CMS Issues CY 2022 Final Rule for Medicare Physician Fee Schedule (MFPS) and Hospital Outpatient Prospective Payment System (HOPPS)/Ambulatory Surgery Center (ASC)

The Centers for Medicare and Medicaid Services (CMS) issued the final rule for the Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective Payment System (HOPPS)/Ambulatory Surgery Center (ASC). These final rules cover physician and hospital outpatient/ambulatory surgery services furnished to beneficiaries on or after January 1, 2022. Highlights are described below:

For MFPS:

  • The finalized conversion factor is $33.5983, which reflects the CY 2021 conversion factor with the application of the statutory update factor of 0.00 percent and budget neutrality factor of -0.10 percent.
  • The finalized changes in RVUs will have an estimated impact for select specialties:
    • Cardiac Surgery 0% (proposed to be -1%)
    • Interventional Radiology -5% (proposed to be -9%)
    • Vascular Surgery -5% (proposed to be -8%).
  • For CY 2020, CMS finalized their proposal that the values of the Malpractice (MP) RVUs and MP GPCI be coordinated because the MP premium data used to update the MP GPCI is the same to determine the risk levels of the specialties. This change would put the next review for implementation in CY 2023. Therefore, there are no finalized changes for CY 2022.
  • There are no finalized updates for GPCIs for CY 2022. CMS refers to updates for CY 2020 as the latest updates for GPCIs.
  • Code 93319 (3D echocardiographic imaging and postprocessing during transesophageal echocardiography, or during transthoracic echocardiography for congenital cardiac anomalies…) is new for CY 2022 and is among the codes selected for work RVU valuation by CMS in the final rule.
  • Finalized updates to Evaluation and Management (E/M) services include:
    • Split (or Shared) Visits – Only the physician or nonphysician practitioner who performs the substantive portion of the split visit can bill for the visit. With the exception of the critical care visits, the substantive portion will be defined by one of three key components (history, exam, MDM) or more than half of the total time spent by the physician and NPP performing the split (or shared) visit, and require a defined modifier when billed on the claim. 
    • New and Established Patients, and Initial and Subsequent Visits – Prolonged services could be billed in addition to the visit when the time-based method is used total time between the two entities used for billing. This would only apply for other outpatient and inpatient/ observation/ hospital/ nursing facility services. Use of prolonged services would not apply to emergency department and critical care visits.
    • Payment for the Services of Teaching Physicians – When total time is used to determine the appropriate E/M office visit level, only the time the teaching physician was present can be included.
    • Telehealth Services – All services added to the Medicare telehealth services under Category 3 (temporary addition for the COVID-19 PHE) will remain on the list until the end of CY 2023. Two additions to the Category 3 list include physician services for outpatient cardiac rehab (93797, 93738) and intensive cardiac rehabilitation (G0422, G0433).
    • Communication Technology-Based Services – The definition of “interactive telecommunications system” has been finalized to permit use of audio-only communications technology for mental health telehealth services under certain conditions when provided to beneficiaries in their home. This includes physicians and practitioners having interactive, real-time and two-way audio-only technology. Code G2252 is permanently recognized by CMS for communication-based services with an assigned payment.
  • For the duration of the PHE, CMS redefined “direct supervision” to be provided through interactive real-time audio-video telecommunication technology.  This allows the physician to provide real-time assistance and direction throughout a procedure or service by allowing them to see and interact with the staff member and patient without adding any unnecessary exposure.  
  • CMS finalized the implementation of section 403 of the Consolidated Appropriations Act, which authorizes Physician Assistants (PAs) to bill for services directly to Medicare and the reimbursement for those services to be paid directly to the PA.

For HOPPS/ASC:

  • CMS finalized their proposal to use CY 2019 data to set the CY 2022 HOPPS and ASC rates rather than the CY 2020 data due to the impact of outpatient service utilization provided during the COVID-19 PHE.
  • Payment rates under HOPPS/ASC are increased by an Outpatient Department (OPD) fee schedule increase factor of 2.0 percent. This increase is based on the final hospital inpatient market basket percentage increase of 2.7 percent reduced by a proposed productivity adjustment of 0.7 percentage point.
  • CMS is also finalizing to continue implementing a statutory 2.0 percentage reduction for hospitals failing to meet the hospital outpatient quality reporting requirements set forth by the Hospital Outpatient Quality Reporting (OQR) Program.
  • The finalized conversion factor for CY 2022 for hospitals that meet the hospital OQR program requirements is $84.457 in the calculation for national unadjusted rates. For those hospitals that fail to meet the hospital OQR program requirements, the CF is $82.810.
  • The wage indexes for CY 2022 include the continued implementation of the OMB labor market area delineations based on 2010 census data with updates. CMS finalized the proposal to implement a 5 percent cap on wage index decreases.
  • The continuation of the rural adjustment factor of 7.1 percent to certain rural sole community hospitals was finalized for CY 2022.
  • The continued use of the C-APC payment policy methodology was finalized, as well as the policy to not convert any standard APCs to C-APCs in CY 2022. Therefore, the number of C-APCs would remain the same as in 2021, which is 69 C-APCs.
  • Code G0463 will continue to be the standardized code for the HOPPS relative payment weights and will be continued to be reimbursed at 40 percent.
  •  In CY 2021, CMS proposed and finalized the policy to eliminate the IPO list over a 3-year transitional period beginning on January 1, 2021, with the full list eliminated by January 1, 2024. 298 services and procedures (including 266 musculoskeletal) were removed from the IPO list. For CY 2022, CMS is finalizing their proposal to stop the elimination of the IPO list and add back the services removed in 2021 with some exceptions. CMS is also finalizing their proposal to codify the five longstanding criteria used to determine whether a procedure or service should be removed from the IPO list. Of interest is code 37182 (insert hepatic shunt – TIPS) which was removed from the IPO list in CY 2021 and assigned APC 5193. For CY 2022, the code is back on the IPO list and assigned a status indicator of “C” (inpatient only procedure).
  • The finalized conversion factor for CY 2022 for ASCs that meet the ASCQR program requirements is $50.043 in the calculation for national unadjusted rates. For those hospitals that fail to meet the hospital ASCQR program requirements, the CF is $48.937.
  • Finalized changes to the list of ASC covered procedures include the following codes. They have been assigned the ASC payment indicator of “X5” (unsafe surgical procedure in ASC. No payment made):
    • 36838 – Distal revascularization and interval ligation (DRIL), upper extremity hemodialysis access (steal syndrome)
    • 37183 – Revision of transvenous intrahepatic portosystemic shunt(s) (TIPS) (includes venous access, hepatic and portal vein catheterization, portography with hemodynamic evaluation, intrahepatic tract recanulization/dilatation, stent placement and all associated imaging guidance and documentation)
    • 43281 – Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; without implantation of mesh
    • 43282 – Laparoscopy, surgical, repair of paraesophageal hernia, includes fundoplasty, when performed; with implantation of mesh
  • CMS is finalizing amendments to the hospital price transparency policy to encourage compliance.

The complete MPFS and HOPPS/ASC PPS final rule summaries can be found on the GORE Coding Resource Center website under “Education – CMS Rules Updates”: https://gore.rccsclients.com/education/rules-updates/.