Overview of the 2022 Physician Fee Schedule Final Rule

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In January, CMS released the overview of the 2022 Physician Fee Schedule final rule. This contains important information about how your care management services will be valued and reimbursed in 2022. The overview is dense – over 1,000 pages. But don’t worry! DocsInk has taken the time to identify key trends and changes that you need to know about. Not only did we make an abridged version….we made an abridged version 🙂

To download DocsInk’s complete 2022 Physician Fee Schedule Final Rule – click here.

In the meantime, here’s short and skinny:

Finalized Conversion Factor

Centers for Medicare and Medicaid Services (CMS) 2022 conversion factor¹ has been set at $34.60. 

What does this mean for your care management service? 
It depends on the type of care management service you provide:

Chronic Care Management (CCM): 

• CMS has adopted the American Medical Association’s (AMA) RVU² Update Committee’s (RUC) recommendation to increase RVU for CCM services to better reflect the value of time spent providing CCM services. 
• As a result, the reimbursement for CCM services has increased in 2022.

Remote Physiologic Monitoring (RPM): 

• There are minimal reimbursement rate adjustments to RPM services based on both slight reductions to RVUs and the conversion factor rate. 
• Based on the conversion factor listed above, the decline in reimbursement will be marginal compared to 2021 rates. 

 Source for RVU definition: https://www.aapc.com/practice-management/rvus.aspx

Chronic Care Management 

• CMS added 1 new CCM CPT code, 99437, which is an add-on code to the existing 99491 code. They also updated the requirement of beneficiary consent. 

99437

Chronic care management  services, provided personally by a physician or other qualified healthcare professionals (QHP), each additional 30 minutes per calendar month with the following required elements: 

1. Multiple (two or more) chronic conditions are expected to last 12 months, or until the death of the patient.
2. Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
3. A comprehensive care plan was established.

What is an add-on code?

Since 99437 is classified as an “add-on” code, it may only be billed in conjunction with CPT code 99491, and it follows the same billing requirements as 99491. 

• One of these requirements is that the care management services must be performed personally by a physician or other qualified healthcare professional (QHP).

This is where a gray area appears in the CMS Final Rule: 

• In CMS’s final rule, CPT Code 99437 “describes CCM services furnished by clinical staff under the supervision of a physician or NPP who can bill E/M services and CCM services personally furnished by a physician or NPP.”
• This is in direct contradiction to the AMA’s CPT codebook for the 99437 CPT code, which specifies that the code can only be performed by a physician or QHP³.

So, what should I do? DocsInk recommends that you err on the side of caution, and only bill for 99437 when the care management service is performed by the physician for QPH in order to avoid being audited.

Beneficiary Consent

During the Public Health Emergency (PHE) CMS allows beneficiary consent to be obtained by auxiliary staff under general supervision, meaning the staff can be remote from the billing provider⁴. Previously, CMS required that beneficiary consent be obtained directly from the billing provider or by staff working directly under their supervision. 

Telehealth 

Category 3 Codes 

In 2021, CMS created a list of Category 3⁵ codes to describe the telehealth visits which will be covered temporarily during the COVID-19 PHE. The 2022 Final Rule extends the reimbursement of the Category 3 telehealth codes throughout the last day of 2023⁶, giving CMS time to evaluate which telehealth visit codes meet the requirement for permanent coverage beyond 2023.

Allowances for Geographic Restrictions and Originating Sites 

During the PHE, waivers were granted under section 1135 of the Social Security Act and the CARES Act, giving CMS the authority to waive geographic origination requirements for the duration of the PHE⁷. To continue these site allowances beyond the PHE, Congress must pass legislation to overturn section 1834(m) of the Social Security Act. 

There is an exception to the geographic restrictions beyond the PHE in regard to the provision of telehealth services in the home of an individual for the treatment, diagnosis, or evaluation of mental health or substance abuse disorder. 

Telemental Health Services

CMS finalized keeping Section 123 of the Consolidated Appropriations Act legislation, which removed geographic restrictions and allowed a patient’s home to be the originating site for telehealth visits when used for the purposes of diagnosis, evaluation, or treatment of a mental health disorder⁸. 

Conditions for Medicare reimbursement:

•  Requires an in-person visit within six months of the initial telehealth service.
• An in-person visit must be conducted by the provider at least once every twelve months thereafter⁹.

Audio-Only Mental Health Services

CMS finalized reimbursement for audio-only telehealth services for the treatment of mental health conditions beyond the PHE. 

The following conditions must be met: 

• The practitioner has the capability to use an interactive telecommunication¹⁰ system that includes video. 
• The beneficiary is incapable of or fails to consent to, the use of video technology 
• The beneficiary is located at their home at the time the service is delivered¹¹.
• The practitioner documents the reason for using audio-only technology in the patient’s medical record, and they use the appropriate service level modifier. 

¹Conversion Factor (CF): the number which is multiplied by the relative value units (RVUs) assigned to each CPT and HCPCS Level II code, which together determine the annual fee-for-service Medicare reimbursement rates.
²Relative Value Units (RVU): define the value of service or procedure relative to all services and procedures. The measure of value is based on the extent of work required from the physician, clinical and non-clinical resources, and expertise required to deliver the service to the patient.
3 According to the American Medical Association (AMA) CPT Codebook, “Code 99437 is reported in conjunction with 99491 for each additional minimum of 30 minutes of a physician or other qualified health professional time.”
4 The PHE will be extended into 2022, however, at this time it is for an indeterminate amount of time.
⁵Category 3 codes are a subset of codes that were added during the PHE, however not every temporary code added is considered a Category 3 code. Codes not considered Category 3 codes.
⁶Codes not considered category 3 will not be considered for reimbursement once the PHE ends.
⁷Prior to the PHE, in order to be reimbursed for telehealth visits, care had to be provided at an eligible site in a rural area.|
8A hotel, car, etc could be classified as “home” for those who are without homes.
9 There is an exception: if the patient and practitioner consider the burdens of the visit to outweigh the benefits. The practitioner must document this on the patient’s medical record, then the in-person visit is not applicable for 12 months.

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