ACR applauds telehealth flexibility, coding changes to proposed 2022 Physician Fee Schedule
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The American College of Rheumatology praised several aspects of a 2022 Medicare physician fee schedule proposed rule, including evaluation and management coding changes and the promise of greater telehealth flexibility.
The ACR issued its statement days after submitting formal comments to CMS regarding the proposed rule. According to the group, rheumatology leaders are “encouraged” by the continued implementation of E/M coding changes, telehealth flexibility and a rheumatology-specific Merit-Based Incentive Payment System (MIPS) Value Pathway, but remain concerned about conversion factor reductions and an electronic health record (EHR) interoperability and digital quality measures proposal.
“We are especially appreciative of CMS’ continued recognition of the value of complex care provided by rheumatologists and other cognitive care specialists by continuing to operationalize the evaluation and management (E/M) coding changes that were set in motion over the last few years,” ACR President David Karp, MD, PhD, said in the statement. “As our nation’s health care system continues to navigate the challenges of a global pandemic, we also appreciate the policies and flexibilities set forth by CMS to help alleviate these challenges while we all work to provide quality care for our patients.
“In light of ongoing volatility and unknowns in the health care system, we would also like to share our concerns with some other aspects of the proposed rule,” he added, “especially the proposed decrease in the conversion factor, CMS’ proposed implementation of the rheumatology MIPS Value Pathway and a new proposal for EHR interoperability and digital quality measures.”
In a letter to CMS Administrator Chiquita Brooks-LaSure on Sept. 10, Karp commented on five aspects of the 2022 Medicare physician fee schedule proposed rule.
E/M Coding Changes
According to Karp, the ACR “appreciates CMS’ ongoing commitment to implementing recent changes to E/M codes that more appropriately reflect the value of cognitive specialists and urges the agency to continue monitoring how the updated codes are operationalized.” In addition, he praised the proposed rule’s revisions to the policy on billing for split/shared visits.
However, he noted that the ACR wishes to ensure that any changes will not become “burdensome” for providers, particularly regarding the tracking of time for their “substantive performance.” The ACR president warned that this may lead to potential billing errors.
Telehealth Flexibility
CMS has proposed extending several policies that allowed for the expanded use of telehealth during the COVID-19 pandemic through the end of 2023. Specifically, CMS would continue to cover its list of Category 3 telehealth services that would have limited coverage at the end of the public health emergency.
Although applauding this extension, the ACR also offered recommendations on how CMS could go farther in offering providers more flexibility, including making permanent the direct supervision waiver, which would allow a supervising physician to serve patients using real-time, interactive audio-video technology.
“This would immediately provide timely access to cognitive services for Medicare beneficiaries and relieve an undue burden to an aging population,” according to the ACR’s press release.
The ACR also expressed support for CMS’ proposal to permanently adopt a code — G2252 — for extended virtual check-ins. According to the ACR, this would allow providers to briefly check in with an established patient using any form of synchronous communication technology, including audio-only formats. This would be especially helpful for rural patients, the group added.
Conversion Factor Reduction, Physician Work
The ACR said it “shares the concerns raised by many specialty provider groups” regarding a CMS proposal to reduce the conversion factor 3.75% in 2022, and urged the agency to maintain the current rate at least through 2023.
“The proposed reduction comes at a time when physician practices and hospitals are facing unprecedented uncertainty about their futures amid the COVID-19 pandemic,” the ACR press release noted, in part. “Implementing reductions now would have a damaging impact on an already strained system.”
Regarding the proposed changes to the relative value united (RVUs), the ACR stated that it recognizes that 2022 is the final year of a 4-year transition period to update the practice expense component with the latest pricing data for supplies and equipment.
“In conjunction with this final year of the equipment pricing update, CMS is also proposing an update to the clinical labor pricing component in CY 2022, which could result in temporary distortions for provider reimbursement,” read the press release. “To minimize disruptions to physician practices, the ACR recommends CMS use a similar four-year transition to implement the clinical labor pricing update.”
EHR Interoperability, Digital Quality Measures
Although the ACR expressed overall encouragement at CMS’ efforts to widen the standardization of clinical data and increase the interoperability of EHRs, Karp said the group harbors several concerns regarding how these efforts will impact smaller practices. The ACR recommended CMS launch an environmental landscape assessment of EHR software capabilities, taking into account factors such as costs to practices, specialty-specific templates and reports, registry participation and patient portal access.
