CMS Releases 2023 Medicare Physician Fee Schedule Rates & Policies

On November 1st, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) final rule. The rule finalizes changes to the MPFS and other Medicare Part B payment policies, along with changes to the Quality Payment Program (QPP).

Here are the big takeaways for emergency medicine from the final rule:

  • CMS Finalizes Cut to the 2023 Conversion Factor Teeing Up End of Year Congressional Action. CMS set the final CY 2023 MPFS conversion factor is set at $33.0607, which is down approximately 4.47 percent, or $1.55, from CY 2022. While CMS estimates that emergency medicine will have no overall financial impact form the finalized policies, this does not account for the evaporating 3% conversion factor remedy Congress provided in 2022. Without additional action by Congress, that payment cut will go into effect for 2023. See EDPMA’s action alert to contact your members of Congress.
  • CMS Maintains Level 4 ED Visit Value, Departing from AMA RUC Recommendation. CMS generally accepted the CPT and RUC revisions for the following E/M code sets: ED visits, inpatient and observation services; discharge management; nursing facility visits; home and residence visits; and cognitive assessment and care planning services. This included accepting the RUC recommended values for those codes with one exception: CMS finalized its proposal to depart from the RUC recommendation for ED level 4 to preserve the current RVUs of 2.74 rather than reducing it to 2.60 as the RUC had recommended. As part of this package of policies, CMS also finalized adoption of the revised CPT documentation guidelines for emergency department (ED) evaluation and management (E/M) visits. (For more information on the ED E/M documentation guideline changes coming January 1, 2023, see information from AMA CPT via this link.)
  • CMS Speaks to Concerns about “8 to 24 Hour Rule.” CMS made clarifications from what it had stated in the proposed rule. While CMS states that the final policy is meant to reflect what is already in the Medicare Claims Processing Manual, CMS admitted it made mistakes in articulating its intended policy in the proposed rule and seeks to clarify these in the final rule. CMS clarified and finalized that the general principles are as follows:
    • When a patient receives inpatient or observation care for less than 8 hours, only the “initial” service shall be reported by the practitioner for the date of admission; no discharge day management code shall be reported
    • When a patient is admitted for inpatient/observation and then is discharged on a different calendar date, the practitioner shall report the “initial service” and the appropriate discharge day management code
    • When a patient receives inpatient or observation care for at least 8 hours and is discharged on the same calendar date, the practitioner should bill the appropriate “same day discharge” code
  • CMS Delays Problematic “Time Only” Split (or Shared) E/M Visit Policy But 2024 Rulemaking Will Prove Crucial: As requested by EDPMA, CMS finalized its one year delay of its planned implementation of defining the “substantive portion” (and thus the billing practitioner) of a split/shared visit as “more than half of the total time.” This policy had been set to go into effect on January 1, 2023. Until January 1, 2024 or until CMS issues new rulemaking, substantive portion will continue to be defined as “one of the three key components (history, exam, or MDM)” of the E/M.
  • CMS Finalized Continuation of Favorable Medicare Telehealth Services for Emergency Medicine But Advocacy Continues for Post-PHE Policies. CMS reiterated that it will issue program instruction or other subregulatory guidance to implement the extension of the telehealth flexibilities that the Consolidated Appropriations Act, 2022 provided for a period of 151 days after the end of the COVID-19 PHE. With the expected extension of the PHE well into 2023, these issues will need to be addressed later in the year.
  • CMS Finalized the Statutorily-Required Category Weights for MIPS and Keeps Performance Threshold to Avoid a Penalty Steady. Per the Medicare and CHIP Reauthorization Act of 2015 (MACRA), the 2023 MIPS performance category weights are as follows: 30% quality; 30% cost; 15% improvement activities; 25% PI. The MIPS performance threshold, which is the minimum number of points needed to avoid a penalty in 2025 based on 2023 performance, will remain at 75 points. As a reminder, under statute, the exceptional performance bonus will no longer be available starting with the 2023 performance year.
  • CMS Makes Facility-Based Clinicians Eligible for “Complex Patient Bonus.” Facility-based clinicians will be eligible for the complex patient bonus, even if they do not submit MIPS data.
  • CMS Finalizes Emergency Medicine “MIPS Value Pathway.” The MIPS Value Pathways (MVP) titled, “Adopting Best Practices and Promoting Patient Safety within Emergency Medicine,” was finalized as proposed as an optional MIPS participation pathway starting in 2023. More information about the Emergency Medicine MVP can be downloaded here. General information about the MVP pathway, including scoring and registration requirements, can be found here.
  • CMS Finalizes Changes to the MIPS Emergency Medicine Specialty Measure Set. Changes to the Emergency Medicine Specialty Set:
    • Added #65: Appropriate Treatment for URI
    • Added #134: Screening for Depression and Follow up Plan
    • Added #226: Tobacco Use: Screening and Cessation Intervention
    • Added #431: Unhealthy Alcohol Use: Screening and Brief Counseling
    • Added new #487: Social Drivers of Health measure
    • Removed Part B claims collection type for #416: ED Utilization of CT for Minor Blunt Health Trauma for Patients Aged 2 through 17 Years
  • Questions Remain About 2023 COVID-19 Exception. CMS has not yet announced whether it will continue to offer the MIPS Extreme and Uncontrollable Circumstances (EUC) Exception due to COVID-19 in 2023.