On 1st November, 2022, the CMS- Centers for Medicare And Medicaid Services issued a final rule that includes updates and changes in policy for Medicare payments under the PFS- Physician Fee Schedule, and other Medicare Part B issues, it will be effective on or after 1st January, 2023.
Brief History of Physician Fee Schedule
Medicare payment has been made under the PFS for the services of physicians and other billing professionals started in 1992. In Medical Billing and Coding Physicians’ services paid under the PFS- Physician Fee Schedule and it is segregated in various types like physician offices, hospitals, ambulatory surgical centers (ASCs), SNF-skilled nursing facilities, hospices, outpatient dialysis facilities, and other post-acute care services, clinical laboratories, and beneficiaries’ homes. Payment is also made to several types of suppliers for technical services, most often in settings for which no institutional payment is made.
Medicare makes payment to physicians and other professionals at one rate based on the full range of resources involved in giving the service in a physician’s office. Physician fee schedule – PFS rates paid to physicians and other billing practitioners as per facility where service provided, like as a hospital outpatient department or an ASC, reflect only the portion of the resources typically incurred by the practitioner in the course of giving the service.
Under the Physician fee schedule separate payment may be made for the professional and technical components of services for many diagnostic tests and a limited number of other services. The technical component (TC) is frequently billed by suppliers, as independent diagnostic testing and radiation treatment, etc, and the professional component is billed by the physician or practitioner.
Payments are based on the relative resources typically used to provide the service. Relative value units (RVUs) are applied to each service for work, practice expense, and malpractice expense, etc. These RVUs become payment rates through the application of a conversion factor. Geographic adjusters or geographic practice cost index are also applied to the total RVUs to account for variation in practice costs by geographic area. Payment rates are calculated to include an overall payment update specified by statute.
CY 2023 PFS Ratesetting and Conversion Factor
CMS- Centers for Medicare And Medicaid Services is finalizing a series of standard technical proposals involving practice expense, including the implementation of the second year of the clinical labor pricing update. We also included a comment solicitation seeking public input as we develop a more consistent, predictable approach to incorporating new data in setting PFS rates. Per statutory requirements, we are also updating the data that we use to develop the geographic practice cost indices (GPCIs) and malpractice RVUs.
With the budget neutrality adjustments, which are required by law to ensure payment rates for individual services don’t result in changes to estimated Medicare spending, the required statutory update to the conversion factor for CY 2023 of 0%, and the expiration of the 3% supplemental increase to PFS payments for CY 2022, the final CY 2023 PFS conversion factor is $33.06, a decrease of $1.55 to the CY 2022 PFS conversion factor of $34.61.
Evaluation and Management (E/M) Visits
The AMA CPT Editorial Panel approved revised coding and updated guidelines for Other E/M visits as part of the ongoing updates to E/M visit codes and related coding guidelines that are intended to reduce administrative burden, which will effective from 1st January, 2023. Similar to the approach we finalized in the CY 2021 PFS final rule for office/outpatient E/M visit coding and documentation,
as part of continuous updates to E/M visits codes and the guidelines for coding that are designed to ease administrative burdens, and reduce administrative burden, the AMA CPT Editorial Panel approved updated guidelines and revised codes for visits to Other E/M facilities, beginning January 1st 2023. Similar to the model that we approved within the CY 2021 PFS final rule on E/M visit coding for outpatients and office visits, as well as documentation, we formulated and adopted the majority of the AMA CPT modifications to documentation and coding for other E/M visit (which comprise hospital inpatient admission, hospital observation the emergency department and nursing facilities home or residential services, and cognitive impairment assessments) starting January 1st 2023. The updated document and coding framework contains CPT changes to the definition of codes (revisions to the descriptors for Other E/M codes) and includes:
- New descriptor time (where appropriate).
- Revision of interpretive guidelines to guide various levels of medical decision making.
- The choice of medical decision making or the time required to select a the appropriate level of code (except for a handful of families who require emergency department visits or cognitive impairment assessments that aren’t scheduled services).
- It was eliminated the need for a exams and histories to determine the level of code (instead there will be a requirement to have a medically-adequate exam and history).