“This should help establish a clearer picture of practices’ reasonable ability to meet CMS’ proposed digital health goals and avoid a situation where providers are held accountable for factors that are beyond their control,” according to the ACR press release.
MIPS Value Pathway for rheumatology
The ACR noted it was “pleased” that the proposed rule includes a new MIPS Value Pathway for rheumatologists, but expressed several concerns with the program’s planned rollout, citing a lack of available details.
The ACR recommended that CMS delay setting a deadline for ending traditional MIPS until the agency can evaluate the success of implementing the new program.
Perspective
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Key takeaways from the proposed rule that directly affect physician reimbursement include: 1) reduction of the MPFS conversion factor; 2) an update to the Employment Cost Index (ECI), and; 3) potential for two separate sequestrations. The proposed rule also extends certain telehealth services through 2023, as well as expanding the role of Advanced Practice Providers and establishes a timeline to sunset the traditional Merit-based Incentive Payment System (MIPS) by 2027.
Rheumatologists and like cognitive-specialists will benefit from CMS rewarding upstream medical services while decreasing payments to more expensive procedure-based specialties. However, all providers regardless of specialty will be adversely affected by this proposal. With regard to the planned update to clinical labor pricing — which has remained stagnant since 2002 and is certainly overdue — the current rule will not reflect the realities of medical practice at this time of the COVID pandemic, including its associated labor shortages and increased costs as a result of disruptions in the delivery of health care.
Additionally, the proposed decrease in the MPFS conversion factor of 3.75% will be implemented when the suspension of the Medicare Fee-for-Service 2% Payment Adjustment (sequestration) is set to expire at the end of 2021, with an additional 4% cut as part of the American Rescue Plan Act’s Statutory Pay-As You-Go (PAYGO) sequester. These cuts will cause serious financial hardship for all physicians, especially the more vulnerable small independent practices.
Reimbursements by Medicare to physicians already underestimate actual and inflationary increases in practice expenses. Additional payment cuts during this unprecedented time of stress on the health care system is unconscionable. In response, we should all join the ACR in requesting that CMS reconsider the planned payment cuts in its current proposal, again emphasizing that we expect more than waiting for an 11th hour rescue plan that simply reverts to the status quo.
Perspective
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David A. McLain, MD, MACR, FACP, FRCP
It is beneficial to rheumatologists that the ACR is commenting on proposed federal rules. These issues affect all of us. Money is not a driving force in rheumatology, and I think rheumatologists are sometimes hesitant to lobby for their own interests.
At the Coalition of State Rheumatology Organizations virtual meeting in September, Emily Graham, RHIA, CCS-P, said something that was surprising: Since 1992, the Medicare conversion factors (for resource-based relative value scale or RBRVS) had been relatively flat. Conversion factors are the base dollar number multiplied by the number of work units for a given service that generates the reimbursement for that service.
The conversion factor in 1992, the first year that they were introduced, was $31.00 per unit of work. Thirty years later, in 2021, the conversion factor is $34.89. The difference is an increase of 11.8% in 30 years or 0.4% per year. In this same time period, inflation has increased 91.3% (from $100 to $191). If the conversion factor had been indexed for inflation, the current one would be $59.22. In other words, a $50 visit in 1992 would be $96 today.
I have always felt that there is a community standard as to the fair charge for a service, whether it was from a lawyer, veterinarian, dentist or plumber. These charges vary from one provider to another, but, in general, there is an amount that is considered reasonable. With the relatively flat Medicare reimbursement since 1992, which is reflected in commercial insurance reimbursement for services as well, we are seeing a financially untenable situation for physicians. As overhead increases with inflation, the profit margin — often the physician’s salary for those self-employed — continues to drop.
Even for physicians who are employees of a large entity, the situation is not much different. A patient recently told me that her 14-year-old dog needed an ACL repair by the orthopedic veterinarian. It was $4000, but she was willing to pay it since the dog was her companion. I asked an orthopedist, and he said his reimbursement was one-third of that amount. With this flat reimbursement, physicians have seen the “community standard” skewed in favor of other service providers. Having spent 13 years of education and training out of high school and seeing the growing disparity with other learned professions, one has to wonder about the future of medicine.
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American College of Rheumatology press release.
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