First Look at the Final Rule: Anesthesia Takes Another Hit
Summary: It should come as no surprise to our readers that reimbursement for Medicare services has been going in the wrong direction. That trend will not be reversed in 2022. This and other items arising from the 2022 Medicare Physician Fee Schedule Final Rule are discussed in today's alert.
On November 2, 2021, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP) Final Rule (FR). The rule includes payment and quality provisions that will take effect on January 1, 2022. In addition, CMS produced a fact sheet summarizing the key provisions of the FR. The following will act to highlight some of the more pertinent provisions of the FR from the anesthesia specialty standpoint.
Conversion Factors
With the budget neutrality adjustment accounting for changes in relative value units (RVUs), as required by law, and the expiration of the 3.75 percent temporary 2021 payment increase (provided by the Consolidated Appropriations Act of 2021), the 2022 PFS conversion factor (CF) is $33.59. This represents a decrease of $1.30 from the 2021 CF of $34.89, or a reduction of 3.71 percent. Our readers will recall that the PFS CF is applicable to anesthesia providers when they submit non-anesthesia services for payment, such as TEE, invasive lines, postoperative pain blocks and ultrasound guidance (USG).
The anesthesia CF for 2022 will be $20.93, according to the American Society of Anesthesiologists (ASA). (The CMS summary of the FR did not include the anesthesia CF.) This represents a disappointment on two fronts. First, it is a decrease from 2021's CF of $21.56, reflecting a 2.9 percent decrease. Second, it is a decrease from the previously projected CF as published in the proposed rule, which had been set at $21.04.
Providers should remember that the PFS CF and the anesthesia CF listed above are based on a national average. The CFs may differ slightly based on your geographical area. Our readers should also keep in mind that, in addition to these CF reductions, there are other payment cuts slated to go into effect on Jan. 1, 2022. These include a 2 percent cut due to the resumption of sequestration and a 4 percent cut due to pay-as-you-go provisions under the American Rescue Plan.
Shared E/M Visits
The 2022 FR further refines CMS' longstanding policies concerning shared evaluation and management (E/M) visits. The provisions on this point include the following:
- Definition of shared (or split) E/M visits as those provided in the facility setting by a physician and a non-physician practitioner (NPP) of the same group. The visit is billed by the physician or practitioner who provides the substantive portion of the visit.
- By 2023, the substantive portion of the visit will be defined as more than half of the total time spent. For 2022, the substantive portion can be history, physical exam, medical decision-making, or more than half of the total time (except for critical care, which can only be more than half of the total time).
- Shared visits can be reported for new as well as established patients, and initial and subsequent visits, as well as prolonged services.
- A modifier is required on the claim to identify these services to inform policy and help ensure program integrity.
- Documentation in the medical record must identify the two individuals who performed the visit. The individual providing the substantive portion must sign and date the medical record.
These revised policies will be codified in a new regulation at 42 CFR 415.140.
Anesthesia Coding Changes
According to the ASA, the FR finalizes the base unit values for six new anesthesia codes. It also finalizes an increase in the base unit value that CMS uses for code 00537. These changes are illustrated in the below chart provided by the ASA:
Critical Care Services
The FR further refines Medicare's longstanding policies covering critical care services and establishes the following:
- When medically necessary, critical care services can be furnished concurrently to the same patient on the same day by more than one practitioner representing more than one specialty. In addition, critical care services can be furnished as split (or shared) visits.
- Critical care services may be paid on the same day as other E/M visits by the same practitioner or another practitioner in the same group of the same specialty, if the practitioner documents that (a) the E/M visit was provided prior to the critical care service at a time when the patient did not require critical care, (b) the visit was medically necessary, and (c) the services are separate and distinct, with no duplicative elements from the critical care service provided later in the day. Practitioners must report modifier -25 on the claim when reporting these critical care services.
- Critical care services may be paid separately in addition to a procedure with a global surgical period if the critical care is unrelated to the surgical procedure. Preoperative and/or postoperative critical care may be paid in addition to the procedure if the patient is critically ill (meets the definition of critical care) and requires the full attention of the physician, and the critical care is above and beyond and unrelated to the specific anatomic injury or general surgical procedure performed (e.g., trauma, burn cases). CMS is creating a new modifier for use on such claims to identify that the critical care is unrelated to the procedure. If care is fully transferred from the surgeon to an intensivist (and the critical care is unrelated), the appropriate modifiers must also be reported to indicate the transfer of care. Medical record documentation must support the claims.
We will provide further details concerning the 2022 Medicare PFS in an upcoming alert. Until then, if you have a question about the FR, please contact your account executive or email us at info@anesthesiallc.com.
With best wishes,
Tony Mira
President and CEO