The Centers for Medicare and Medicaid Services (CMS) on July 7 released the proposed 2023 Medicare Physician Fee Schedule rule, addressing Medicare payment and quality provisions for physicians in the coming year. Under the proposal, physicians will see a decrease to the conversion factor on Jan. 1, 2023, going from $34.6062 to $33.0775. CMS estimates that the physician rule will decrease payments to cardiologists by 1 percent from 2022 to 2023 through updates to work, practice expense, and malpractice RVUs. This estimate is based on the entire cardiology profession and can vary widely depending on the mix of services provided in a practice. 

This rule represents the continuation of a troubling trend. The confluence of conversion factor cuts, statutory cuts on the horizon from sequestration and PAYGO rules, and a 0% payment update that fails to account for significant inflation in practice costs creates long-term financial instability in the Medicare physician payment system. By working in concert with other medical societies, the ACC was able to forestall these cuts last year. The 2023 PFS makes clear the need to redouble efforts to ensure patient access to Medicare-participating physicians and services is not threatened. In an important step to speak with a unified voice, the ACC and many in organized medicine have aligned with the AMA on a set of principles to guide advocacy efforts on Medicare physician payment reform.

Highlights from the proposed rule as they relate to payment policy, rate setting and quality provisions include: 

Physician Fee Schedule

• The proposed rule includes updates to work and/or practice expense (PE) values for codes describing Evaluation and Management (E/M) services, External Extended ECG Monitoring, and Cardiac Ablation. The agency would adopt changes to several E/M code families, including hospital, emergency medicine, nursing facility and home visits, as recommended by the CPT Editorial Panel and AMA/Specialty Society RVS Update Committee (RUC). Additionally, the rule includes proposed work and PE values for new/revised codes describing Endovascular Pulmonary Arterial Revascularization and Pulmonary Angiography. More information is available in supporting data tables.
  
  
• The rule proposes to delay until 2024 the split (or shared) visits policy finalized in CY 2022 for one year with a few exceptions. This change will redefine the definition of substantive portion, as more than half of the total time. Clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, or medical decision making, or more than half of the total practitioner time spent to define the substantive portion, instead of using total time to determine the substantive portion.

• CMS did not propose changes to the Appropriate Use Criteria (AUC) Program or the timeline for its implementation. However, separate from the PFS rulemaking, the agency issued a notice on the AUC Program page that the penalty phase of the program will not begin Jan. 1, 2023, even if the COVID-19 public health emergency (PHE) ends in 2022. No timeline is offered for when implementation may begin. 

• CMS seeks public comment on strategies for improving the Global Surgical Package valuation. CMS still believes that there is strong evidence suggesting that the RVUs for global packages are inaccurate. 

Medicare Telehealth and Other Services Involving Communications Technology

• The rule includes proposed policy changes to maintain certain elements of the various telehealth flexibilities authorized on a temporary basis during the COVID-19 PHE. Reflecting legislation passed last year, these policies will remain in place until 151 days following the conclusion of the PHE per the proposed rule. 
  
  
• After the 151-day period following the end of the PHE CMS proposes removing many of the services that had been temporarily allowed, including audio-only services. 
  
  
• CMS has proposed maintaining a number of the temporary PHE telehealth codes in place as Category 3 telehealth codes through at least 2023 to gather more data for future consideration of eventual permanent status as a Medicare telehealth allowed services.
  
  
• CMS also proposes that following the 151-day period after the PHE concludes that telehealth claims will require the appropriate place of service indicator rather than the 95 modifier.
  
  
• Without making new proposals regarding the use of the provision of direct supervision through virtual presence—a mechanism currently available for cardiovascular rehabilitation services—CMS again seeks additional information on whether that flexibility should be made permanent.
  
  
• The current list of telehealth services and their status is available here. 

2023 Quality Payment Program Performance Period

The Centers for Medicare and Medicaid Services is proposing several updates to the Quality Payment Program and Medicare Shared Saving Program for 2023. It also includes a timeline for implementation of the new voluntary Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs).  