We have finalized our proposal to keep the current policies on billing which apply to E/Ms and we are considering possible modifications that could be needed for the future rulemaking process. We also completed the creation of Medicare-specific codes for the payment of other E/M extended services similar to the ones CMS has adopted in CY 2021 for the payment of extended services for office/outpatients. They will report these services using three distinct special Medicare-specific G codes.
Split (or Shared) E/M Visits
This policy determines which professional should bill for a shared visit by defining the “substantive portion,” of the service as more than half of the total time. Therefore, for CY 2023, as in CY 2022, the substantive portion of a visit is comprised of any of the following elements:
- History.
- Performing a physical exam.
- Medical Decision Making.
Spending time (more than half of the total time spent by the practitioner who bills the visit).
As finalized, clinicians who furnish split (or shared) visits will continue to have a choice of history, or 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, until CY 2024.
Telehealth Services
For Calendar year For CY 2023 we are working on various policies pertaining to Medicare services for telehealth, such as making a number of services temporary telehealth options to the PHE to be available until CY 2023 to give additional time to the gathering of data which could support being included as permanently enhancements to the Medicare Telehealth Services List. We’ve finalized our plans to extend the period of time during which services will be listed in the telehealth list during the PHE, for at least at least 151 days after the conclusion of the PHE in accordance to our commitment to the Consolidated Appropriations Act, 2022 (CAA 2022).
We have announced our intention to incorporate the telehealth provisions in sections 301-305 of the CAA in 2022, through a program instruction or any other guidance from subregulatory authorities to make sure that the transition is smooth after the expiration of the PHE. These guidelines, for instance, the ability of telehealth to be provided across any geographical area and in any location (including the home of the patient) and permitting certain services to be provided via audio-only telecommunications systems; and permitting occupational therapists, physical speech-language pathologists, therapists and audiologists to offer the services via telehealth, will stay in effect during the PHE until 151 days after the PHE has ended. The CAA 2022 will also delay the in-person visit requirement for mental health services that are provided through telehealth to 152 days after the expiration period of the PHE.
We have finalized the plan that allows doctors and physicians to continue billing using the location of services (POS) indicator, which would have been reported if the service had been delivered in person. These claims will need to be billed with the modification “95” to distinguish the services as Telehealth services. Claims may be billed using the location of service code that is used in the event that the telehealth service has been delivered in-person until the latter of the closing date the year CY 2023 or at the end of the year when the PHE expires.
The Telehealth Originating Site Facility Fee has been updated for CY 2023, which can be found with the list of Medicare Telehealth List of Services at the following website: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes
Behavioral Health Services
In light of the present requirements of Medicare beneficiaries to have better access to services in the field of behavioral health, CMS has considered regulatory changes that could help eliminate barriers currently in place and increase the use of the services offered by behavioral health professionals for example, licensed professional counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs). Thus, CMS is preparing a final plan to include an exemption to the requirement of direct supervision in the “incident of” regulation in 42 CFR 410.26 to permit behavioral medical services offered under the direction of an physician a non-physician practitioner (NPP) instead of under direct supervision when these supplies or services are provided by auxiliary staff that include LPCs and LMFTs in conjunction with the expertise of a doctor (or NPP). CMS clarifies that any service that is provided solely for the purpose of diagnosing and treating of mental health disorders or substance use disorder may be offered by auxiliary staff under the supervision of the doctor or NPP who is authorized to provide and charge for services in connection with their professional services. CMS believes that this modification will make it easier to access and expand the scope of the behavioral health services. In addition, CMS indicated in the final rule that we plan to make payment arrangements for the new codes that address the behavioral training of caregivers during CY 2024.
In the 2022 CMS Behavioral Health Strategy (https://www.cms.gov/cms-behavioral-health-strategy), CMS included a goal to improve access to, and quality of, mental health care services and included an objective to “increase detection, effective management, and/or recovery of mental health conditions through coordination and integration between primary and specialty care providers.” In CY 2017 and 2018 PFS rulemaking, CMS received comments that initiating visit services for behavioral health integration (BHI) should include in-depth psychological evaluations delivered by a clinical psychologist (CP), and that CMS should consider allowing professionals who were not eligible to report the approved initiating visit codes to Medicare to serve as a primary hub for BHI services. With the growing demand for mental health care and the feedback from our clients and are currently preparing our plan to establish an entirely new code for General BHI which describes a personal service provided by clinical psychologists (CPs) or CSWs or clinical social workers (CSWs) to reflect monthly care integration in which the services provided by CSW or CP serve as the central for care integration. CMS is also completing the proposal to allow for a mental health diagnostic examination to be used as the initial visit for the new BHI general service.
