medicare Part B vaccine benefit.

CMS FINALIZES POLICIES REQUIRING MANUFACTURER REFUNDS FOR DISCARDED SINGLE-DOSE OR SINGLE-USE DRUGS

Under current law,[18] drug manufacturers must provide a refund to CMS for certain discarded amounts from a refundable single-dose container or single-use package drug. The refund amount is equal to the amount of discarded drug that exceeds an applicable percentage, which is required to be at least 10 percent, of total charges for the drug in a given calendar quarter. This refund applies to refundable single-dose container or single-use package drugs beginning January 1, 2023.

In this final rule, CMS is finalizing a number of its proposals as relate to the definition of a refundable single-dose container or single-use package drug and relevant exclusions per statute (e.g., radiopharmaceuticals or imaging agents, drugs that require filtration during the drug preparation process).

While CMS solicited comments on drugs with unique circumstances for which a higher applicable percentage may be appropriate, for CY 2023, the Agency ultimately only identified one group of products which it would adopt a higher percentage and had noted this group in its proposed rule: 35% for drugs reconstituted with a hydrogel and with variable dosing based on patient-specific characteristics. This would currently only apply to one product, Jelmyto® (mitomycin for pyelocalyceal solution).

In response to numerous comments requesting higher applicable percentages for different drugs, CMS indicates plans to collect additional information about drugs that may have unique circumstances and the process to be used to identify those unique circumstances based on manufacturer input. CMS will revisit additional increased applicable percentages through future notice and comment rulemaking.

Additionally, CMS is finalizing its proposal to require use of the current JW modifier, for reporting discarded amounts of drugs, and the new JZ modifier, for attesting that there were no discarded amounts. Providers will be required to report the JW modifier beginning January 1, 2023 and the JZ modifier no later than July 1, 2023 in all outpatient settings.

Regarding when initial reports on refunds would be issued, CMS is not finalizing its previously proposed initial invoice timeline of October 2023. In light of implementation of this policy and the new inflation rebate programs under the Inflation Reduction Act, CMS is not finalizing the timing of the first report or the date the first refund payments are due. The Agency has noted that it plans to issue preliminary report on estimated discarded drug amounts based on claims from the first two calendar quarters of 2023 no later than December 31, 2023 and will revisit the timing of the first report in future rulemaking.

CMS CODIFIES EXISTING CLINICAL LABORATORY FEE SCHEDULE (CLFS) SPECIMEN COLLECTION AND TRAVEL ALLOWANCE PAYMENT POLICIES

Under current law,[19] CMS must provide a nominal fee for specimen collection for laboratory testing and a fee to cover transportation and personnel expenses for trained personnel to collect specimens from homebound patients and inpatients (not in a hospital).

Though CMS’ longstanding policies and practices regarding the statutory requirements for the laboratory specimen collection and travel allowance are outlined in Medicare Claims Processing guidance, the Office of Inspector General and others have noted inconsistencies regarding Medicare Contractor implementation of these policies and unclear or conflicting guidance to providers regarding the travel allowance.

In response to comments and stakeholder feedback, CMS is finalizing the following proposals:

An increase in the general specimen collection fee from $3 to $8.574. As required by PAMA, this amount will increase by $2 for specimens collected from a Medicare beneficiary in a SNF or by a laboratory on behalf of a home health agency, which will result in a $10.57 specimen collection fee for those beneficiaries.
A policy to update this fee amount annually by the percent change in the Consumer Price Index for all Urban Consumers (CPI-U).
Codify in regulations and make some modifications and clarifications regarding (1) general requirement, (2) travel allowance basis, (3) travel allowance amount, and (4) travel allowance amount calculation.
Codify and clarify various laboratory specimen collection fee policies because the policies implementing the statutory requirements for the laboratory specimen collection fee, which are currently described in the Medicare Claims Processing Manual, Chapter 16, did not have corresponding text in regulations and some of the manual guidance is no longer applicable.
Specify that CMS will pay $3 for all specimens collected in one patient encounter.
Clarify that one specimen collection fee would be allowed for each single patient encounter – this means that, if different types or multiple specimens are drawn from one patient, only one specimen collection fee would be allowed.
Indicate the specimen collection requirements that must be met for a specimen collection fee to be payable .
Clarify the requirement that the specimen must be collected by a “trained technician” and that a specimen collected by a trained technician would have to be either blood collected through venipuncture or a urine collected by catheterization.
Delete the section in the manual regarding physician specimen collection as codes exist to describe these services when performed by physicians under the PFS .
Codify in regulations and make some modifications and clarifications regarding (1) general requirement, (2) travel allowance basis, (3) travel allowance amount, and (4) travel allowance amount calculation.

CMS will make conforming changes to the Medicare Claims Processing Manual, Chapter 16 to reflect changes or clarifications and remove sections that are no longer applicable.

CMS DOES NOT FINALIZE PROPOSALS TO REDEFINE SKIN SUBSTITUTE PAYMENT POLICIES, TOUTS TOWN HALL IN CY 2023

CMS currently uses the term “skin substitute” to define a group of products used to cover appropriate wounds with the intent of stimulating the healing process. CMS has previously defined skin substitutes as a category of “biological and synthetic products that are most commonly used in outpatient settings for the treatment of diabetic foot ulcers and venous leg ulcers.”[20] CMS has also clarified that this definition does not include bandages or standard dressings.

CMS proposed several changes to the policies for skin substitute products to streamline the coding, billing, and payment rules. The Agency proposed to replace the term ‘skin substitute’ with the term ‘wound care management’ or ‘wound care management products’ and to treat and pay for these products as incident to supplies under the PFS beginning January 1, 2024.

