Coding and Billing

2022 Medicare Physician Fee Schedule: What to Expect & Plan For

By Mark Wright, OD, FCOVD
and Carole Burns, OD, FCOVD

Dec. 1, 2021

The Centers for Medicare & Medicaid Services (CMS) issued the final rule that includes updates on policy changes for Medicare payments occurring on or after January 1, 2022.

Since 1992, Medicare payment under the Physicians Fee Schedule (PFS) pays for services occurring in a variety of settings such as physician offices, hospitals, ambulatory surgical centers (ASCs), skilled nursing facilities and other post-acute care settings, hospices, outpatient dialysis facilities, clinical laboratories and beneficiaries’ homes. Every November CMS publishes its final rule, which dictates what physicians will be paid in the next fiscal year.

Create a spreadsheet with this information so that you can review your fees as well as determine what deductibles and co-pays will be for 2022.

Medicare is paying you less in 2022 than in 2021
What you need to know is that the Medicare payments to providers is reduced next year compared to what was paid in 2021. Medicare uses a complex formula to determine physician reimbursement. In the current formula, the 2022 Medicare conversion factor is reduced by approximately 3.85% from 34.8931 in 2021 to 33.5983 in 2022. The remainder of the Medicare payment cuts do not fall under the purview of CMS and must be addressed by Congress.

We go through this same issue every year. We are threatened with a decrease in Medicare reimbursement in November, then Congress acts to lessen the decrease and we all are grateful. Congress could fix this with a single change to the law, but no matter which side of the aisle is in charge, they choose to only address one year at a time. (If we were cynical, we would see this as an ongoing funding scheme for everyone from lobbyists to politicians who benefit if this is only addressed one year at a time.)

Here are some of the other changes found in the final rule
Evaluation and Management (E/M) Visits
CMS continues to be engaged in an ongoing review of payment for E/M visit code sets. For CY 2022, CMS finalized several policies that take into account the recent changes to E/M visit codes which took effect January 1, 2021. CMS is also clarifying and refining policies reflected in certain manual provisions that were recently withdrawn. Specifically, CMS is making many refinements to the current policies for split (or shared) E/M visits, critical care services and services furnished by teaching physicians involving residents.

Split (or shared) E/M visits
CMS continues to refine the longstanding policies for split (or shared) E/M visits to better reflect the current practice of medicine, the evolving role of non-physician practitioners (NPPs) as members of the medical team, and to clarify conditions of payment that must be met to bill Medicare for these services. In the CY 2022 PFS final rule, CMS is establishing the following:

• Definition of split (or shared) E/M visits as E/M visits provided in the facility setting by a physician and an NPP in 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).

• Split (or 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.

• Codifying these revised policies in a new regulation at 42 CFR 415.140.

Telemedicine Services
• The updated Medicare telemedicine services list remains through December 31, 2023, allowing additional time to evaluate whether certain services should be permanently added to the Medicare telemedicine services list.

• CMS has implemented statutory requirements to remove geographic restrictions and add the home of the beneficiary as a permissible originating site for telemedicine services furnished for the purposes of diagnosis, evaluation or treatment of a mental health disorder.

• CMS is limiting the use of audio-only telemedicine to mental health services furnished by practitioners who have the capability to furnish two-way, audio/video communications, but where the beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology.

Quality Payment Program
• Transition to the Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPs) will not occur until the 2023 performance year.

• The performance threshold for the 2022 performance year/2024 payment year will be set at 75 points, which is an increase of 15 points from the previous year.

• The additional performance threshold will be set at 89 points.

• For individuals, groups, and virtual groups reporting traditional MIPS, quality will be weighted at 30 percent, cost at 30 percent, promoting interoperability at 25 percent and improvement activities at 15 percent.

• CMS finalized its proposal to extend the CMS Web Interface as a quality reporting option for registered groups, virtual groups or other APM Entities for the 2022 performance period.

• CMS will be maintaining the 70 percent data completeness requirement in the 2023 performance period in response to stakeholder comments.

For more information:
2022 Physician Fee Schedule Final Rule
CMS 2022 Physician Fee Schedule Fact Sheet

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