Pediatric Coding Alert

Find out why CMS changed its mind on split/shared visits.

The Center for Medicare & Medicaid Services (CMS) recently published the final rule for calendar year (CY) 2023, and not without a surprise or two. Not everything looks as you may expect it to, so buckle up as we walk you through some useful information to help you get the new year started.

Get Ready for an Even Lower CF

As you may remember, the proposed rule outlined a 4.4 percent conversion factor (CF) decrease, and those who were hoping for CMS to make a change to the fee schedule got their wish… but not in the best way. The 2023 Medicare Physician Fee Schedule (MPFS) CF finalized an even higher decrease than what was proposed.

For 2023, the final MPFS CF is $33.06, a decrease of 4.5 percent (or $1.55) from the CY 2022 MPFS conversion factor of $34.60. “We were hoping that CMS would finalize a smaller cut to the PFS conversion factor than the 4.4 percent reduction the agency proposed. Unfortunately, despite our comments, CMS wound up doing the exact opposite and finalized a slightly higher reduction,” American College of Emergency Physicians (ACEP) reports.

See How Immunization RVUs Compare

As we reported in Pediatric Coding Alert Volume 25, Number 9 (https://www.aapc.com/codes/coding-newsletters/my-pediatric-coding-alert/proposed-rule-picture-a-proposed-increase-in-immunization-admin-rvus-172996-article), the proposed increase in immunization relative value units (RVUs) should positively offset a significant CF decrease. This is still a distinct possibility, but with a few caveats.

According to the final rule, CMS is following through by increasing the total RVUs for the following codes:

• 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) (0.49 increased to 0.65)
• 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)) (0.49 increased to 0.58)
• +90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)) (0.37 increased to 0.42)

While “the increase in RVUs is large enough that it offsets the decrease in the conversion factor,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians, CMS is maintaining 90473 (Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/ toxoid)) and decreasing the RVUs for the following:

• +90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care profes­sional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)) (0.37 decreased to 0.30)
• +90474 (Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)) (0.37 decreased to 0.35)

Many commercial payers either set their fees as a percentage of the Medicare fees or just use the same RVUs; so even though peds practices don’t typically have many patients covered by Medicare, this decrease is something to consider this year when you’re thinking about your bottom line.

Understand Split/Shared Visits

In the CY 2022 MPFS final rule, CMS finalized a phase-in approach to the split/shared billing policy. During the one-year transition period, Medicare finalized that the provider who performed the substantive portion of the visit could bill under their national provider identifier (NPI). The agency also finalized the definition of the substantive portion of an evaluation and management (E/M) visit, except for critical care visits, as:

• CY 2022: The provider (physician or APP) who performed the patient history, physical examination, or medical decision making (MDM) — or — the provider who spent more than half of the total time rendering the service
• CY 2023: The provider who spends more than half of the total time rendering the service

2023 proposed rule: In the CY 2023 proposed rule, CMS noted they received “continued concerns about the implementation of [the] phased-in approach.” Reasons include concerns about using only more than half of the total time to identify the substantive portion as well as requests to recognize MDM as the substantive portion.

Instead of requiring providers to use the substantive portion definition of “more than half of the total time” on Jan. 1, 2023, CMS is proposing to delay the policy implementation until CY 2024 after receiving feedback from stakeholders.

2023 final rule: Clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, or 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 lists two reasons in the CY 2023 MPFS proposed rule to explain and defend their change of heart:

• 1) 2023 E/M updates: On Jan. 1, 2023, several E/M codes updated to fall in line with the 2021 E/M changes to coding for office and other outpatient services. Examples of these codes include 99221-99223 (Initial hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination …) and 99281-99285 (Emergency department visit for the evaluation and management of a patient …). Delaying the split/shared visit policy implementation until 2024 gives providers a transition year to get acclimated to the 2023 E/M guidelines and get their practices up to speed on the incoming changes.
• 2) Feedback: The delay allows CMS to gather more comments and feedback from interested stakeholders regarding the policy and how it could be altered or further refined.

Additionally, in a March 2022 letter to CMS administrator Chiquita Brooks-LaSure, several medical organizations, including the AMA, strongly urged CMS to discontinue its split/shared visits policy and not move forward with the transition set to take effect in 2023. The organizations felt the policy wouldn’t allow providers to effectively co-manage patients’ needs and was contrary to clinical alignment (https://searchlf.ama-assn.org/letter/documentDownload?uri=/unstructured/binary/letter/LETTERS/Sign-on-letter-to-CMS-re-Split-or-Shared- Visits-Final-03-29-22.pdf).

For a fact sheet on the CY 2023 Physician Fee Schedule Final Rule, please visit: https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-final-rule.