Author: Tony Mira
It’s that time of year again. The government has released its massive proposed 2022 Medicare Physician Fee Schedule, and it contains more disappointing news relative to anesthesia and ancillary reimbursement.
Some suggestions can be rather upsetting, and some recommendations can be downright discouraging. Such is the case for the proposals coming out of the Centers for Medicare and Medicaid Services (CMS) this month—at least in the eyes of many in the healthcare community. On July 13, CMS released its 2022 Medicare Physician Fee Schedule (PFS) Proposed Rule (PR). This 1,747-page document addresses topics from teaching guidelines to telehealth services, along with many others. It represents the government’s current thinking on what next year’s Medicare requirements and reimbursement rates should look like. It’s not set in stone, but the mortar is hardening.
Based on our initial analysis of the issues that will be deemed most important to our readers, a portion of the PR material will not be well received by those who bill out services to Medicare. We’ll get to the worst news first, to be followed by a summary of other highlights from the PR.
According to a PR fact sheet published by CMS, the agency is proposing changes involving (a) practice expense for certain services associated with the proposed update to clinical labor pricing, (b) a market-based supply and equipment pricing update, and (c) standard rate-setting refinements. More importantly, based on the proposed budget neutrality adjustment and the expiration of the 3.75 percent payment increase provided in 2021 by the Consolidated Appropriations Act of 2021 (CAA), the proposed 2022 non-anesthesia conversion factor (CF) is set at 33.58. This represents a 3.75 percent decrease from the 2021 CF of 34.89.
For our anesthesia clients, the news is also disconcerting. The 2022 PR calls for a 2.5 percent decrease in the 2021 anesthesia CF of 21.56 to the new rate of 21.0442. So, while inflation is set to dramatically increase in the next few months according to the prognostications of many in the financial industry, wages for anesthesiologists and anesthetists will be going down—at least in terms of this government payer. Remember also that it’s not just the anesthesia CF that these providers need to worry about. They should also be concerned with the above-referenced reduction in the general CF that is connected with reimbursement for the ancillary services they provide, such as invasive line placements, emergency intubations, postoperative pain procedures, ultrasound guidance and TEE services.
Finally, there are a couple of other factors to keep in mind as it concerns reimbursement issues for 2022:
- Both the general CF and the anesthesia CF listed in the PR reflect a national average. The actual CF applicable to your practice will ultimately depend on your specific geographical locality.
- The pause in the previously passed two-percent sequestration cut is set to expire on December 31, 2021, which will mean an additional reduction in Medicare revenue for providers (in addition to the aforementioned CF cuts) unless Congress acts once more to push these cuts further down the road or eliminate them altogether.
Evaluation and Management
According to the PR fact sheet, CMS is reviewing payment for evaluation and management (E/M) code sets. These codes represent clinician visits with patients and come into play for the anesthesia specialty when an anesthesiologist, for example, performs a pain round (except for rounding on an indwelling epidural catheter) or an anesthesia consult. The government is making several proposals that take into account the recent changes to E/M visit codes, which took effect January 1, 2021. They are also proposing to clarify and refine policies that were reflected in certain Current Procedural Terminology (CPT) manual provisions that were recently updated.
Included within these E/M policy refinements are provisions related to split (or shared) visits in the facility setting. This is where a physician may see a patient in the morning, for example, and a non-physician practitioner (NPP) within the same group practice sees the same patient later in the day. Together, these visits can currently be billed out as one combined encounter under either provider’s NPI. The PR recommends the following changes for these types of visits, which would end up being recorded at 42 CFR 415.140:
- Definition of split (or shared) E/M visits as evaluation and management (E/M) visits provided in the facility setting by a physician and an NPP in the same group.
- The practitioner who provides the substantive portion of the visit (more than half of the total time spent) would bill for the visit.
- Split (or shared) visits could be reported for new as well as established patients, and for initial and subsequent visits, as well as prolonged services.
- Requiring reporting of a modifier on the claim to help ensure program integrity.
- Documentation in the medical record that would identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the medical record.
Critical Care Services
Proposed changes within the 2022 PR related to critical care services include the following:
- Use American Medical Association (AMA) CPT prefatory language as the definition of critical care visits, including bundled services.
- Allow critical care services to be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty, and that critical care services can be furnished as split (or shared) visits.
- No other E/M visit can be billed for the same patient on the same date as a critical care service when the services are furnished by the same practitioner, or by practitioners in the same specialty and same group to account for overlapping resource costs.
- Critical care visits cannot be reported during the same time period as a procedure with a global surgical period.