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The 2,414 page final rule for the CMS Physician Fee Schedule (PFS) was published on November 2, 2021, and contains a number of changes that are important for pulmonary/critical care/ sleep providers. As is typical, the rule does bring some good news, as well as decisions that are seemingly contrary to logic and precedence. Most of the changes will be effective on January 1, 2022, although some will become effective when the inpatient evaluation and management (E/M) changes take effect in 2023. For more information, please see 2021-23972.pdf (federalregister.gov).
The first change to be noted is a decrease in the conversion factor from $34.89 to $33.59. This is due primarily to the expiration of the 3.75% increase that was mandated by the Consolidated Appropriations Act of 2021. On a positive note, CMS did institute a plan to update clinical labor prices over the next 4 years, which will result in an increase in reimbursement for practice expense costs. CMS predicts that the combined impact of these two changes will result in no change in reimbursement for pulmonary or critical care medicine. Unfortunately, CMS did not publish data for sleep medicine.
There will be substantial changes in critical care services beginning next year. The CPT® definition of critical care will continue to be recognized by CMS, and the list of bundled services remains the same. Providers may now report critical care services with E/M visits done on the same day. The E/M visit must precede the critical care service, and it must be documented that the patient did not require critical care services at that time. The critical care visit must also be billed with a –25 modifier. This also applies to multiple practitioners in the same group of the same specialty. Critical care services provided concurrently by multiple practitioners of different specialties may now be billed by each individual practitioner if the services are medically necessary. There was a concern that CMS would not allow billing of critical care services during a surgical global period, but this will be allowed if the critical care services are unrelated to the general surgical procedure performed. There will be a new modifier developed to allow CMS to track this care. If critical care management is transferred from the surgeon to an intensivist, then the latter will append modifier –55 (postoperative management only), as well as the new modifier. Finally, and most importantly, CMS now recognizes the benefit of team-based care and will allow split (or shared) billing of critical care services. Physicians and qualified nonphysician providers (NPP) add their times to determine the level of critical care services. The provider who is responsible for more than half of the critical care time should be the billing provider.
Pulmonary rehabilitation CPT codes 94625 and 94626 were accepted by CMS but the RVU values recommended by the RUC were not. CPT code 94625 received a finalized work RVU of 0.36 and code 94626 received 0.56. On a more positive note, patients hospitalized with COVID-19 who are having persistent symptoms, including respiratory dysfunction, for at least 4 weeks after hospitalization would now qualify for pulmonary rehab services. The current pulmonary rehabilitation HCPCS code G0424 is replaced by the two new CPT codes and should no longer be used after December 31, 2021.
These are but a few of the changes in the final rule that may impact one’s practice. Additional changes may be found in the final rule link 2021-23972.pdf (federalregister.gov) and in future CHEST Physician editions.
The 2,414 page final rule for the CMS Physician Fee Schedule (PFS) was published on November 2, 2021, and contains a number of changes that are important for pulmonary/critical care/ sleep providers. As is typical, the rule does bring some good news, as well as decisions that are seemingly contrary to logic and precedence. Most of the changes will be effective on January 1, 2022, although some will become effective when the inpatient evaluation and management (E/M) changes take effect in 2023. For more information, please see 2021-23972.pdf (federalregister.gov).
The first change to be noted is a decrease in the conversion factor from $34.89 to $33.59. This is due primarily to the expiration of the 3.75% increase that was mandated by the Consolidated Appropriations Act of 2021. On a positive note, CMS did institute a plan to update clinical labor prices over the next 4 years, which will result in an increase in reimbursement for practice expense costs. CMS predicts that the combined impact of these two changes will result in no change in reimbursement for pulmonary or critical care medicine. Unfortunately, CMS did not publish data for sleep medicine.
