The Centers for Medicare and Medicaid Services (CMS) on Nov. 1 released the final 2023 Medicare Physician Fee Schedule (MPFS), addressing Medicare payment and quality provisions in the coming year. Under the proposal, clinicians will see a decrease to the conversion factor from $34.6062 to $33.0607 as of Jan. 1, 2023. For cardiologists, CMS estimates that the rule will decrease payments by 1% compared with 2022 as a result of updates to work, practice expense, and malpractice relative value units (RVUs). This estimate is based on the entire cardiology profession and can vary widely depending on the mix of services provided in a practice.

Of note, following extraordinary and unprecedented efforts of ACC members, leaders, and Advocacy staff in collaboration with the Heart Rhythm Society and other stakeholders, CMS altered its earlier proposed work RVUs for electrophysiology (EP) ablation services as part of the Final Rule. CMS will implement RVUs recommended by the American Medical Association (AMA) Relative Value Scale Update Committee (RUC) that are higher than the earlier proposal for SVT, VT, and AF ablation. These values are still lower, overall, than the 2022 work RVUs. RVUs for additional ablation services are unchanged from 2022 or the proposed rule. By adopting the RUC recommendations for the main ablation services, the RVUs for this family of codes will be 11.2% higher than proposed and 3.7% lower than 2022.  For more detail on ablation services, access ACC’s ablation summary.

Other highlights as they relate to payment policy, rate-setting and quality provisions include:

Physician Fee Schedule

• The final 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. Additionally, work values for new/revised codes describing Endovascular Pulmonary Arterial Revascularization and Pulmonary Angiography are finalized mostly below RUC recommendations. More information is available in supporting data tables.
• The agency adopted the AMA’s changes to several E/M code families, including hospital inpatient, observation care visits, consultations, emergency medicine, nursing facility and home visits, as recommended by the CPT Editorial Panel and AMA/Specialty Society RVS Update Committee (RUC). CMS adopted the E/M documentation guidelines for payment purposes. The revised E/M services will also be based on the level of the MDM as defined for each service or the total time for E/M service performed on the date of the encounter. CMS did not adopt the revised prolonged services codes, but the agency will be implementing a Medicare specific code instead.
• The rule delays until 2024 the split (or shared) visits policy finalized in 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 enact changes to the Appropriate Use Criteria (AUC) Program or the timeline for its implementation. However, separate from the MPFS rulemaking, the agency earlier this year announced on their website 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 sought 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 and will continue to welcome additional insights from interested parties as they consider appropriate next steps.

Medicare Telehealth and Other Services Involving Communications Technology

• The rule includes 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. 
• After the 151-day period following the end of the PHE, the rule removes many of the services that had been temporarily allowed. This includes audio-only services (except in certain cases of mental health) despite many comments urging the continuation of coverage.
• A number of the temporary PHE telehealth codes have been maintained 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.
• Following the 151-day period after the PHE concludes, telehealth claims will require the appropriate place of service indicator rather than the 95 modifier. 
• New proposals regarding the use of the provision of direct supervision through virtual presence – a mechanism currently available for cardiovascular rehabilitation services – are not included in the final rule. Rather, CMS is seeking additional information on whether that flexibility should be made permanent.  

*The current list of telehealth services and their status is available here. For guidance on conducting a telehealth visit for pre, during and post-visit, access ACC’s Telehealth Workbook.

2023 Quality Payment Program Performance Period

The final rule also includes several updates to the Quality Payment Program and Medicare Shared Savings Program for 2023, as well as an implementation timeline for the new voluntary Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs). 

Highlights include:

• CMS expanded the inventory of MVPs by 5 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. The rule adds six quality measures and two improvement activities, and removes two improvement activities.
• The opportunity to provide feedback on new MVP candidates and solicit feedback from interested parties and the general public through a comment period. 
• Sets 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, 15% for the improvement activities performance category, and 25% for the Promoting Interoperability performance category. 
• Facility-based MIPS eligible clinicians would be eligible to receive the complex patient bonus beginning with performance year 2023.
• 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. 
• Allowing ACOs inexperienced with performance-based risk to participate in one 5-year agreement under a one-sided shared savings model. 
• The implementation of a health equity adjustment of up to 10 bonus points to an ACO’s MIPS quality performance category score for certain participants.
• Reductions in 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. 
• The adoption of 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 finalizes a total of 198 quality measures in 2023, addresses changes to 76 existing MIPS quality measures, adds nine quality measures, one new administrative claims measure, one composite measure, five high priority measures, and two new patient-reported outcome measures. The rule removes 11 quality measures from the MIPS quality measure inventory and partially removes two quality measures (retained for use with the MVPs).
• The delay of the requirement for full QCDR measure testing to begin with the 2024 performance period and does not change the requirements that QCDR measures be fully tested prior to inclusion in an MVP. 
• Starting in 2024, CMS will remove 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. 

Need for Long-Term Reform

The confluence of conversion factor cuts, statutory cuts from sequestration and PAYGO rules, and a 0% payment update that fails to account for significant inflation in practice costs, further creates long-term financial instability in the Medicare physician payment system. Patient access to Medicare-participating physicians and services continues to be threatened and the ACC is working closely with its partner CV societies and the broader house of medicine to urge congressional action that is aligned with the AMA’s set of payment reform principles.

ACC Advocacy staff will continue to provide more detailed information on elements of the final rule in the weeks ahead. 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 Sheet (Note: clicking link downloads zip file).

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, COVID-19 Hub, Diabetes and Cardiometabolic Disease, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Prevention, Pulmonary Hypertension and Venous Thromboembolism, Vascular Medicine, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Pulmonary Hypertension, Interventions and Imaging, Interventions and Vascular Medicine, Angiography, Nuclear Imaging, Hypertension

Keywords: Medicare Part B, Humans, Electrocardiography, Policy, Hospitals, Telemedicine, Technology, Cardiology, Malpractice, Angiography, Referral and Consultation, Physical Examination, Electrophysiology, Emergency Medicine, Clinical Decision-Making, Documentation, Fee Schedules, Public Health, Motivation, Mental Health, Inpatients, Hypertension, Pulmonary, House Calls, Cardiologists, Cardiac Rehabilitation, COVID-19, Area Under Curve, American Medical Association, Centers for Medicare and Medicaid Services, U.S., Relative Value Scales, ACC Advocacy

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