The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that announces and solicits public comments on proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, on or after January 1, 2022.
The calendar year (CY) 2022 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a health care system that results in better accessibility, quality, affordability, empowerment, and innovation.
Since 1992, Medicare payment has been made under the PFS for the services of physicians and other billing professionals. Physicians’ services paid under the PFS are furnished in a variety of settings, including physician offices, hospitals, ambulatory surgical centers (ASCs), skilled nursing facilities and other post-acute care settings, hospices, outpatient dialysis facilities, clinical laboratories, and beneficiaries’ homes. Payment is also made to several types of suppliers for technical services, most often in settings for which no institutional payment is made.
For most services furnished in a physician’s office, Medicare makes payment to physicians and other professionals at a single rate based on the full range of resources involved in furnishing the service. In contrast, PFS rates paid to physicians and other billing practitioners in facility settings, such as a hospital outpatient department (HOPD) or an ASC, reflect only the portion of the resources typically incurred by the practitioner in the course of furnishing the service.
For many diagnostic tests and a limited number of other services under the PFS, separate payment may be made for the professional and technical components of services. The technical component is frequently billed by suppliers, like independent diagnostic testing facilities and radiation treatment centers, while the professional component is billed by the physician or practitioner.
Payments are based on the relative resources typically used to furnish the service. Relative value units (RVUs) are applied to each service for work, practice expense, and malpractice expense. These RVUs become payment rates through the application of a conversion factor. Geographic adjusters (geographic practice cost index) are also applied to the total RVUs to account for variation in practice costs by geographic area. Payment rates are calculated to include an overall payment update specified by statute.
PAYMENT PROVISIONS
CMS is proposing a series of standard technical proposals involving practice expense, including the implementation of the fourth year of the market-based supply and equipment pricing update, changes to the practice expense for many services associated with the proposed update to clinical labor pricing, and standard rate-setting refinements.
CRITICAL CARE
Similarly, we are proposing to refine our longstanding policies for critical care services. In the CY 2022 PFS proposed rule we are proposing: To use American Medical Association (AMA) Current Procedural Terminology (CPT) prefatory language as the definition of critical care visits, including bundled services.
VACCINE ADMINISTRATION SERVICES COMMENT SOLICITATION
The pandemic has highlighted the importance of access to COVID-19 vaccines, as well as access to other preventive vaccines. Over the last several years, Medicare payment rates for physicians and mass immunizers for administering certain preventive vaccines (flu, pneumonia and hepatitis B vaccines) have decreased by roughly 30%. Given the ongoing stakeholder interest in this issue, the proposed rule includes a comment solicitation to obtain information on the costs involved in furnishing preventive vaccines, with the goal to inform the development of more accurate rates for these services. More specifically CMS is seeking information on:
- The different types of healthcare providers who furnish vaccines and how have those providers changed since the start of the pandemic.
- How the costs of furnishing flu, pneumococcal, and hepatitis B vaccines compare to the costs of furnishing COVID-19 vaccines, and how costs may vary for different types of health care providers.
- How the COVID-19 PHE may have impacted costs, and whether health care providers envision these costs to continue.
CMS is also seeking stakeholder input on two other issues. First, we are seeking input on our preliminary policy to pay $35 add-on for certain vulnerable beneficiaries when they receive a COVID-19 vaccine at home. CMS is interested in stakeholder input on what qualifies as the “home” and how we can balance ensuring program integrity with beneficiary access.
Second, as the market for COVID-19 monoclonal antibody products matures, CMS is also seeking comments on whether we should treat these products the same way we treat other physician-administered drugs and biologicals under Medicare Part B.
Other areas covered include:
- Evaluation and Management (E/M) Visits
- Split (or shared) E/M visits
- Telehealth Services under the PFS
- Therapy Services
- Physician Assistant (PA) Services
- Payment for Medical Nutrition Therapy (MNT) Services and Related Services
- Changes to Beneficiary Coinsurance for Additional Procedures Furnished During the Same Clinical Encounter as a Colorectal Cancer Screening
- Opioid Treatment Program (OTP) Payment Policy
- Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
- Mental Health Services furnished via Telecommunications Technologies for RHCs and FQHCs
- Rural Health Clinic (RHC) Payment Limit Per-Visit
- Payment for Attending Physician Services Furnished by RHCs or FQHCs to Hospice Patients
- COVID-19 Vaccines Furnished in RHCs and FQHCs (Technical Updates)
- Tribal FQHC Payments – Comment Solicitation
- Electronic Prescribing of Controlled Substances-- Section 2003 of the SUPPORT Act
- Requiring Certain Manufacturers to Report Drug Pricing Information for Part B
- Determination of ASP for Certain Self-administered Drug Products
- Part B Drug Payment for Section 505(b)(2) Drugs
- Clinical Laboratory Fee Schedule: Laboratory Specimen Collection and Travel Allowance
- Medical Nutrition Therapy Coverage and Payment Issues
- Appropriate Use Criteria (AUC) Program
- Pulmonary Rehabilitation
- Medicare Shared Savings Program
- Updates to the Open Payments Financial Transparency Program
- Medicare Provider Enrollment
- Medicare Ground Ambulance Data Collection System
