Pulmonology Coding Alert

 What defines substantive portion of split/shared billing in 2023?

When the Centers for Medicare & Medicaid Services (CMS) issued its calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) proposed rule, the public had strong reactions to the decreased conversion factor (CF) for the upcoming year. The final rule posted on Nov. 18, 2022, and pulmonology practices are clamoring to know if Medicare adjusted the CF following stakeholders’ feedback.

Learn how your practice’s bottom line will be affected by the CY 2023 MPFS final rule.

What Will a Larger CF Decrease Mean for Your Practice?

Proposed: Estimated CF of $33.0775 — a 4.4 percent decrease from 2022

Finalized: Estimated CF of $33.0607 — a 4.5 percent decrease from 2022

CMS estimates the CY 2023 PFS CF to be $33.0607, which is 4.5 percent lower than the CY 2022 CF. The agency arrived at this number by taking the CY 2022 CF “without the 1-year 3.00 percent payment increase provided by the Protecting Medicare and American Farmers from Sequesters Cuts Act” and multiplied it by the -1.60 percent budget neutrality (BN) adjustment.

The temporary 3 percent increase in PFS payments for CY 2022 expired at the end of 2022, which is why it was not factored into the CY 2023 CF. Additionally, the BN adjustments are required by law to balance the increased spending caused by proposals to increase relative value units (RVUs) in the PFS.

The finalized 2023 MPFS CF is a higher decrease than the 4.4 percent decrease put forth in the proposed rule. “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,” the American College of Emergency Physicians (ACEP) reported in a release.

The loss of that temporary 3 percent increase is causing practices to anticipate lower reimbursement for 2023. “While the final rule CF is slightly different from the proposed CF, the biggest concern is the overall decrease in payments,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Congress could intervene before the end of 2022 and adjust the CF, as they did in 2021 at the last minute, but that had not occurred as of publication time. “It’s now officially up to Congress to take action to avert this cut. … ACEP will continue making this issue one of its top legislative priorities, and we are hopeful that Congress will include some sort of fix in a year-end package,” according to ACEP.

However, until that happens, practices will be preparing for a more costly 2023 that could impact care delivery.

“Our practices will feel a heavier hit to their bottom line along with the continuing issues of inflation, employee shortages, and rising wages. The potential impact is overwhelming, especially since it raises serious concerns on patient access and care delivery,” Pohlig adds.

Pausing a Time-Based Billing Policy Could Help Providers

Proposed: Delay shared/split billing policy implementation until CY 2024

Finalized: As proposed

Finalized in the CY 2022 MPFS final rule, what counts as the substantive portion of a split/shared visit will remain in effect until CY 2024. Prior to the CY 2023 final rule, time was going to be the sole factor in determining which provider could bill for a split/shared visit under their national provider identifier (NPI). Instead, CMS finalized delaying the implementation of what constitutes the substantive portion of split/shared visits until CY 2024.

In 2023, the substantive portion of a split/shared visit is determined by the provider who spent more than half of the total time rendering the service, or who performed the patient history, physical examination, or medical decision making (MDM).

“The delay of time-based selection of the billing provider for split/shared services will help pulmonology practices ward off a reduction in payment for these services, when possible. Physicians were struggling to identify a way to retain billing in their name if the rule for the billing provider selection was limited to how much time each provider spent,” Pohlig says.

According to CMS, both physicians and nonphysician practitioners (NPPs) from the same group practice may provide evaluation and management (E/M) services in a facility setting and count the work provided toward split/shared billing. NPPs, also referred to as advanced practice professionals (APPs), are qualified providers who may be supervised by physicians or collaborate with physicians to render care to patients.

“While an inpatient APP could spend more time than a physician (especially when the ratio of APPs to physicians are greater), the time-based requirement would have disregarded the collaborative nature of the physician-APP relationship, and the fact that the physician has the final input in patient management,” Pohlig adds.

The final rule was published in the Federal Register on Nov. 18, 2022, and is available at www.federalregister.gov/documents/2022/11/18/2022-23873/medicare-and-medicaid-programs-cy-2023-payment-policies-under-the-physician-fee-schedule-and-other.