Final Physician Fee Schedule: What Will We See in 2023?

The Final Physician Fee Schedule (PFS) and Quality Program Rule for 2023 was released on November 1, 2022, and with it, some significant changes. Notably, the Centers for Medicare & Medicaid Services (CMS) issued some significant delays to proposed changes based on comments received from industry group and specialty associations, as well as individually submitted comments. This article will take you through some of the most critical changes documented in the 2023 PFS.

Basic Rate Changes

As we’ve seen in the previous few rulings, the conversion factor (CF) will again decrease. This is due to several factors including adjustments for budget neutrality and the expiration of the temporary 3% statutory increase.

In terms of the Geographic Practice Cost Index (GPCI) the 2023 GAF equation will be:

(0.50238 * work GPCI) + (0.45593 * PE GPCI) + (0.04169 * MP GPCI).

As a reminder, the 1.0 Work GPCI floor required by Section 101 of the Consolidated Appropriations Act, 2021 [December 27, 2020] extended the Work GPCI floor through December 31, 2023. 

Telehealth Changes

• Category 1 Changes: Five new services were finalized as Category 1 Telehealth Services:
  • Prolonged Service Codes G0316 – G0318
  • Chronic Pain Management Treatment Codes G3002 – G3003
• Category 3 Changes: The list of Category 3 services will be retained until the end of 2023 and CMS has added 54 additional services to that list in the 2023 PFS.
• Modifier Changes:
  • Providers can use modifier -93 to indicate the provision of audio-only services
  • Facilities like Rural Health Clinics and Federally Qualified Health Centers must continue to use the -FQ modifier
  • Providers have the option to use FQ or 93 or both if appropriate
  • Supervising providers should use the FR modifier on applicable telehealth claims

Public Health Emergency (PHE) Updates

We do not yet have an end date for the PHE but current estimation is that the PHE will be renewed through April though there are no guarantees.

For 151 days after the end of the PHE, certain things will be allowed to continue:

• Services that were temporarily included during the PHE without a category will remain covered
• Geographic and originating site restrictions will remain waived
• Certain audio-only services will remain permitted
• RHCs and FQHCs may continue to be reimbursed for telehealth services
• The delay of the in-person requirements for mental health services completed via telehealth will remain

After Day 152 and forward, certain extended allowances will discontinue, including:

• Audio-only services will no longer be allowed or fall under the definition of a telehealth service; except for certain services related to opioid use and/or other permitted mental-health services
• Providers should use modifier -95 along with the appropriate Point of Sale which should identify where services would have otherwise been rendered through the end of the year in which the PHE ends.
• The following codes will also be removed as approved telehealth services:
  • Radiation Tx Mgmt 77427
  • Eye Exam Codes 92002 & 92004
  • Interrogation vad 93750
  • Vent Mgmt Codes 94002-94004
  • Eval pt use of inhaler 94664
  • Cognitive Test 96125
  • Initial Observation Care 99218-99220
  • Subsequent Care Codes 99224-99226
  • Initial Hospital Care 99221-99223
  • Observ/hosp same date 99234-99236
  • NF Care Initial 99305-99306
  • Domicil/r-Home Visit NP Codes 99324-99328
  • Home Visit NP 99341-99345
  • Phone E/M Codes 99441-99443
  • Neonate Critical Care 99468
  • Ped Critical Care 99471 and 99475
  • Initial Day Hospital Neonate Care 99477

This final rule also includes changes to inpatient and observation codes, discharge day codes, shared services and more. For a deeper analysis of this information, watch our FREE webinar on the PFS Final Rule for 2023.

Resources:

• CMS Final Rule on CSM Newsroom https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-final-rule
• CMS Final Rule on Federal Register https://www.federalregister.gov/documents/2022/07/29/2022-14562/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other

Taya Gordon, MBA, FACMPE, CMOM
LinkedIn: https://www.linkedin.com/in/tayagordon/
Twitter: https://twitter.com/tayamoheiser