Skip to main content Back to Top

Physician Fee Schedule (PFS) Proposed Rule CY 2022


This proposed rule makes changes to the Physician Fee Schedule (PFS), which governs payment policy in Medicare Part B for ambulatory care practice. The proposed 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 (CMS) is also seeking 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 outlined 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. 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 is proposing to allow a number of telehealth codes to remain on the telehealth list until December 31, 2023 to allow additional time to determine whether they should be made permanent. ASHP is seeking member feedback on member experiences with telehealth utilization and reimbursement. Specifically, we are looking for feedback on whether pharmacists have been able to utilize telehealth codes, if telehealth reimbursement is sufficient to support service provision, what (if any) additional codes should be added, and what other changes are necessary to make telehealth provision sustainable over the long term? Additionally, we are seeking member feedback on the following proposed changes:

    • Audio-Only Services: CMS is allowing certain E/M services as well as mental health services to be provided using audio only, rather than requiring video. CMS indicates that it intends to discontinue audio-only E/M telehealth services when the public health emergency (PHE) ends, but is proposing to continue allowing certain mental health services, including opioid treatment services and services at federally qualified health centers (FQHCs) and rural health centers (RHCs), to be provided audio-only on a permanent basis.

    • Virtual Supervision: CMS is continuing to seek feedback on whether to make “virtual supervision” (e.g., immediate availability of a supervising physician or NPP through virtual means) permanent for certain incident-to services without limitation. CMS also seeks feedback on whether the policy should be sunset for a subset(s) of services and whether a modifier should be used when virtual supervision is used. 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 Provision and Reimbursement: In an effort to “develop an accurate and stable payment rate”, CMS is reviewing payment rates for COVID-19 and other preventive vaccines (e.g., influenza, shingles, pneumonia). CMS is seeking feedback from vaccine providers regarding vaccine provision costs, including supplies and resources. Further, CMS is asking whether the process for regular updates to vaccine reimbursement should be revised. ASHP is seeking member feedback to inform our comments and provide CMS with accurate, detailed input regarding vaccine provision and reimbursement.

  • Electronic Prescribing of Controlled Substances: CMS is proposing to implement the second phase of electronic prescribing of controlled substances (EPCS) (schedules II – V) for Medicare Part D drugs. Specifically, CMS is proposing 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. Further, CMS is proposing to extend the effective date for EPCS compliance one year to January 1, 2023 and to January 1, 2025 for Medicare Part D prescriptions in long-term care facilities.

  • Medicare Diabetes Prevention Program (MDPP): In order to increase supplier enrollment in the MDPP, CMS is proposing several changes to the program. For suppliers enrolling after Jan. 1, 2022, CMS proposes to 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). Concurrently, to incentivize supplier participation, CMS is proposing to increase performance payments and beneficiary attendance payments for Core and Core Maintenance sessions by 5%.

  • Concurrent Billing of CCM and TCM Services in RHCs and FQHCs: Consistent with other PFS settings, CMS is proposing 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 proposal, 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.

  • Split/Shared Billing: CMS is proposing to change 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 is proposing to allow split/shared billing for both new and established patient visits and to use split/shared billing 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, CMS is proposing to define “substantive portion” to mean “more than half of the total time spent by the physician or NPP performing the visit.” ASHP is seeking input regarding any impacts the proposed changes would have on pharmacy practice or patient care models.

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 proposed rule). However, the timeframe for adoption of certain policies set forth in this year’s proposed rule is likely to be extended due to COVID-19. For instance, the CII e-prescribing policy is slated to take effect in 2023. Similarly, given continued uncertainty around COVID-19 variants, it is likely that CMS will provide more flexibility than usual around implementation of new policies, particularly those that receive substantial pushback from stakeholders.

We strongly encourage members to submit feedback, questions, or concerns to ASHP to assist in the development of our written comments on the proposed rule. Comments are due to CMS on September 13, 2021 so please send any input to Jillanne Schulte Wall at [email protected] by September 3, 2021.  We will update members when CMS releases a final rule in late fall 2021.