In the 2022 CMS Behavioral Health Strategy for more information visit https://www.cms.gov/cms-behavioral-health-strategy
Chronic Pain Management and Treatment Services
We believe the CPM HCPCS codes will improve payment accuracy for Chronic Pain Management and Treatment Services, prompt more practitioners to welcome Medicare beneficiaries with chronic pain into their practices, and encourage practitioners already treating Medicare beneficiaries who have chronic pain to spend the time to help them manage their condition within a trusting, supportive, and ongoing care partnership. Finalized new HCPCS codes, G3002 and G3003, and valuation for chronic pain management and treatment services (CPM) for Calendar year 2023.
The finalized codes include a bundle of services furnished during a month that we believe to be the starting point for holistic chronic pain care, aligned with similar bundled services in Medicare, such as those furnished to people with suspected dementia or substance use disorders.
Opioid Treatment Programs (OTPs)
For Calendar Year 2023 and subsequent years in order to stabilize the price for methadone, CMS is finalizing the proposal to revise methodology for pricing the drug component of the methadone weekly bundle and the add-on code for take-home supplies of methadone.
CMS will base the payment amount for the drug component of HCPCS codes G2067 and G2078 for CY 2023 and subsequent years on the payment amount for methadone in CY 2021 and update this amount annually to account for inflation using the PPI for Pharmaceuticals for Human Use (Prescription).
Audiology Services
CMS- Centers for Medicare and Medicaid Services finalized a policy to allow beneficiaries direct access to an audiologist without an order from a physician or NPP for non-acute hearing conditions. As per new policy will use a new modifier instead of using a new HCPCS G-code as we proposed ─ because we were persuaded by the commenters that a modifier would allow for better accuracy of reporting and reduce burden for audiologist.
The services can be billed using the codes audiologists already use with the new modifier, and include only those personally furnished by the audiologist. The finalized direct access policy will allow beneficiaries to receive care for non-acute hearing assessments that are unrelated to disequilibrium, hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids. This modification in our finalized policy necessitates multiple changes to our claims processing systems, which will take some time to fully operationalize, but audiologists may use modifier AB, along with the finalized list of 36 CPT codes, for dates of service on and after January 1, 2023.
CMS finalized the proposal to permit audiologists to bill for this direct access (without a physician or practitioner order) once every 12 months per beneficiary. Medically reasonable and necessary tests ordered by a physician or other practitioner and personally provided by audiologists will not be affected by the direct access policy, including the modifier and frequency limitation.
Dental and Oral Health Services
Medicare currently pays for dental services in a limited number of circumstances, specifically when that service is an integral part of specific treatment of a beneficiary’s primary medical condition. Medicare payment for dental services is generally precluded by statute.
But, some examples are restoration of the jaw after injuries or fractures or tooth extractions to prepare for radiation therapy for cancer that affects your jaw or oral examinations prior to kidney transplants. CMS has proposed the clarification and codification of some features of Medicare fee-for-services policy for dental treatments. CMS also sought feedback on the payment of additional dental services that were integrally linked to, and significantly related to and vital to the clinical efficacy of the medical services that are not covered by Medicare like dental exams as well as necessary treatment in advance of organ transplants heart valve replacements and valvuloplasty procedures. In effect in CY 2023 CMS 1) finalized our plan that clarifies and codifies specific features of our current Medicare FFS payment guidelines for dental care when the treatment is an integral aspect of the treatment for the primary medical condition of the beneficiary and two) other scenarios of clinical necessity under the conditions of Medicare Part A as well as Part B reimbursements could be made for dental services like dental exams, and other necessary treatments prior to or concurrently with organ transplants replacement of the cardiac valve, and the valvuloplasty procedure. We are also finalizing the payment for dental examinations and other required treatments prior to treatment of neck and head cancers beginning in CY 2024. We are also finalizing the process for CY 2023 to examine and review public suggestions regarding Medicare payment for dental treatment in different situations. In addition, we are trying to respond to commenters who have thoughtful comments and questions regarding the operational aspect of processing claims and billing for these services.
