As we previously announced, on July 7th, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) proposed rule. For CY 2023, CMS proposes an MPFS conversion factor of $33.0775. That represents a 4.42% reduction from the CY 2022 MPFS conversion factor due to the expiring 3.0% boost to the conversion factor provided by Congress for CY 2022 as well as an additional budget neutrality adjustment generated by the CY 2023 proposed policies. While CMS has estimated that the overall impact of the rule on emergency medicine is a 1% increase in payments, this estimate does not factor in the expiring CY 2022 congressionally-mandated 3% boost to the conversion factor. This generally means that, without Congressional intervention, emergency medicine could see a 2% reduction in payments in 2023 compared to 2022. This will be compounded even further given the 2% sequestration that is already applied to Medicare payments as well as if Congress allows the looming 4% cut go into effect due to budgetary “pay-as-you-go” (PAYGO) rule. EDPMA along with other stakeholders will continue to urge Congress to avoid these and future cuts.
Payment Policies
ED E/M Codes
CMS proposed adopting the revised CPT documentation guidelines for emergency department (ED) evaluation and management (E/M) visits. These changes are intended to align documentation for all E/M code sets (other than critical care services) with the documentation guidelines adopted for office and outpatient E/Ms in CY 2021. (For more information on the ED E/M documentation guideline changes coming January 1, 2023, see information from AMA CPT via this link.)
Because of these documentation guideline changes, the AMA RUC also embarked on a revaluation of all affected codes sets. In this rule, CMS proposed accepting the values for emergency department (ED) evaluation and management (E/M) services as recommended by the AMA RUC for CPT 99281, 99282, 99283, and 99285. However, CMS rejected the RUC recommendation of 2.60 for CPT 99284 and instead proposes to maintain the current work relative value units (RVUs) of 2.74. The 2023 work RVUs compared with 2022 work RVUs are included in the following table:
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Proposed CY 2023 ED Visit wRVUs |
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| CPT Code | 2023 wRVU | Relative to 2022 wRVUs |
| CPT 99281 | 0.25 | -48.0% (0.48) |
| CPT 99282 | 0.93 | 0% (0.93) |
| CPT 99283 | 1.60 | 0% (1.60) |
| CPT 99284 | 2.74 | 0% (2.74) |
| CPT 99285 | 4.00 | 0% (4.00) |
Split (or Shared) Visits
CMS had previously finalized a new January 1, 2023 billing policy for instances in which a physician delivers an E/M service along with a non-physician practitioner. CMS had stated that the practitioner that would bill the service would be the one who performed the “substantive portion” of the service. For January 1, 2023, CMS had set out to define “substantive portion” as “more than half of the total time.” As EDPMA requested, CMS has delayed the policy that would have based the determination of the billing practitioner solely on time. The policy is proposed for delay through January 1, 2024 while CMS collects additional input. In the meantime, “substantive portion” will continue to be defined as one of the three key components (history, exam, or MDM) of the E/M or more than half of the total time.
Medicare Telehealth Services
CMS continues to evolve its telehealth policies after the sudden expansion of telehealth services in response to the COVID-19 public health emergency (PHE). As part of the Consolidated Appropriations Act, 2022 (CAA, 2022), Congress extended the flexibilities for telehealth originating site and geographic requirements for a period of 151 days after the end of the COVID-19 PHE. (See below for information regarding the latest extension of the PHE.). In the CY 2023 MPFS proposed rule, CMS takes several steps to effectuate these provisions from the CAA, 2022. However, it is important to note that the emergency department visits and critical care services are only approved as Medicare telehealth services through December 31, 2023. If the PHE should extend past that date, or the “151 days after the end of the COVID-19 PHE” were to extend into 2024, CMS would need to take additional steps to allow for continued telehealth billing for ED visits and critical care services. CMS has, though, communicated an openness to adding codes in this category to the list permanently if CMS receives more data supporting such a change.
Quality Reporting
The CY 2023 MPFS proposed rule also presents policies related to the Quality Payment Program (QPP) for 2023 and beyond. CMS is proposing relatively few changes compared to previous years and many of the key changes are requirements that CMS is statutorily obligated to implement per the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Key proposals and policies include:
Merit-Based Incentive Payment System (MIPS)
- As required under MACRA, the 2023 performance category weights will be: 30% quality; 30% cost; 15% improvement activities; 25% promoting interoperability.
