ACP letter to CMS lists concerns with changes to flexible policies in response to pandemic, expiration of direct supervision flexibility, approach to split/shared billing
Sept. 23, 2022 (ACP) — In a Sept. 6 letter to federal officials, the American College of Physicians says it is largely pleased by the proposed Medicare Physician Fee Schedule for 2023, but several areas still need to be revised before the new policies are finalized.
“We’re generally encouraged by the proposals. CMS has been responsive to our advocacy, and there continues to be open dialogue with both CMS and congressional leaders,” said Dejaih Johnson, an ACP associate for regulatory affairs. “Still, there are a number of proposals that we hope to see refined, and we’re supporting an extension of public health emergency-related flexibilities.”
In terms of positive developments, ACP is especially happy to see that the proposed rule increases the value for evaluation and management (E/M) codes used in inpatient settings. “This is a significant step in recognizing the value that internal medicine physicians contribute to their patients and our health care system,” Johnson said. “The revisions to this code family, coupled with the 2021 revisions to outpatient E/M codes, are a huge step in burden reduction as well.”
However, ACP told CMS that it remains concerned about changes to flexible policies that have been put in place in response to the COVID-19 pandemic. Unless action is taken, provisions such as reimbursement for audio-only E/M services (CPT codes 99441 through 99443) will end.
“ACP believes the continued coverage of these services is imperative to providing access to care for patients in rural, underserved, and urban areas,” Johnson noted. “This modality has extended care to the most vulnerable patients, and to allow coverage to expire is to leave millions of beneficiaries without any resolve. The College continues to work with various entities in determining the appropriate degree of coverage, but we strongly believe that if there is too big a delta between audio-only and audio-visual or face-to-face care, then audio-only will not be utilized and patients will be without the benefits.”
ACP is also concerned about the expiration of the direct supervision flexibility, which allows for the supervising physician or other practitioner to be immediately available via virtual presence rather than physically present. “This flexibility appropriately supports the expansion of telehealth services and empowers clinicians to supervise clinical staff virtually, at their discretion,” Johnson explained. “For these reasons, ACP has opposed the return to the in-person requirement since it places an extra onus on the supervising clinician. As we move into this next phase, the College continues to work with CMS on providing information that supports the extension of virtual presence flexibilities where clinically appropriate.”
ACP is also urging an overhaul to the approach to billing for split/shared visits in the physician-non-physician practitioner (NPP) care delivery model. “Ahead of the 2023 rulemaking cycle, ACP and nearly 20 other organizations expressed concerns that CMS’ policy would negatively impact the model as well as the patient experience,” Johnson said. “The College strongly supports the collaboration between primary care, specialty care, and NPP teams, and we have recommended that the billing requirements should promote harmony with recent revisions to the E/M code family by using either medical decision-making (MDM) or time to determine who performed the substantive portion of these joint visits. CMS noted that their delaying the previously finalized time-only approach was a direct result of this advocacy, but we’ve still got more work to do.”
Moving ahead on this front, Johnson said, “ACP continues to emphasize with CMS that where the physician participates and meaningfully contributes to the MDM, even if the physician does not perform the MDM in its entirety or has not spent more than half of the total time, the physician’s work should be appropriately recognized and the NPP should be encouraged to work to the top of their license — consulting with the physician when the situation is particularly difficult.”
Finally, ACP continues to work with congressional leaders to resolve — once and for all — the annual threat of steep payment cuts due to “budget neutrality” requirements.
“The issue of budget neutrality is multidimensional and complex, which only compounds the financial toll that the pandemic has taken and the continual destabilization that leads to unpredictable reimbursements,” Johnson said. “The College recently supported the Supporting Medicare Providers Act of 2022, which would negate the impact that the budget neutrality cuts would have on Medicare coverage for 2023. But we recognize that longer-term solutions are needed. ACP continues to be firmly committed to working with Congress to find a long-term solution that gives physicians stability and predictability while helping preserve continuity of care for their patients.”
The final fee schedule for 2023 is expected to be released in the early part of November, according to Johnson. “ACP will prepare a summary of this final rule for members and will continue to provide feedback to CMS both within and outside of the rulemaking cycle,” Johnson noted.