Skin Substitutes
CMS suggested a variety of changes to the policy for products that substitute skin to simplify the billing, coding and payment procedures and create consistency for these products in the different settings. Particularly, CMS proposed to change the terms used to describe products that are substituted for skin to “wound care management products’ and to treat and charge on these goods as an incident to supplies covered under the PFS beginning 1st January,2024. After reviewing comments regarding the proposal, we believe that it is beneficial to give those interested with more opportunities to express their opinions on the specifics of changes to the coding system and payment systems prior to establishing a definitive date for when the change to more suitable and compatible payment and coding systems for the products will be complete. We will hold an Town Hall in early CY 2023 in which interested parties will be able to discuss the concerns of commenters and discuss possible methods for the payments for skin substitutes in the PFS. We will be taking into consideration the feedback on the issue in our response CY 2023 rulemaking, as well as feedback from Town Hall Town Hall in order to improve the proposed policy for skin substitutes in the future rulemaking.
Colorectal Cancer Screening
For Calendar Year 2023 CMS will finalize the proposed changes to expand our Medicare coverage to include screening for colorectal cancer accordance with the current United States Preventive Services Task Force and recommendations of professional societies. CMS broadening Medicare protection for specific screening tests for colorectal cancer by reducing the age of minimum of payment and coverage limit from 50 years to 45 years. In addition expanding regulatory definition of tests for screening for colorectal cancer to include a complete colorectal screening, which includes a follow-up colonoscopy for screening is required following an initial Medicare covered stool-based screen for colorectal cancer yields an affirmative result.
One of the benefits of our policy on an all-inclusive colorectal cancer screen will be that for the majority of people the cost sharing policy will not apply to either the first stool-based test, nor for the follow-up colonoscopy. Both policies are a reflection of our intention to improve access to quality medical care and improve the patient health outcomes through preventative and earlier detection services and also through efficient treatment options. Our updated screening guidelines for colorectal cancer directly help us achieve our goals for health equity by providing access to much-needed preventative and earlier detection for rural communities as well as communities of color, which are most affected by the prevalence of colorectal cancer. Our policies are also in direct support of Vice President Biden’s Cancer Moonshot Goal to cut the mortality rate due to cancer by at minimum 50 percent in for the next twenty years. This is in line with his recent announcement for March 2022 to be National Colorectal Cancer Awareness Month.
Specific Single-Dose Manufacturers of Containers or Single-Use Packaging Pharmaceuticals to provide refunds for amounts that have been disposed of
Section 90004 under the Infrastructure Investment and Jobs Act (Pub. L. 117-9 15 November 2021) modified section 1847A of the Act including provisions that oblige manufacturers to pay a reimbursement for CMS for certain amounts that are discarded from a single-dose container that is refundable or single-use packaging drug. The amount of refund refers to the quantity of the drug that is discarded that is greater than a certain percentage, which has to be at minimum 10% of the all allowed charges for the drug within the current calendar quarter. The proposed amendments to subsection 90004 in the Infrastructure Act included: how the amount of drugs that are discarded is defined as well as a definition of which drugs are eligible for the refund process (and exclusions) as well as when and how frequently CMS will inform the manufacturers about refunds, the time and how frequently payment of refunds by producers to CMS is required; the refund calculation method (including the applicable percentages) and an arbitration process for disputes; and provisions for enforcement. The refund will be applicable to refundable single-dose containers or single-use packaging drugs from January 1st 2023.
CMS is completing as it was proposed what constitutes a refundable container for single doses or package for single-use as a biological or drug that is subject to payment under Part B and comes from a single dose container or single-use box. CMS is finalizing the exclusions to this definition that are stipulated by law for substances that are radiopharmaceuticals or imaging agents, substances that require filtering during the preparation of the drug or for drugs that were that are approved prior to or following the date of enactment the Infrastructure Act (that is, November 15th 2021) that payments under Part B have been paid for less than 18 month.
