';
The Centers for Medicare and Medicaid Services (CMS) has released the calendar year (CY) 2022 Medicare Physician Fee Schedule (MPFS) proposed payment rule. Some of the proposed provisions include:
CY 2022 Physician Fee Schedule (PFS) Payment Rate Update
With the proposed budget neutrality adjustment to account for changes in RVUs (required by law), and expiration of the 3.75 percent payment increase provided for CY 2021 by the Consolidated Appropriations Act, 2021 (CAA), the proposed CY 2022 PFS conversion factor is $33.58, a decrease of $1.31 from the CY 2021 PFS conversion factor of $34.89. The PFS conversion factor reflects the statutory update of 0.00 percent and the adjustment necessary to account for changes in relative value units and expenditures that would result from our proposed policies.
Evaluation and Management (E/M) Visits
CMS is engaged in an ongoing review of payment for E/M visit code sets. For CY 2022, there are several proposals that take into account the recent changes to E/M visit codes, as explained in the AMA CPT Codebook, which took effect January 1, 2021. CMS is also proposing to clarify and refine policies that were reflected in certain manual provisions that were recently withdrawn.
CMS is proposing to refine their longstanding policies for split (or shared) E/M visits to better reflect the current practice of medicine, the evolving role of non-physician practitioners (NPPs) as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services. In the CY 2022 PFS proposed rule, the following is proposed:
Telehealth Services under the PFS
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) and is proposing to allow certain services added to the Medicare telehealth list to remain on the list to the end of December 31, 2023, so that there is a path to evaluate whether the services should be permanently added to the telehealth list following the COVID-19 PHE. Section 123 of the CAA removed the geographic restrictions and added the home of the beneficiary as a permissible originating site for telehealth services when used for the purposes of diagnosis, evaluation, or treatment of a mental health disorder, and requires that there be an in-person, non-telehealth service with the physician or practitioner within six months prior to the initial telehealth service, and thereafter, at intervals as specified by the Secretary.
CMS is proposing to require an in-person, non-telehealth service be provided by the physician or practitioner furnishing mental health telehealth services within six months prior to the initial telehealth service, and at least once every six months thereafter. CMS is requesting feedback on whether a different interval may be necessary or appropriate for mental health services furnished through audio-only communication technology. CMS is also seeking comment on how to address scenarios where a physician or practitioner of the same specialty/subspecialty in the same group may need to furnish a mental health service due to unavailability of the beneficiary’s regular practitioner.
CMS is also soliciting comment on: (1) whether additional documentation should be required in the patient’s medical record to support the clinical appropriateness of audio-only telehealth; (2) whether or not we should preclude audio-only telehealth for some high-level services, such as level 4 or 5 E/M visit codes or psychotherapy with crisis; and (3) any additional guardrails we should consider putting in place in order to minimize program integrity and patient safety concerns.
Therapy Services
CMS is implementing the final part of section 53107 of the Bipartisan Budget Act of 2018, which requires CMS, through the use of new modifiers (CQ and CO), to identify and make payment at 85 percent of the otherwise applicable Part B payment amount for physical therapy and occupational therapy services furnished in whole or in part by physical therapist assistants (PTAs) and occupational therapy assistants (OTAs), for dates of service on and after January 1, 2022.
For CY 2022, in response to numerous stakeholder questions and to promote proper therapy care, CMS is proposing to revise the de minimis standard established to determine whether services are provided “in whole or in part” by PTAs or OTAs. Specifically, CMS is proposing to revise the de minimis policy to allow a timed service to be billed without the CQ/CO modifier in cases when a PTA/OTA participates in providing care to a patient with a physical therapist or occupational therapist (PT/OT), but the PT/OT meets the Medicare billing requirements for the timed service without the minutes furnished by the PTA/OTA by providing more than the 15-minute midpoint (also known as the 8-minute rule).
Overall, the de minimis standard would continue to be applicable in the following scenarios:
Physician Assistant (PA) Services
CMS is proposing to implement section 403 of Division CC of the CAA that authorizes Medicare to make direct payment to PAs for professional services they furnish under Part B beginning January 1, 2022. Medicare currently can only make payment to the employer or independent contractor of a PA. Consequently, PAs could not bill and be paid by the Medicare program directly for their professional services; they also did not have 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, PAs would be able to bill Medicare directly for their services and reassign payment for their services.
Vaccine Administration Services Comment Solicitation
Over the last several years, Medicare payment rates for physicians and mass immunizers for administering certain preventive vaccines (flu, pneumonia and hepatitis B vaccines) have decreased by approximately 30 percent. Given the ongoing stakeholder interest in this issue, the proposed rule includes a comment solicitation to obtain information on the costs involved in furnishing preventive vaccines, with the goal to inform the development of more accurate rates for these services. More specifically CMS is seeking information on:
CMS is also seeking stakeholder input on a proposed policy to pay $35 add-on for certain vulnerable beneficiaries when they receive a COVID-19 vaccine at home. CMS is interested in stakeholder input on what qualifies as the “home” and how they can balance ensuring program integrity with beneficiary access. CMS is also seeking comments on whether they should treat these products the same way we treat other physician-administered drugs and biologicals under Medicare Part B.
Opioid Treatment Program (OTP) Payment Policy
CMS is proposing to allow OTPs to furnish counseling and therapy services via audio-only interaction (such as telephone calls) after the conclusion of the COVID-19 PHE in cases where audio/video communication is not available to the beneficiary, including circumstances in which 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 is proposing to require that OTPs use a service-level modifier for audio-only services billed using the counseling and therapy add-on code and document in the medical record the rationale for a service being furnished using audio-only services, in order to facilitate program integrity activities.
