Author: Tony Mira
Last month, we published an alert outlining the provisions of the 2022 Medicare Physician Fee Schedule (PFS) Proposed Rule (PR) that were most pertinent to the practice of anesthesia. As promised in that alert, this article will act to provide further details arising from the PR that may impact our readers’ practices—including those in the chronic pain specialty. Again, this material is based on a summary of the 2022 PFS PR provided by the Centers for Medicare and Medicaid Services (CMS) and the PR itself.
The PR calls for the following adjustments relative to codes that reflect anesthesia services:
· 00537 (Anesthesia for cardiac electrophysiologic procedures including radiofrequency ablation) – Medicare’s base unit value will move from the current 7 to 10. This would align CMS’s valuing of the code to the value currently assigned in the Relative Value Guide (RVG).
· 01935 and 01936 (Anesthesia for percutaneous image guided procedures on the spine and spinal cord) – These codes will be deleted and replaced by six more refined codes. While both of the current codes have base values of five, only two of the new codes would retain that value. The other four codes would have a base value of four. Here are the descriptors for the six new codes:
✳︎ Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; cervical or thoracic
✳︎ Anesthesia for percutaneous image-guided injection, drainage or aspiration procedures on the spine or spinal cord; lumbar or sacral
✳︎ Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; cervical or thoracic
✳︎ Anesthesia for percutaneous image-guided destruction procedures by neurolytic agent on the spine or spinal cord; lumbar or sacral
✳︎ Anesthesia for percutaneous image guided neuromodulation or intravertebral procedures (eg, Kyphoplasty, vertebroplasty) on the spine or spinal cord; cervical or thoracic
✳︎ Anesthesia for percutaneous image guided neuromodulation or intravertebral procedures (eg, Kyphoplasty, vertebroplasty) on the spine or spinal cord; lumbar or sacral
As far as the chronic pain side, the facet joint neurolytic codes (CPT 64633 – 64636) were identified by CMS as being potentially over-valued. As a result, the PR includes a slight decrease in the work relative value units (RVUs) associated with the primary facet codes. However, the facet add-on codes will retain their current value.
Under the 2022 PR, when total time is used to determine the office/outpatient E/M visit level, only the time that the teaching physician was present can be included. During the public health emergency (PHE), the time that the teaching physician is present via audio/video real-time communications technology may also be included in the total time considered for visit level selection. The PR goes on to note that “outside the circumstances of the COVID-19 PHE, the teaching physician presence requirement can be met virtually, through audio/video real-time communications technology, only in residency training sites that are located outside of a metropolitan statistical area.”
In addition, under the primary care exception, only MDM could be used to select the visit level. The rationale CMS provides for this proposal is its desire to “guard against the possibility of inappropriate coding that reflects residents’ inefficiencies rather than a measure of the time required to furnish the services.”
Telehealth Services under the PFS
As CMS continues to evaluate the temporary expansion of telehealth services that were added to the telehealth list during the COVID-19 public health emergency (PHE), the agency is proposing to allow certain services that were added to the Medicare telehealth list to remain on the list through December 31, 2023. The agency explains that this will allow “a glide path to evaluate whether the services should be permanently added to the telehealth list following the COVID-19 PHE.”
Physician Assistant Services
The Proposed Rule implements section 403 of Division CC of the CAA that authorizes Medicare to make direct payment to physician assistants (PAs) for professional services they furnish under Part B, beginning January 1, 2022. Currently, Medicare can only make payment to the employer or independent contractor of a PA, meaning PAs have not had the ability to bill and be paid by the Medicare program directly as, for example, nurse practitioners have historically been able to do. Physician assistants have also not had the option to reassign payment for their services or to incorporate with other PAs to bill the program for PA services. Beginning January 1, 2022, all this changes, assuming these proposals become final.
Procedures Furnished During Colorectal Screening
The PR implements Section 122 of the CAA. This section reduces, over time, the amount of coinsurance a beneficiary will pay for such services. The CMS summary puts it this way:
For services furnished on or after January 1, 2022, the coinsurance amount paid for planned colorectal cancer screening tests that require additional related procedures shall be equal to a specified percent (i.e., 20 percent for 2022, 15 percent for 2023 through 2026, 10 percent for 2027 through 2029, and zero percent beginning 2030) of the lesser of the actual charge for the service or the amount determined under the fee schedule that applies to the test.
The incremental reduction of coinsurance percentage applies to removal of tissue or other matter, or for another procedure that is furnished in connection with and in the same clinical encounter as the screening.
The 2022 PR allows treatments under the Opioid Treatment Program (OTP) to furnish counseling and therapy services via audio-only interaction (such as telephone calls) after the conclusion of the PHE in cases where the beneficiary is not capable of, or does not consent to, the use of devices that permit a two-way audio/video interaction, provided all other applicable requirements are met. CMS will require those submitting OTP services to use a specially designated modifier for audio-only services billed using the counseling and therapy add-on code. Providers of such services must also document in the medical record the rationale for a service being furnished using audio-only services.
Electronic Prescribing of Controlled Substances
Finally, for our chronic pain practitioners, the 2021 PFS Final Rule implemented Section 2003 of the SUPPORT Act, which mandated electronic prescribing of Schedule II-V controlled substances (EPCS) under Medicare Part D, beginning Jan. 1, 2021. However, CMS is now proposing to extend the compliance date for EPCS requirements until Jan. 1, 2023.
The PR also stipulates that, in order for prescribers to be considered compliant, they must prescribe at least 70 percent of their Part D controlled substance prescriptions electronically per calendar year. The exceptions to this stipulation are as follows:
· Prescriptions issued where the prescriber and dispensing pharmacy are the same entity
· Prescribers who prescribe 100 or fewer Part D controlled substance prescriptions per year
· Prescribers who are prescribing during a recognized emergency (like a natural disaster or pandemic)
· Prescribers who request and receive a waiver from CMS due to extraordinary circumstances