However, after reviewing comments, CMS states that it would be beneficial to provide stakeholders more time to comment on the specific date when the transition to more consistent payment and coding for skin substitute products would be completed. CMS also notes that it will hold a town hall in early 2023 with interested parties to address concerns and discuss methodologies to pay for these products in a consistent manner under the PFS.

CMS INCREASES BEHAVIORAL HEALTH ACCESS

Circumstances surrounding the PHE for Covid-19 led to an increased demand for behavioral health services. Further compounding this issue, the COVID-19 pandemic contributed to provider shortages, creating significant barriers to access. To increase Medicare Beneficiary access to these services, CMS finalizes several changes to the behavioral health services delivery process to increase access and quality of care.

Removal of the Direct Supervision Requirement

In this final rule, CMS amends the direct supervision requirement to a general supervision requirement, removing the requirement that the physician or supervising provider be physically present during the administration of the service.^[21] This change grants broader access to payment for Licensed Professional Counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs), who were previously only paid on the PFS if under the direct (physically present) supervision of a billing physician or other practitioner. CMS also clarifies that any service furnished primarily to diagnose and treat a mental health or substance use disorder can be performed by auxiliary personnel under general supervision.

New G-Code for Chronic Pain Management Finalized

CMS finalizes establishment of a separate coding and payment for chronic pain management (CPM) services to improve pain care for beneficiaries using two new HCPCS “G” codes to describe monthly CPM services. Moving forward, CMS will monitor the use of these codes to identify utilization patterns.

G3002 can be billed up to three times per month
G3003 may be billed for each additional 15 minutes of care, an unlimited number of times, as medically necessary per month, after G3002 has been billed.

Additionally, CMS finalizes a new G code for general behavioral health services provided by Clinical Psychologists (CPs) and Clinical Social Workers (CSWs), which is cross walked CPT code 99484, similar care provided by a physician.

HCPCS code	Descriptor
G0323	Care management for behavioral health conditions, at least 20 minutes of clinical psychologist or clinical social worker time, per calendar month

CMS DOES NOT FINALIZE FOUR NEW REMOTE THERAPEUTIC MONITORING HCPCS “G” CODES

CMS is not finalizing its proposal to establish four new HCPCS “G” codes related to remote therapeutic monitoring (RTM) services. For CY 2023, CMS proposed to replace existing RTM codes 98980 and 98981 with HCPCS “G” codes: GRTM1, GRTM2, GRTM3, and GRTM4. Codes GRTM1 and GRTM2 were intended to lessen the supervisory burden of physicians and non-physician practitioners by including clinical labor activities that can be provided by auxiliary staff under general supervision. Codes GRTM3 and GRTM4 were intended to increase patient access to remote therapeutic monitoring services by more clearly defining RTM services for nonphysician healthcare practitioners.

However, in response to significant stakeholder concerns concerning the establishment of these codes, CMS will not finalize its proposal. Instead, CMS will maintain existing 98980 and 98981 RTM codes and clarifies existing RTM billing policies to permit general supervision for all RTM services. CMS notes that further changes to RTM billing and coding may be considered in future rulemaking.

Further, CMS clarifies that even when multiple devices are provided to a patient, the services associated with all the medical devices can be billed by only one practitioner, only once per patient, per 30-day period, and only when at least 16 days of data have been collected.

***

This Applied Policy® Summary was prepared by Simay Okyay McNutt with support from the Applied Policy team of health policy experts. If you have any questions or need more information, please contact her at sokyay@appliedpolicy.com or at 202-558-5272

[1] This conversion factor includes the update from the Protecting Medicare and American Farmers from Sequester Cuts Act (PMA, Pub. L. 117-71).

[2] Pub. L. 117-71.

[3] See Table 136 on page 1438 of the unpublished rule.

[4] Includes a CY 2023 RVU budget neutrality adjustment of -1.60 percent.

[5] Budget Control Act of 2011 (Pub. L. 112-25).

[6] PAYGO can be triggered in situations where budget enforcement rules are not followed. Specifically, the American Rescue Plan Act of 2021 (ARPA, Pub. L. 117-2) triggered PAYGO for 2022, but the PMA deferred this impact to 2023.

[7] Sequestration was established under the Balanced Budget and Emergency Deficit Control Act of 1985, Pub. L. 99-177.

[8] https://sgp.fas.org/crs/misc/R45106.pdf.

[9] CPT is a registered trademark of the American Medical Association.

[10] An ACO is an organization that consists of doctors, insurance providers and hospitals with the goal of providing better healthcare through communication and coordination, while saving money and improving quality of care provided to patients. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ACO

[11] The National Association of ACOs (NAACOS) responded very positively to the proposed changes for the Medicare Shared Savings Program. https://www.naacos.com/press-release–many-significant-aco-changes-included-in-proposed-medicare-rule

[12] This list includes approved Medicare Part B telehealth services.

[13] See Table 12 of the unpublished rule

[14] Pub. L. 117-103.

[15] Table 14 of the unpublished rule

[16] 42 C.F.R. § 424.57(c)(1)(ii)(A).

[17] 42 C.F.R. § 424.57(c)(1)(ii)(A).

[18] Section 90004 of the Infrastructure Investment and Jobs Act (Pub. L. 117-9).

[19] Section 1833(h)(3) of the Social Security Act.

[20] 85 FR 80605.

[21] 42 CFR § 410.26(a)(1)(iii)

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