2023 Fee Schedule: Implications for Anesthesia and Pain Practices

Summary

The 2023 Medicare fee schedule contains new rules that will impact many of our readers. This alert will discuss changes that will primarily affect those in a chronic pain practice but that may also impact some anesthesia and critical care providers.

"I feel a change comin' on"; it's a lyric that Bob Dylan used to express the societal transition that was taking shape in what is now a bygone era. While there are changes that inevitably come with the rise of each new generation, we are reminded each November of the yearly changes that lay in store for America's healthcare providers. Last month, the Centers for Medicare and Medicaid Services (CMS) published the 2023 Medicare Physician Fee Schedule (PFS) Final Rule (FR), which contains changes in reimbursement rates, coding rules, documentation requirements, etc.

In our last alert dealing with the 2023 PFS FR, we addressed some of the key regulations affecting anesthesia providers in the new year. In this alert, we will take a look at FR provisions that may have a direct impact on chronic pain practices. We will use CMS's official fact sheet on the FR and a newly released Medicare Learning Network (MLN) article about the 2023 changes to help summarize the new pain practice regulations for next year.

Evaluation and Management

The CMS fact sheet notes that the American Medical Association (AMA) CPT Editorial Panel approved revised evaluation and management (E/M) coding and updated guidelines for the Other E/M category of visits, effective January 1, 2023. As it concerns these changes, the FR asserts that CMS has "finalized and adopted most of these AMA CPT changes in coding and documentation for Other E/M visits (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment) effective January 1, 2023." This revised coding and documentation framework includes CPT code definition changes (revisions to the Other E/M code descriptors), including:

•  New descriptor times (where relevant)
  
• Revised interpretive guidelines for levels of medical decision making
• Choice of medical decision making or time to select code level (except for a few categories, such as emergency department visits and cognitive impairment assessment, which are not timed services)
• Eliminated use of history and exam to determine code level; rather there is a requirement for a medically appropriate history and exam

CMS finalized its proposal to maintain the current billing policies that apply to E/M services. The FR also creates Medicare-specific coding for payment of Other E/M prolonged services, similar to what CMS adopted in 2021 for payment of Office/Outpatient prolonged services. These services will be reported with three separate Medicare-specific G codes.

Split (or Shared) E/M Visits

The FR confirms a year-long delay of the split (or shared) visits policy that CMS had established in 2022. That policy determines which professional should bill for a shared visit by defining the "substantive portion" of the service as more than half of the total time. For 2023, as in 2022, the substantive portion of a visit is comprised of any of the following elements:

• History
• Physical exam
• Medical Decision Making (MDM)
• Time (more than half of the total time spent by the practitioner who bills the visit)

To recap, for 2023, clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, 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.

Telehealth Services

The 2023 PFS FR extends the duration of time that certain services are included under telehealth during the public health emergency (PHE) for at least 151 days following the end of the PHE, in alignment with the Consolidated Appropriations Act, 2022 (CAA, 2022). These include the following:

• Telehealth services may be furnished in any geographic area and in any originating site setting (including the beneficiary's home).
  
• Certain services may be furnished via audio-only telecommunications systems.
• The CAA, 2022, also delays the in-person visit requirements for mental health services furnished via telehealth until 152 days after the end of the PHE.

The 2023 PFS FR allows practitioners to continue to bill with the place of service (POS) indicator that would have been reported had the service been furnished in person. These claims will require the 95 modifier to identify them as telehealth services. Claims can continue to be billed with the POS code that would be used if the telehealth service had been furnished in person through the later of the end of 2023 or end of the year in which the PHE ends.

Chronic Pain Management Services

The FR creates new HCPCS codes (G3002 and G3003), as well as new valuation for chronic pain management and treatment services (CPM) for 2023. The finalized codes include a bundle of services furnished during a month that CMS believes to be the starting point for "holistic chronic pain care," aligned with similar bundled services in Medicare, such as those furnished to people with suspected dementia or substance use disorders.

The CPM codes include the following elements in the code descriptor: diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and coordination between relevant practitioners furnishing care, such as physical and occupational therapy, complementary and integrative care approaches, and community-based care, as appropriate.

We will be providing further information on the 2023 rule changes as more information becomes available, including more detailed information relative to chronic pain and E/M changes. Until then, if you have questions about this topic, please contact your account executive or you can reach out to us at info@anesthesiallc.com.