Background
The Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2023 Medicare Physician Fee Schedule (PFS) proposed rule, which governs payment policy in Medicare Part B for ambulatory care practice. The proposed rule also encompasses changes to related programs, including the Quality Payment Program and the Medicare Shared Savings Program, among others. CMS is proposing a net decrease to overall PFS payment for CY 2023. The agency is also proposing changes in a number of other areas, including provision of telehealth, electronic prescribing of controlled substances, billing for split/shared evaluation and management (E/M) services, opioid treatment programs, preventive vaccine services, and more. CMS updates these rules annually, so many of the policy changes outlined for 2023 build on existing policies.
Major Proposed Changes for CY 2023
- Telehealth Services: CMS is proposing to allow a number of telehealth codes to remain available until 151 days after the end of the COVID-19 public health emergency (PHE) to allow the agency more time to determine whether they should be made permanent. Under the Consolidated Appropriations Act of 2022, CMS is required to continue "allowing telehealth services to be furnished in any geographic area and in any originating site setting, including the beneficiary's home, and allowing certain services to be furnished via audio-only telecommunications." CMS is also delaying implementation of last year's proposal to require an in-person visit to continue to receive mental healthcare via telehealth until 152 days after the end of the PHE. For allowable audio-only services, CMS is proposing that providers append Current Procedural Terminology (CPT) modifier 93 to each claim for those services.
ASHP is seeking feedback on member experiences with telehealth utilization and reimbursement. Specifically, we are looking for feedback on whether pharmacists have been able to utilize telehealth codes, if telehealth reimbursement is sufficient to support service provision, what (if any) additional codes should be added, and what other changes are necessary to make telehealth provision sustainable over the long term.
- Vaccine Provision and Reimbursement: Building on last year's PFS, CMS is proposing to move forward with regularly updating the payment for preventive vaccines. Specifically, CMS is proposing to annually update payment based on the Medicare Economic Index and adjusted by locality based on the geographic adjustment indicator. CMS is also proposing to maintain the add-on payment for COVID-19 vaccinations provided to beneficiaries at home through CY 2023. Additionally, CMS clarifies that payment policies for vaccines and monoclonal antibody products for COVID-19 will remain in effect until the "Emergency Use Authorization for drugs and biological products is terminated," regardless of when the larger COVID-19 public health emergency ends.
- Manufacturer Refunds for Medication Waste: CMS is beginning the process of implementing a provision of the Infrastructure and Investment Jobs Act of 2021 that requires "manufacturers to provide a refund to CMS for certain discarded amounts from a refundable single-dose container or single-use package drug" once the amount of waste reaches a certain threshold of a product's total allowed charges (at least 10%) in a quarter. The agency is seeking feedback on a number of elements, including:
- Determining how to calculate discarded amounts;
- Defining which drugs should be included;
- Creating a notification system for manufacturers;
- Developing a refund calculation system and enforcement process.
ASHP is seeking member input regarding implementation of the waste provisions, particularly those related to calculation of discarded amounts and the process for defining which drugs should be subject to this provision.
- Electronic Prescribing of Controlled Substances (EPCS): CMS is continuing its rollout of EPCS for Part D covered drugs. In the proposed rule, CMS sets out a general timeline for evaluating prescriber compliance with EPCS requirements. CMS intends to use Prescription Drug Event (PDE) data from the year under evaluation (not the preceding year) as soon as PDE data is available. CMS will maintain its current policy of sending non-compliance letters to prescribers through CY 2024 and begin phasing in additional penalties (which it is still in the process of determining) in CY 2025.
- Chronic Pain Management Services: In an effort to approve treatment access for chronic pain patients, CMS is proposing new codes for chronic pain management and treatment services. The new codes include bundled services provided each month. The proposed bundle outlines a robust list of services, including "diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and 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 and community-based care, as appropriate."
ASHP is seeking member feedback regarding the services proposed as part of the bundle, particularly medication management, as well as any other element(s) of chronic pain treatment that should be raised with CMS.
- Opioid Treatment Programs (OTP): Beginning in 2023, CMS is proposing to change the payment methodology for methadone. Specifically, the drug component of methadone treatment will be made under HCPCS codes G2067 and G2078 for CY 2021 updated annually to account for inflation using the PPI for Pharmaceuticals for Human Use (Prescription).
CMS is also proposing loosening restrictions on the provision of certain OTP services via telehealth. Specifically, audio-only services may be used to initiate treatment for buprenorphine when the beneficiary lacks access to audio-visual communications equipment. Additionally, the OTP intake add-on code may be used when initiation of buprenorphine is provided via two-way audio-visual communications technology, as authorized by the Drug Enforcement Administration (DEA) and the Substance Abuse and Mental Health Services Administration (SAMHSA).
- Split/Shared Billing: In 2022, CMS redefined "substantive portion" for split/shared billing to mean "more than half of the total time spent by the physician or NPP performing the visit." CMS is now proposing to delay implementation of that decision until CY 2024. Until then, clinicians can continue current split/shared billing practices, meaning that they 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.
CMS Request for Information (RFI)
The proposed rule also includes a more general request to "engage with interested parties and stakeholders and solicit comment regarding ways to identify and improve access to high value, potentially underutilized services by Medicare beneficiaries." ASHP is seeking member feedback to build out our comments to CMS on the RFI, including information regarding which, if any, services are currently underutilized, as well any recommendations to improve those services.
Applicability and Timing
In general, policy proposals adopted in a PFS proposed rule become effective on January of the next calendar year (January 1, 2023 for this proposed rule).
We strongly encourage members to submit feedback, questions, or concerns to ASHP to assist in the development of our written comments on the proposed rule. Please send any input to Jillanne Schulte Wall at [email protected] by August 29. We will update members when CMS releases a final rule in late fall 2022.