The proposed rule will be published in the July 23, 2021 Federal Register. Comments will be accepted until September 13, 2021.
Today, the Centers for Medicare and Medicaid Services (CMS) announced they will be opening a National Coverage Determination (NCD) analysis on the treatment for Alzheimer’s disease. This NCD process will allow CMS to carefully review and determine whether Medicare will establish a national Medicare coverage policy for monoclonal antibodies targeting amyloid for the treatment of Alzheimer’s disease. NCDs are program instructions developed by CMS to describe the nationwide conditions for Medicare coverage for a specific item or service. This NCD analysis will be applicable to national coverage considerations for aducanumab, which was recently approved by the Food and Drug Administration (FDA), as well as any future monoclonal antibodies that target amyloid for the treatment of Alzheimer’s disease.
Currently, coverage determinations for aducanumab are being made at the local level by Medicare Administrative Contractors (MACs) who represent 12 jurisdictions across the country. CMS’s coverage decisions are based on careful analysis of the evidence and benefits a given therapy provides to Medicare beneficiaries. To determine whether a national policy is appropriate, CMS will follow a standard process that includes multiple opportunities for the public to participate and present comments through both listening sessions and the CMS Coverage website. The analysis will determine whether the evidence meets the Medicare law’s requirements that items or services be “reasonable and necessary for the diagnosis or treatment of illness or injury….” To make this determination, CMS uses a formal process established by statute. The process includes an assessment of the clinical evidence such as published clinical studies, professional society guidelines, and public comments to determine coverage.
Following this analysis, CMS will post a proposed NCD, which will be open to a second 30-day public comment period. After reviewing all comments received on a proposed determination, CMS will announce its final decision for a national policy which could range from Medicare coverage of this product type, coverage with evidence development, non-coverage, or deference to the Medicare Administrative Contractors. A proposed decision is expected to be posted within 6 months and a final within 9 months.
As part of the NCD process, a 30-day public comment period will begin today. CMS will also host two public listening sessions in July to provide an opportunity for public input.
To register for the listening sessions:
July 22, 2021 from 9:00 am–11:00 am (EDT) or
July 27, 2021 from 2:00 pm–4:00 pm (EDT)
NCDs are posted on the CMS Medicare Coverage Center website and provide stakeholders with the Medicare coverage criteria, a summary of the evidence considered, and CMS’s rationale for the decision. Comments can be submitted and viewed here.
The ID/A Coalition is aware that the Office of Developmental Programs (ODP) has requested a meeting with Centers for Medicare & Medicaid Services (CMS) to discuss the plan for the American Rescue Plan funds and has requested that CMS advise ODP to continue the enhanced rates that were in effect January 1, 2021–June 30, 2021. In a letter to Daniel Tsai, Deputy Administrator and Director for the Center for Medicaid and CHIP Services (CMCS), the Coalition wrote:
“We request that CMS support the continuance of these increased rates, rather than permit the rates to be reduced as proposed. The providers of these services continue to incur increased costs to providing services as a result of the on-going nature of the pandemic. Measures need to be taken in order to prevent the spread of COVID, and providers are dealing with the inability to attract and retain employees to provide these services. The rate was insufficient prior to the pandemic, and the additional stressors to the system have amplified this issue. The continued increased rates are critical to the provider’s ability to provide these important services.”
As we learn how CMS responds to this request, we will share any further information with members.
Monday, July 19, 2021
2:30 pm–4:00 pm
AND
Tuesday, July 20, 2021
9:00 am–10:30 am
This training session will provide an overview of the Office of Developmental Programs’ (ODP) QA&I Interim Year 2 Review Process for Fiscal Year (FY) 2021–2022. ODP encourages all Administrative Entity, Supports Coordination Organizations, and Provider QA&I leads to join the session. For more information on the ODP QA&I Interim Year 2 Review Process, see ODP Announcement 21-052; the link to the announcement is here. Also, please read the Pennsylvania Office of Developmental Program’s Quality Assessment and Improvement FY 21–22 Interim Year 2 Review Process document distributed to all stakeholders on July 7, 2021 prior to participating in the training. There is a link to the process document available here.
In addition, only register for one training session at the follow links:
ODP Announcement 21-053 announces the opportunity for public comment on the draft Room and Board Bulletin. The public comment period is open for 30 days from July 13, 2021 until August 13, 2021.
Under 55 Pa. Code Chapter 6100, room and board agreements:
This bulletin was drafted to provide clarification on policies and procedures to providers for collecting and calculating room and board, provider responsibilities covered under room and board, and instructions on how to complete the Room and Board Residency Agreement.
COMMENTS: Interested stakeholders are invited to review and make comments on the proposed Room and Board Bulletin as outlined below. Comments received by 11:59 pm on August 13, 2021 will be reviewed and considered for revisions to the bulletin.
Comments submitted in writing should be addressed to:
Denise Adams-Moore,
Department of Human Services,
Office of Developmental Programs,
625 Forster Street, Room 510,
Harrisburg, PA 17120.
Comments submitted through email should be sent to ODP using subject header “Room and Board Bulletin Public Comment.”
There will be two webinars offered to provide an overview of the bulletin, answer questions, and provide an opportunity for participants to provide verbal comment. ODP encourages you to sign up for only one session that is most appropriate for your role, as there are limited spaces. These sessions will be recorded and posted on MyODP.