Highlights include: 

• The addition of five proposed new MVPs for 2023, bringing the total MVPs to 12. The proposed new MVPs include Advancing Cancer Care; Optimal Care for Kidney Health; Optimal Care for Patients with Episodic Neurological Conditions; Supportive Care for Neurodegenerative Conditions; and Promoting Wellness.
   
• An expansion of the Advancing Care for Heart Disease MVP to include measures for subspecialists such as electrophysiology, heart failure and intervention. This proposal includes the addition of six quality measures and two improvement activities, and the removal of one improvement activity.
  
  
• A proposal to evaluate new MVP candidates and solicit feedback from interested parties and the general public through a comment period.
  
  
• Multiple requests for information (RFIs) focusing on health equity, enhanced conversion factor updates, QCDR, quality registry and health IT vendor support, and digital quality measurement.
  
  
• Setting the 2023 performance threshold at 75 points for the 2023 performance year. There is no longer an additional performance threshold for exceptional performance starting in 2023.
  
  
• Minor changes to the Cost, Quality, Improvement Activities, and Promoting Interoperability performance categories. The 2023 weights of performance categories are: 30% for the quality performance category, 30% for the cost performance category, 5% for the improvement activities performance category, and 25% for the Promoting Interoperability performance category.
  
  
• A proposal that facility-based MIPS eligible clinicians would be eligible to receive the complex patient bonus.
  
  
• Adjustments to the Medicare Shared Savings Program to advance health equity including advanced shared savings payments (referred to as advance investment payments) to low revenue ACOs, inexperienced with performance-based risk Medicare ACO initiatives, that are new to the Shared Savings Program, and that serve underserved populations.
  
  
• CMS proposes to allow ACOs inexperienced with performance-based risk to participate in one 5-year agreement under a one-sided shared savings model.
  
  
• CMS proposes to implement a health equity adjustment of up to 10 bonus points to an ACO’s MIPS quality performance category score for certain participants.
  
  
• Proposals to reduce ACO administrative burdens including marketing material review, beneficiary notification, data sharing, and SNF three-day rule waiver application.
  
  
• The extension of the incentive for reporting eCQMs/MIPS CQMs through performance year 2024 to align with the sunsetting of the CMS Web Interface reporting option.
  
  
• A proposal to adopt an alternative quality performance standard that incorporates a sliding scale to avoid “all-or-nothing" scoring.
  
  
• ACOs are required to report the 10 measures under the CMS Web Interface or the three eCQMs/MIPS CQMs and administer the CAHPS for MIPS survey. CMS will calculate the two claims-based measures.
  
  
• The rule proposes a total of 192 quality measures in 2023, addresses changes to 73 existing MIPS quality including nine quality measures, including one new administrative claims measure, on composite measure, five high priority measures, and two new patient-reported outcome measures and removes 17 quality measures.
  
  
• CMS proposes to delay the requirement for full QCDR measure testing to begin with the 2024 performance period and proposes to not change the requirements that QCDR measures be fully tested prior to inclusion in an MVP.
  
  
• Starting in 2024, CMS proposes removing QCDRs and qualified registries that have not submitted any MIPS data for either of the two years preceding the applicable self-nomination period and continue to not submit MIPS data.  

ACC Advocacy Staff will continue to provide more detailed information on elements of the proposed rule in the weeks ahead. In addition, the ACC will develop comments for submission within the 60-day comment period. Look for updated information on ACC.org/Advocacy and in upcoming issues of The Advocate newsletter. Additional information on the rule can be found in the CMS Press Release, MPFS Fact Sheet, Shared Savings Fact Sheet, and QPP Fact Sheets.

Not long before the final rules are released in the fall, experts will discuss federal legislative and regulatory topics at ACC’s 2022 Legislative Conference October 16-18 in Washington, DC. Don’t miss this opportunity to learn about hot button issues facing cardiologists and to ensure the voice of cardiology is heard on Capitol Hill. Access online registration here.

Keywords: Policy, Hospitals, Cardiology, Physicians, Prospective Payment System, Fee Schedules, Outpatients, Medicare, Centers for Medicare and Medicaid Services, U.S., ACC Advocacy

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