Academy Advocacy Clearly Visible in 2022 MPFS Final Rule

Separate CMS Announcement of MIPS ‘Extreme Circumstances’ Exception Also a Win

November 23, 2021, 6:00 a.m. News Staff — The 2022 Medicare physician fee schedule and Quality Payment Program final rule delivers several family medicine wins following staunch AAFP advocacy — including a long-overdue increase to clinical labor pricing that will help physician practices hire and retain essential clinical staff.

Last year’s legislation offset what would have been a similar dip in the 2021 conversion factor imposed by CMS’ statutory budget-neutrality requirements. With the COVID-19 public health emergency still in effect, lawmakers are expected to consider a like fix for 2022. The Academy has steadily lobbied for this remedy and Nov. 22 threw its support behind a new bill  the 2021 increase for another year.

Clinical Labor Pricing Update

For the first time since 2002, CMS will update the clinical labor portion of practice expense relative value units to reflect current wage data and other clinical labor costs. The final rule says the update will roll out over four years; the Academy had urged an immediate transition to ensure Medicare payments reflect the significantly increased costs of employing vital clinical staff.

Telehealth

The final rule retains all services previously added to the Medicare telehealth services list on a Category 3 (temporary) basis until the end of calendar year 2023. The goal of this provision is to avoid an abrupt end to coverage of telehealth services that were added during the pandemic by allowing physicians to continue to offer them at least to patients in rural areas. The Academy’s summary of the rule includes coding information for the services relevant to family physicians.

As directed by the Consolidated Appropriations Act of 2021, and effective after the end of the COVID-19 public health emergency, the rule provides permanent coverage of tele-mental health services after the end of the PHE by

• removing geographic restrictions for telehealth services provided to diagnose, evaluate or treat a mental health disorder;
• adding a patient’s home as a permissible originating site for telehealth services for the diagnosis, evaluation or treatment of a mental health disorder; and
• requiring that the billing practitioner (or another practitioner of the same specialty in the same group) must have furnished an in-person service to the beneficiary within the six months before the date of the initial telehealth service and at least every 12 months thereafter.

The Academy — which has steadily advocated for the integration of physical and mental health care in as many practices possible — had expressed strong support for this change but objected to the required in-person services. “Evidence does not support the need for such an ongoing requirement for mental health services,” the Academy told CMS in September. In response to the AAFP’s concerns, CMS lengthened the in-person timeline from six months to one year.

CMS also finalized a requirement for the use of a new modifier for services furnished using audio-only communications but did not make a permanent allowance for audio-only telehealth services, as the AAFP had called for as a way to improve health equity.

In a related win for the Academy and primary care patients in underserved communities, the final rule allows rural health clinics and federally qualified health centers to offer tele-mental health services beyond the pandemic.

Evaluation and Management Coding

CMS is implementing policy changes affecting E/M coding, including codes for visits split or shared by a physician and a nonphysician health professional in the same group in the facility setting, the Academy’s summary notes. Such visits are billed by the physician or nonphysician clinician who provides the substantive portion of the visit, with that portion defined in 2022 as history, physical exam, medical decision-making or more than half of the total time (except for critical care, which can be defined only as more than half the time). In 2023, CMS will define the substantive portion of the visit as more than half of the total time spent.

CMS requires a modifier on the claim to identify these services, and documentation in the medical record must identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the medical record.

Vaccine Administration

Starting Jan. 1, CMS will pay $30 a dose for the administration of the influenza, pneumococcal and hepatitis B virus vaccines, nearly double the rate paid for the same service in 2021. The 2022 MPFS also maintains this year’s $40-per-dose rate for administration of the COVID-19 vaccines through the end of the calendar year in which the PHE ends. Effective Jan. 1 of the year following the end of the PHE, the payment rate for COVID-19 vaccine administration will be set at a rate to align with the payment rate for the administration of other Part B preventive vaccines. CMS will continue the additional payment of $35.50 for at-home COVID-19 vaccine administration under certain circumstances through the end of the calendar year in which the PHE ends.

Appropriate Use Criteria for Advanced Diagnostic Imaging

CMS finalized its proposal to begin the payment penalty phase of the AUC program on Jan. 1, 2023, or Jan. 1 of the year following the end of the PHE, whichever is later. The Academy continues to call on Congress to repeal the program. In its comments to CMS about the MPFS as proposed, the Academy reiterated its position that the AUC program “is overly burdensome, complex and … does not consider quality, patient outcomes or other important factors, which are more appropriately addressed in alternative payment models.”

Quality Payment Program

CMS is implementing several changes to the traditional MIPS track of the QPP.

• In the Quality category, the “data completeness” criteria threshold of 70% for the 2022 and 2023 performance periods will be maintained; CMS had proposed to increase the threshold to 80% for the 2023 performance period.
• In the Cost category, the 2022 rule adds five new episode-based cost measures, including two chronic condition episodes.
• In the Promoting Interoperability category, CMS will require eligible clinicians to report or claim an applicable exclusion for the Immunization Registry Reporting and Electronic Case Reporting measures but is establishing a fourth exclusion criteria for Electronic Case Reporting “such that practices using certified electronic health record technology that is not certified to the electronic case reporting criterion prior to the selected performance period may claim an exclusion for the measure and not be penalized,” the AAFP’s summary says.
• Beginning with the 2022 performance period, CMS will apply automatic reweighting of the Promoting Interoperability category for small practices (15 or fewer ECs). The category’s weight will be redistributed to the other performance categories. The AAFP supported this new policy.

Scoring policies updated in the final rule include

• historical benchmarks for the 2022 performance period, using data submitted for the 2020 performance period;
• a floor for quality measures in a participant’s first two years in the MIPS program, starting in performance year 2022, with a seven-point floor for those in their first year; and
• a 2022 performance period performance threshold of 75 points, with an exceptional performance threshold of 89 points.

The AAFP argued in its comments on the proposed rule that the steep increase to the performance threshold during the pandemic would be untenable for many practices.

CMS will move forward with implementing MIPS Value Pathways beginning in 2023. The Academy is advocating for this new reporting option to be more meaningful and less burdensome for family physicians.