Reimbursement Decreases on the Horizon With the 2023 Proposed PFS Rule

The 2023 Medicare Physician Fee Schedule (PFS) rule has arrived, released by the Centers for Medicare & Medicaid Services (CMS) on Tuesday, July 7, 2022. Radiology will once again experience a threat to payments as the pandemic continues to bring consequences for healthcare. As usual, the proposed rule outlines potential updates to a variety of policies and provisions that dictate payment for many services included in the Quality Payment Program (QPP), the Merit-Based Incentives Payment System (MIPS), and Advanced Alternative Payment Models (APMs). Keep in mind that these policies are proposed and will not be made final until the release of the final rule.

Conversion Factor Targets Reimbursement

Once again, CMS has greeted healthcare with a woefully contradictory view for radiology of the proposed rule with CMS Administrator Chiquita Brooks-LaSure stating: “At CMS, we are constantly striving to expand access to high quality, comprehensive healthcare for people served by the Medicare program. Today’s proposals expand access to vital medical services like behavioral healthcare, dental care, and cancer treatment options, all while promoting access, innovation, and cost savings in the Medicare program.”

To further explain the conversation factor and the decision-making CMS went on to explain, “We are proposing a series of standard technical proposals involving practice expense, including the implementation of the second year of the clinical labor pricing update. We have also included a comment solicitation seeking public input as we develop a more consistent, predictable approach to incorporating new data in setting PFS rates. We hope to implement changes that will promote transparency and predictability in payment amounts. Per statutory requirements, we are also updating the data that we use to develop the geographic practice cost indices (GPCIs) and malpractice RVUs.”

However, the radiology community is about to be set for another year of reimbursement suffering if the proposed rule becomes final law or if further legislation isn’t passed. For 2023, CMS is projecting a conversion factor of $33.0775 as opposed to the 2022 conversion factor of $34.6062. The ACR notes that the calculations were made by “first removing the one-year 3 percent increase provided by the Protecting Medicare and American Farmers from Sequester Cuts Act and then applying a negative 1.55 percent budget neutrality update. The budget neutrality update appear to be largely related to increased values for several evaluation and management code families, including hospital, emergency medicine, nursing facility and home visits.”

This seemingly small decrease has a biting impact to radiology reimbursement. CMS projects a decrease of three percent for radiology. For interventional radiology a sharper aggregate decrease of four percent is expected. Nuclear medicine will see a blow of three percent. Meanwhile radiation oncology and radiation therapy centers will brace for a one percent decrease. Some circumstances around the decrease remain the adjustments in relative value units (RVUs) along with the second year of the transition to clinical labor pricing updates according to the College’s analysis. Furthermore, the ACR warns that “If Congress does not intervene to extend the three percent increase provided by the Protecting Medicare and American Farmers from Sequester Cuts Act, the percent decreases mentioned above will be greater for CY 2023.”

Controversy Over Colorectal Cancer Screening Coverage

CMS is looking to make changes to the colorectal cancer screening services. Even more, they are examining policy updates to correlate with those updates that occurred with the United States Preventive Services Task Force (USPSTF). The USPSTF is looking to have screening start at age 45 as opposed to age 50. According to the ACR, “CMS proposed to expand the definition of colorectal cancer screening to include a follow-up screening colonoscopy after a positive result on a Medicare covered non-invasive stool-based screening test. CMS believes this would reduce screening barriers by ensuring patients will not be responsible for cost sharing for the additional test.”

However, the proposed policies fail to include any trace of CT colonography for colorectal cancer screening. The ACR notes that “CMS recently responded to the ACR’s formal reconsideration request that there is not sufficient evidence to support changing the current noncoverage determination for CT colonography. The ACR will meet with CMS in the near future to discuss its rationale for the decision.”

These are not all the impacts of the proposed PFS policy. Explore more regulatory, policy, and coding knowledge to master compliance and coding with our monthly Radiology Compliance Manager.

Information Sources:

https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule

https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule

https://www.acr.org/-/media/ACR/Files/Advocacy/AIA/ACR-Preliminary-Summary-2023-MPFS-PR-FINAL.pdf