CMS releases final 2023 Medicare reimbursement rules

2019 07 31 17 01 7432 Medicare Puzzle 400

The U.S. Centers for Medicare and Medicaid Services (CMS) has published its final Medicare Physician Fee Schedule (MPFS) and Hospital Outpatient Prospective Payment System (HOPPS) rules for 2023.

In the MPFS, radiology reimbursement cuts are projected to be lower than initially estimated from the agency's proposed rule in July. In its preliminary analysis, the American College of Radiology (ACR) estimates that the 2023 MPFS changes will result in an overall 2% decrease in radiology reimbursement. Payments for interventional radiology are expected to drop by an aggregate decrease of 3%, while nuclear medicine will decline by 2% and radiation oncology and radiation therapy centers will dip by 1%.

The ACR had previously projected that the proposed draft rule would have led to a 3% drop in radiology and nuclear medicine reimbursement, as well as 4% decrease for interventional radiology and a 1% decrease for radiation oncology.

"[The final rule's] reductions are less than the reductions in the proposed rule due to CMS correcting an error in the calculation of the malpractice relative value units (RVUs)," the ACR wrote in its preliminary analysis.

The ACR noted, however, that part of the decrease is due to changes in the RVUs and the second year of the transition to clinical labor pricing updates.

"If Congress does not intervene to extend the 3 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," the ACR wrote.

The 2023 conversion factor will be $33.0067, compared with $34.6062 for 2022.

In other developments, the ACR said that the CMS accepted the Relative Value Scale Update Committee (RUC)-recommended values for 10 radiology-pertinent codes, including increases in values for contrast x-ray of the knee joint and the percutaneous arteriovenous fistula creation code family.

"Additionally, based on the ACR's comments, CMS also revised its values for the neuromuscular ultrasound code family in the final rule; it had initially proposed a reduction in value," the ACR wrote. "CMS also agreed to maintain the RUC-recommended direct practice expense inputs for the neuromuscular ultrasound codes and the percutaneous arteriovenous fistula creation codes based on stakeholder feedback."

Furthermore, the CMS finalized its plan to move forward with the second year of its four-year transition to its updated clinical labor values. The agency did, however, update prices for several clinical staff types that pertain to radiology. The vascular interventional technologist (L041A -- formerly angio technician) will increase from 0.6 to 0.84 and the mammography technologist (L043A) will increase from 0.62 to 0.79. In addition, the clinical labor value of a CT technologist will increase from 0.76 to 0.78, according to the ACR.

Other provisions in the final rule include changes to practice expense data collection/methodology and telehealth service. In addition, the CMS finalized its proposed coverage of colorectal cancer screening services to begin at age 45 and expanded the definition of colorectal cancer screening to include a follow-up screening colonoscopy after a positive stool-based screening test.

The ACR said it submitted comments requesting that the CMS extend coverage of colorectal cancer screening to include CT colonography. However, the CMS responded that this comment was "outside the scope of the rule."

This summer, the CMS informed ACR that it believes that there isn't sufficient evidence to support changing the non-coverage determination currently in place for CT colonography.

"The ACR is continuing to discuss coverage of CT colonography with appropriate CMS staff," the college wrote.

The final 2023 MPFS also included changes to a number of policies for the Quality Payment Program (QPP) and its Merit-based Incentives Payment System (MIPS) and Alternative Payment Models (APMs).


The final HOPPS rule included a 3.8% increase in conversion factor to reach $85.59 for 2023. In its summary of HOPPS final rule, the ACR noted that CMS will continue to implement the statutory 2 percentage point reduction in payment for hospitals that fail to meet the hospital outpatient quality reporting requirements by applying a reporting factor of 0.9807% to the OPPS payments and copayments for all applicable services. Also, the reduced conversion factor for hospitals failing to meet the Hospital Outpatient Quality Reporting (OQR) Program requirements is $83.93.

Among other changes, CMS has placed the CPT code (71271) for Low Dose CT for Lung Cancer Screening in ambulatory payment classification (APC) 5522 with a payment rate of $106.88. In addition, CMS has placed the code for a visit to determine lung low-dose CT eligibility (G0296) in APC 5822, with a payment rate of $75.85.

Payment rate changes were also made to the seven imaging APCs.

Changes in payment rate for imaging Imaging APCs
APC Group Title 2022 payment rate 2023 payment rate
5521 Level 1 Imaging with Contrast $82.61 $86.88
5522 Level 2 Imaging without Contrast $111.19 $106.88
5523 Level 3 Imaging without Contrast $235 $233.52
5524 Level 4 Imaging without Contrast $493.48 $503.13
5571 Level 1 Imaging with Contrast $182.43 $180.34
5572 Level 2 Imaging with Contrast $376.09 $368.43
5573 Level 3 Imaging with Contrast $730.67 $740.75

The CMS is also now recognizing add-on-CPT codes for software-as-a-service products such as LiverMultiScan, Optellum, and QMRCP and will pay separately for them.

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