There will be substantial changes in critical care services beginning next year. The CPT® definition of critical care will continue to be recognized by CMS, and the list of bundled services remains the same. Providers may now report critical care services with E/M visits done on the same day. The E/M visit must precede the critical care service, and it must be documented that the patient did not require critical care services at that time. The critical care visit must also be billed with a –25 modifier. This also applies to multiple practitioners in the same group of the same specialty. Critical care services provided concurrently by multiple practitioners of different specialties may now be billed by each individual practitioner if the services are medically necessary. There was a concern that CMS would not allow billing of critical care services during a surgical global period, but this will be allowed if the critical care services are unrelated to the general surgical procedure performed. There will be a new modifier developed to allow CMS to track this care. If critical care management is transferred from the surgeon to an intensivist, then the latter will append modifier –55 (postoperative management only), as well as the new modifier. Finally, and most importantly, CMS now recognizes the benefit of team-based care and will allow split (or shared) billing of critical care services. Physicians and qualified nonphysician providers (NPP) add their times to determine the level of critical care services. The provider who is responsible for more than half of the critical care time should be the billing provider.
Pulmonary rehabilitation CPT codes 94625 and 94626 were accepted by CMS but the RVU values recommended by the RUC were not. CPT code 94625 received a finalized work RVU of 0.36 and code 94626 received 0.56. On a more positive note, patients hospitalized with COVID-19 who are having persistent symptoms, including respiratory dysfunction, for at least 4 weeks after hospitalization would now qualify for pulmonary rehab services. The current pulmonary rehabilitation HCPCS code G0424 is replaced by the two new CPT codes and should no longer be used after December 31, 2021.
These are but a few of the changes in the final rule that may impact one’s practice. Additional changes may be found in the final rule link 2021-23972.pdf (federalregister.gov) and in future CHEST Physician editions.
The 2,414 page final rule for the CMS Physician Fee Schedule (PFS) was published on November 2, 2021, and contains a number of changes that are important for pulmonary/critical care/ sleep providers. As is typical, the rule does bring some good news, as well as decisions that are seemingly contrary to logic and precedence. Most of the changes will be effective on January 1, 2022, although some will become effective when the inpatient evaluation and management (E/M) changes take effect in 2023. For more information, please see 2021-23972.pdf (federalregister.gov).
The first change to be noted is a decrease in the conversion factor from $34.89 to $33.59. This is due primarily to the expiration of the 3.75% increase that was mandated by the Consolidated Appropriations Act of 2021. On a positive note, CMS did institute a plan to update clinical labor prices over the next 4 years, which will result in an increase in reimbursement for practice expense costs. CMS predicts that the combined impact of these two changes will result in no change in reimbursement for pulmonary or critical care medicine. Unfortunately, CMS did not publish data for sleep medicine.
There will be substantial changes in critical care services beginning next year. The CPT® definition of critical care will continue to be recognized by CMS, and the list of bundled services remains the same. Providers may now report critical care services with E/M visits done on the same day. The E/M visit must precede the critical care service, and it must be documented that the patient did not require critical care services at that time. The critical care visit must also be billed with a –25 modifier. This also applies to multiple practitioners in the same group of the same specialty. Critical care services provided concurrently by multiple practitioners of different specialties may now be billed by each individual practitioner if the services are medically necessary. There was a concern that CMS would not allow billing of critical care services during a surgical global period, but this will be allowed if the critical care services are unrelated to the general surgical procedure performed. There will be a new modifier developed to allow CMS to track this care. If critical care management is transferred from the surgeon to an intensivist, then the latter will append modifier –55 (postoperative management only), as well as the new modifier. Finally, and most importantly, CMS now recognizes the benefit of team-based care and will allow split (or shared) billing of critical care services. Physicians and qualified nonphysician providers (NPP) add their times to determine the level of critical care services. The provider who is responsible for more than half of the critical care time should be the billing provider.
Pulmonary rehabilitation CPT codes 94625 and 94626 were accepted by CMS but the RVU values recommended by the RUC were not. CPT code 94625 received a finalized work RVU of 0.36 and code 94626 received 0.56. On a more positive note, patients hospitalized with COVID-19 who are having persistent symptoms, including respiratory dysfunction, for at least 4 weeks after hospitalization would now qualify for pulmonary rehab services. The current pulmonary rehabilitation HCPCS code G0424 is replaced by the two new CPT codes and should no longer be used after December 31, 2021.
These are but a few of the changes in the final rule that may impact one’s practice. Additional changes may be found in the final rule link 2021-23972.pdf (federalregister.gov) and in future CHEST Physician editions.