Understanding CMS changes for the 2023 Medicare Physician Fee Schedule

Billing and coding seem to get more involved as we enter each new year and next year does not seem to be any different.  Every year CMS issues new, revised, and deleted codes to the code sets. These frequent changes make it critically important to ensure compliance and ongoing training and education is provided for providers and coding professionals.

Some of the highlights in the Final Rule for 2023 Medicare Physician Fee Schedule (MPFS) include:

• E/M Changes: The main focus was the “other” E/M visits (inpatient, ED visits or nursing facility stays). These “other” codes allow either time or medical decision making to be selected when deciding the E/M visit level.
• Behavioral Health: CMS created a new code describing general behavioral health integration.This may not affect a lot of community-based practices, but if it does, it is recommended that you review the changes under the final rule.
• Prolonged Services Code: CMS differs from the AMA on the definition of prolonged services and created their own set of prolonged services G codes. Providers and coders should review Table 34 – Required Time Thresholds to Report Other E/M Prolonged Services, noting codes that providers can use based on their setting.
• Split/Shared E/M: The Split/Shared E/M Visits policy that was finalized in 2022 has been delayed until 2024.Clinicians continue to have the choice of meeting the definition of substantive portion based on history, physical exam, medical decision making or more than half the total physician time spent.

Practices were given codes to use during the pandemic for telehealth visits.  Has that changed?

• While the current Public Health Emergency (PHE) is scheduled to end Jan. 11, 2023, the administration has not given a termination notice so at a minimum, the PHE will extend until April 2023.
• In the CY 2021 PFS final rule, CMS created a new category (Category 3) for adding services on a temporary basis to Medicare’s approved list of telehealth services. Coverage and payment for Category 3 services will be retained until end of CY 2023.Regarding services that are temporarily included on telehealth list during the COVID-19 PHE, but not on Category 1, 2 or 3 basis, CMS will maintain these services on list for 151 days following end of the PHE. Make sure you check in April to see if the government has extended or cancelled the PHE.
• If your practice continues with telehealth appointments, it is imperative to know the codes and the updates for both your coders and providers. More information can be found at https://www.cms.gov/medicare/medicare-general-information/telehealth/telehealth-codes.
• Practices are urged to contact their MAC to ensure they are following the rules for telehealth, including using the correct POS codes with modifier 95.

The InfoDive support team is ready to help your practice answer any questions you have regarding coding and reimbursement.  Whether it’s seeing reports to gauge your revenue stream, or look for any discrepancies, InfoDive support can help. They can even help with those specific questions around rules for the Hospital Outpatient Prospective Payment System or Medicare Shared Savings Program. Contact them at InfoDiveSupport@intrinsiq.com.