Physicians are required to file their annual fee schedules with CMS (Centers for Medicare & Medicaid Services) by January 1st of each year. The physician fee schedule is used to determine the amount of reimbursement physicians receive for services provided to Medicare beneficiaries. In addition, the physician fee schedule is used as a reference point for determining the amount of payment made to physicians under the Medicare program.

To implement the Medicare Physician Fee Schedules, CMS has developed two separate systems: the Medicare Physician Fee Schedule (MPFS) and the Medicare Supplier Fee Schedule (MSF). The MPFS is a national system that applies to all providers of covered professional services, including hospitals, nursing homes, durable medical equipment suppliers, hospices, home health agencies, and certain other entities. The MSF is a regional system that applies to all non-hospital providers of covered professional services.

The Medicare Physician Fee Schedule is published annually in the Federal Register and includes information regarding the amounts payable to physicians for services rendered during the calendar year. In this article, we give you a quick overview of changes to the Medicare Physician Fee Schedule that will take place on January 1, 2022.

A summary of the Physician Final Rule for 2022

In November 2021, the Centers for Medicare & Medicaid Services (CMS) published the Medicare Physician Fee Schedule (MPFS) Final Rule. The Final Rule made further changes to the MPFS, which became effective on January 1, 2022.

Medicare reimbursement assumes-and physicians are expected to provide a full range of services and treatments that meet the needs of their patients. They are updated every year to reflect the most recent scientific evidence, changes in technology, and practice patterns. They are meant to improve quality healthcare, improve patient care, and help people get the care they need.

Medicare payment rates are updated annually based on inflation and other factors. They are subject to change on April 1 each year. More information about Medicare reimbursement can be found on the Centers for Medicare & Medicaid Services (CMS) website.

The RVUs are the relative values assigned to physician work. These values are determined by the Medicare Physician Advisory Committee, which is comprised of doctors and non-doctors with expertise in the field of health care. The RVUs attached to each service determine how much physicians earn from Medicare.

The geographic adjustment factor is based on the difference in costs of providing medical care between practice locations around the country. It can increase or decrease a physician’s Medicare payment, depending on whether the area they practice in has higher or lower practice costs than those nationwide.

Expanded Data Reporting (EDR) 10C and EDR 11C provide physicians with a single report containing their actual Medicare payments, as well as their RVUs, GPCI, adjustments, and other important information needed to submit appeals effectively. These are the national allowable, calculated based on RVUs:

Two percent Medicare cuts will also affect final payments because Congress won’t be able to stop the cuts. Lab tests, for example, are not part of the physician fee schedule, so these rates will not be affected.

Vaccine Administration

As of 2021, the cost of influenza, pneumococcal, and hepatitis B virus vaccines will increase to $30 from $17.63 on average. G0008 (influenza), G0009 (pneumococcal), and G0010 (hepatitis B) are included here. Geographic adjustments may apply.

As of January 1, the year following the end of the Public Health Emergency (PHE), COVID-19 vaccine administration and monoclonal antibody infusion services will remain at the current rates. Unless and until another extension is made, the PHE will remain in effect until January 16, 2022.

Split/Shared Services

Services that are split or shared depending on the fact sheet from the doctor and the non-physician practitioner (NPP) that was given on the date of service.

Incident-to guidelines must be followed in the office. Shared visits will be restricted to institutional settings starting in 2022.

Telehealth’s new POS

Telehealth services are now available through a new POS added by the Centers for Medicare & Medicaid Services (CMS). With the new POS 10, telehealth services are delivered to the patient’s home. POS 02: Telehealth services that are not provided in the patient’s home are also listed as POS 02. Effective April 1, 2022, this new POS will be available for use.

During the COVID-19 PHE, CMS will cover telehealth services until the end of 2023 while they continue to look at changes to the permanent policy. Practices that use load sharing will see their originating site fee, Q3014, go up a little in 2022. It will go from $27.02 to $27.59.

Physician Assistants

As part of the evolving role of non-physician practitioners (NPPs), CMS will be able to make direct payments to physician assistants (PAs). Payments are only available to the PA’s employer at the moment. Beginning January 1, 2022, PAs will be able to bill Medicare directly for professional services or integrate with other PAs and bill Medicare for PA services.

Addition of Modifier 93

On January 1, 2022, a new modifier 93 (Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system) became effective. With this modifier, physicians or other healthcare professionals can report on medical services provided through audio-only communication with patients. As the name implies, synchronous telemedicine consists of a real-time, two-way conversation between a physician or other qualified healthcare provider and a patient located far from the physician. This modifier is intended for payers that prefer E/M codes instead of the time-based CPT codes 99441–99443 for billing calls.

COVID-19 Immunization Diagnosis Codes

Three new diagnosis codes were announced by CMS for April 2022, including two codes for COVID-19 vaccination status. Coding for inpatient reimbursement has primarily been designed for hospital use. A hospital’s reimbursement is based on the most frequently used resources during a diagnosis.

Z28.310 – Covid-19 unvaccinated (To be assigned to patients who have not received one or more doses of the Covid-19 vaccine)

Z28.311 – COVID-19 partially vaccinated (Assignation when the patient has received at least one dose of the multidose COVID-19 vaccine regimen but not the entire regimen)

Z28.39 – Another under-immunization status

New Code Update: 99211 Consistency Adjustment

This code descriptor will be used as of 2022, describing office or other outpatient visits for evaluating and managing established patients that do not require the presence of a physician or provider of health care. 99211 requires that these services be medically necessary (i.e., clinically indicated) and accompanied by a plan of care by a physician or other qualified healthcare professional.

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