- CMS maintains its policy to provide clinicians with the option to participate in MIPS through MIPS Value Pathways (MVPs) starting with the 2023 performance year. MVPs are more streamlined sets of existing MIPS measures and improvement activities focused on a condition, procedure, or patient population. Clinicians who opt-in to this pathway will benefit from slightly reduced reporting requirements (i.e., reporting 4 vs. 6 quality measures and attesting to 2 vs. up to 4 improvement activities). CMS also will allow voluntary “subgroup” reporting for those participating through MVPs, which becomes a requirement for multi-specialty groups reporting MVPs starting in 2026. Beyond that, MVP scoring and reporting rules generally align with traditional MIPS policies. Starting with 2023, CMS will offer an MVP titled, “Adopting Best Practices and Promoting Patient Safety within Emergency Medicine,” which CMS is proposing to modify slightly.
- In 2023, clinicians may also continue to participate in traditional MIPS. CMS proposes to modify the Emergency Medicine Specialty Set, to add the following recommended measures:
- #65: Appropriate Treatment for Upper Respiratory Infection (URI)
- #134: Screening for Depression and Follow-Up Plan
- #226: Tobacco Use: Screening and Cessation Intervention
- #431: Unhealthy Alcohol Use: Screening & Brief Counseling
- #TBD: Screening for Social Drivers of Health (new measure)
- CMS proposes to maintain a MIPS performance threshold of 75 points for the 2023 performance year. This is the minimum number of points needed to avoid a penalty in 2025. As a reminder, per MACRA, clinicians in MIPS may no longer qualify for an exceptional performance bonus starting in 2023.
- CMS also proposes to increase the quality measure data completeness threshold from 70% to 75% for the 2024 and 2025 performance periods.
- Importantly, CMS makes no mention of extending the Extreme and Uncontrollable Circumstances (EUC) hardship exception related to COVID-19 for 2023, which has been offered since the 2019 performance year. Although CMS could make an announcement about this later in the year, practices should assume for now that CMS will no longer offer this exception after this year.
- CMS also makes numerous requests for information (RFI) related to potential future MIPS policies, including how to better incorporate health equity into the quality performance category and public reporting, and whether to expand risk indicators for calculating the complex patient bonus.
Qualifying Participants (QP) in Advanced Alternative Payment Models (APMs)
Currently under MACRA, clinicians who participate sufficiently in an Advanced APM (which incorporates risk, the use of certified EHR technology and quality measures) are considered QPs, qualify for a 5% lump sum incentive payment, and are excluded from MIPS. However, after this year, there is no further statutory authority for a 5% APM incentive payment for QPs. In performance year 2023/payment year 2025, the statute does not provide for any type of incentive for eligible clinicians who become QPs. Beginning with performance year 2024/payment year 2026, MACRA authorizes an enhanced conversion factor (CF) update for QPs. QPs will receive a 0.75% base CF update and those who are not QPs (including MIPS eligible clinicians, who will still be subject to MIPS payment adjustments) will receive a 0.25% based CF update. In this rule, CMS voices concern about these shifting incentives and the effect it might have on clinician movement away from MIPS and towards APMs. CMS requests feedback from the public on potential administrative actions that CMS could take to address these concerns.
Also under MACRA, the minimum patient and payment thresholds that must be met to achieve QP status will increase starting in 2023 to 75% (vs. 50%) for the Medicare payment amount and 50% (vs. 35%) for the Medicare patient count. This will make it more challenging for clinicians to achieve QP status starting next year. Although CMS does not have the authority to change this policy without Congressional action, the agency seeks feedback on potentially making QP determinations at the individual clinician level rather than at the APM entity level. This could help discourage APM Entities from removing specialists from their Participation Lists for purposes of meeting the QP threshold, but it could also cause clinicians who currently do not meet the QP threshold on their own, but gain status through their APM Entity, to lose QP status.
CMS held a listening session on these topics on July 21, where it heard from leaders of national societies representing physicians and accountable care organization (ACO) who voiced serious concerns about these changes in policy, the challenges that APM entities and clinicians have faced trying to participate in these resource intensive models, and the need for Congressional action to extend the 5% incentive payment and current QP thresholds.
A summary of these and other policies and proposals can be found in the Regulatory Resources section of the QPP Resource Library.
Medicare Shared Savings Program (SSP)
CMS also proposes several changes to the SSP designed to strengthen financial incentives for long-term participation in Accountable Care Organizations (ACOs), increase participation of ACOs serving high-risk and high dually eligible populations, support the transition of ACOs to all-payer quality measure reporting, increase health equity, and reduce burden.
EDPMA plans to comment on the proposed rule before the end of the 60-day comment period deadline of September 6, 2022. #EDPMAHasYourBack