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Issue Brief: Physician Fee Schedule (PFS) Final Rule CY 2022

Center for Medicare and Medicaid Services (CMS)

November 3, 2021


This final rule makes changes to the Physician Fee Schedule (PFS), which governs payment policy in Medicare Part B for ambulatory care practice. The final rule also encompasses changes to related programs, including the Quality Payment Program, the Diabetes Prevention Program, and the Medicare Shared Savings Program among others. The Centers for Medicare and Medicaid Services (CMS) also sought stakeholder feedback regarding potential methods to “encourage healthcare providers serving vulnerable populations to participate in accountable care organizations (ACOs) and other value-based care initiatives, including whether any adjustments should be made to quality measure benchmarks to take into account ACOs serving vulnerable populations.” CMS updates these rules annually, so many of the policy changes finalized for 2022 build on existing policies.

Major Proposed Changes for CY 2022

  • Incident-To Billing for Pharmacist Services: In last year’s final PFS rule, CMS clarified the billing rules for pharmacist-provided evaluation and management (E/M) services. Noting that it recognizes the value of pharmacist-provided patient care services, the agency nevertheless believes that because pharmacists are not Medicare-eligible providers, the statute limits reimbursement for incident-to E/M services provided by them to 99211. However, CMS stated its willingness to consider pharmacist-specific does to capture services previous reimbursed under the higher-level (99212 – 99215) E/M codes.

Although ASHP continues to disagree with CMS’s interpretation of the statute, in order to ensure that pharmacist services are reimbursed commensurate with their duration and complexity, we have been working with CMS to develop new pharmacist-specific E/M codes. Based on member input, we noted that an ideal solution would be the addition of a pharmacist modifier to existing E/M codes. Barring that, we developed and submitted a draft pharmacist-specific code set to CMS. Ensuring that pharmacists’ patient care services are reimbursed commensurate with their duration and complexity is critical to maintaining patient access to care and remains a top ASHP priority. The final rule does not include any changes to E/M coding for pharmacists’ services, but we continue to seek meetings with the agency on this topic outside of the rulemaking process. We will continue to work closely with our members and the agency to find a workable solution to the E/M billing change.

  • Telehealth Services: CMS finalized a proposal to allow a number of telehealth codes added during the COVID-19 public health emergency to remain on the telehealth list until December 31, 2023. CMS is continuing to review the codes to determine whether they should be made permanent.

Audio-Only Telehealth Services: For CY 2022, CMS will allow audio-only communications only for mental health services, including substance use disorder services, and only in situations where the beneficiary requests audio-only versus two-way audio-visual communications. CMS is instituting a new modifier for these services that requires the provider to verify that it had the ability to provide two-way communications, but did not because the patient either preferred or required audio-only services. CMS is also proposing that in order to receive reimbursement for audio-only services, within 6 months of the telehealth services, patients receiving such services must have an in-person visit “for the diagnosis, evaluation, or treatment of mental health disorders (other than for treatment of a diagnosed SUD or co-occurring mental health disorder).”

Virtual Supervision: CMS did not make a decision regarding making “virtual supervision” (e.g., immediate availability of a supervising physician or NPP through virtual means) permanent for certain incident-to services without limitation, noting that they are continuing to seek feedback on the issue. Virtual supervision is critical to creating and sustaining care models that fully integrate pharmacists. ASHP will continue to advocate aggressively to make virtual supervision a permanent option for services reimbursed under the PFS.

  • Vaccine and Monoclonal Antibody Reimbursement: In an effort to “develop an accurate and stable payment rate”, CMS reviewed payment rates for COVID-19 and other preventive vaccines (e.g., influenza, shingles, pneumonia). For CY 2022, CMS will pay $30 for administration of influenza, pneumococcal, and hepatitis B vaccines and will maintain the current payment rates for COVID-19 vaccines ($40 per shot), but asked for additional input on a number of vaccine administration-related questions. Specifically, CMS is seeking further feedback from vaccine providers regarding vaccine provision costs, including supplies and resources. CMS is also asking whether the process for regular updates to vaccine reimbursement should be revised for CY 2023 and beyond.

For CY 2022, CMS will maintain the current payment rates for COVID-19 monoclonal antibody (mAb) treatment ($450 in healthcare setting; $750 in home). However, in subsequent years, practitioners will be reimbursed for mAb administration in the same way they are reimbursed for administering similar complex biologic products.

  • Electronic Prescribing of Controlled Substances: CMS will implement the second phase of electronic prescribing of controlled substances (EPCS) (schedules II – V) for Medicare Part D drugs beginning on January 1, 2023 (and January 1, 2025 for Medicare Part D prescriptions in long-term care facilities). Specifically, CMS finalized a number of exceptions to EPCS, including when the prescriber and dispensing pharmacy are the same entity, for low-volume prescribers (i.e., >100 Part D controlled substances prescriptions per year), and for prescribers in natural disaster areas or who have an extraordinary circumstances waiver. CMS indicated that it will initially enforce EPCS compliance through warning letters to prescribers who have not implemented the mandate.
  • Medicare Diabetes Prevention Program (MDPP): In order to increase supplier enrollment in the MDPP, CMS finalized a number of changes to the program. For suppliers enrolling after Jan. 1, 2022, CMS will use Center for Medicare & Medicaid Innovation (CMMI) waiver authority to waive the enrollment fee beyond the COVID-19 public health emergency period. Further, to address supplier feedback that the current structure of the program is cumbersome, for beneficiaries starting MDPP on or after Jan. 1, 2022, the services will only be a single year with no Ongoing Maintenance phase (months 13 – 24), thereby aligning it with the precursor CDC Diabetes Prevention Program. Concurrently, to incentivize supplier participation, CMS will increase performance payments and beneficiary attendance payments for Core and Core Maintenance sessions.
  • Concurrent Billing of CCM and TCM Services in RHCs and FQHCs: Consistent with other PFS settings, CMS finalized a proposal to allow concurrent billing of chronic care management (CCM) and transitional care management (TCM) services in rural health centers (RHCs) and federally qualified health centers (FQHCs). Under the final rule, CCM and TCM can be provided to the same beneficiary during the same service period, as long as all requirements for billing the relevant codes are met. ASHP applauds CMS for finalizing a change that creates consistency between settings and improves patient access to care services.
  • Split/Shared Billing: CMS finalized a change to the definition of split/shared visit to apply only in institutional settings. For outpatient settings, split billing will not be available because the “incident-to” regulations govern situations “where a non-physician practitioner (NPP) works with a physician who bills for the visit, rather than billing under the NPP’s own provider number.” In institutional settings, CMS will allow split/shared billing for both new and established patient visits and for critical care and certain Skilled Nursing Facility E/M visits. For critical care visits, no other E/M services can be billed for that patient by same group or same specialty on the same day. Further, because only the physician or NPP providing the “substantive portion” of care during split/shared visit can bill for the services, for 2022 CMS will allow the substantive portion to be determined on the basis of “history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which can only be more than half of the total time).” For 2023 and after, substantive portion means more than half the total time spent by the physician or NPP performing the visit.

Applicability and Timing

In general, policy proposals adopted in a PFS proposed rule become effective on January of the next calendar year (so January 1, 2022 for this final rule). However, certain policies such as the ECPS mandate have implementation dates in 2023. CMS is also seeking more information on a number of policies, including virtual supervision and telehealth, pushing off decisions on implementation of those policies until after 2022.