For certain drugs that have unique conditions, CMS solicited comment on whether an additional percentage of applicable is appropriate for a drug that is reconstituted with hydrogel and then administered through a the ureteral catheter or nephrostomy tube into kidneys. In this case there is a substantial quantity of reconstituted hydrogel which sticks to the vial’s wall in preparation, and is unable to be removed from the vial to be administered. Based on the feedback that were received CMS will be deciding on an higher applicable percentage of 35 percent in this medication.
CMS has also requested feedback on whether there are additional drugs that have unique circumstances that need to be increased in the percentage applicable to them. Based on the public’s comments, CMS plans to collect additional data on drugs that might have particular circumstances, as well as what additional percentages are appropriate in each situation. CMS will consider additional, more applicable percentages in the future through rules on notice and comments.
CMS has finalized the requirements for using the JW modifier, to report the amount of drugs that were discarded and also the JZ modifier, which attests that there was not a single discarded quantities. CMS has finalized that providers will have to submit the JW modifier starting the 1st of January, 2023. They will also report the JZ modifier by the 1st of July, 2023, in every outpatient setting. In the rule that was proposed, CMS proposed that an initial invoice for refunds is to be sent to the manufacturer at the end of October in 2023. We think it is advantageous to increase efficiency with respect to reconciliation and invoicing process of the discarded drug refunds as well as in the new incentive programs that are under the Inflation Reduction Act, and this is why we aren’t deciding the timeframe for the initial report to manufacturers, or the time by which the initial refunds are due. However, we are finalizing the release of an initial report on the estimated amounts of drugs that have been discarded in accordance with claims made during the first two quarters of 2023. of 2023 by the 31st of December, 2023. We we will revisit the timing of the initial report as we develop future rules.
Preventive Vaccine Administration Services
In this regulation, CMS finalized refinements to the amount that is paid for preventive vaccination within the Medicare Part B vaccine benefit. This includes the pneumococcal, influenza, hepatitis B, and COVID-19 vaccine as well as their administration. CMS approved the plan to update annually the amount of payment for the administration of vaccines on the basis of the rise in the MEI and also to adjust the amount for geographical location based on GAF. (GAF) of the PFS area where the preventive vaccine is administered. CMS has also approved the proposal to maintain the cost for COVID-19 at-home vaccinations to CY 2023.
In addition, due to the difference between the two types of declarations, a PHE designated under Section 319 of the Public Health Service Act (PHS Act) and an Emergency Use Authorization (EUA) declaration made under section 564 of the Food, Drug, and Cosmetic Act (FD&C Act) as well as there is a possibility they may not expire at exactly at the same time. CMS is defining the policies that were finalized in the 2022 CY PFS final rule on administering COVID-19 vaccination and monoclonal antibodies, to ensure that these policies will be in place until the closing in the year when the EUA declaration for medicines and biological products will be canceled. In addition, CMS is finalizing the plan to provide and pay for the monoclonal antibody products that are covered to prevent exposure of COVID-19 within Medicare Part B. Medicare Part B vaccine benefit.
Updated Medicare Economic Index (MEI) for CY 2023
CMS has proposed to review and alter the MEI in CY 2023. We sought your input on the future use of 2017.-based MEI is a factor to be considered in PFS the setting of rates as well as GPCIs. The method proposed for making an 2017-based MEI is based on an estimation of the base year’s costs by using publicly available data from the U.S. Census Bureau NAICS 6211 Offices of Physicians. The method proposed allows the use of data that represents the present market conditions for owners of physicians rather than simply accounting for the expenses of self-employed doctors and also allow to allow for the MEI to be updated often since the data sources that are suggested are revised and made available frequently.
The finalization of basis of the MEI cost weights used to set PFS rates won’t affect the overall cost of PFS products, but it may result in major modifications to payment distribution across PFS services across various areas of expertise and geographical regions. In our ongoing efforts to enhance the PFS payments, we are focusing on greater controls and greater transparency and to ensure stability of payments, we recommended not to apply the new MEI cost-share weights when determining PFS rates for the CY 2023 period. CY 2023. We also sought advice regarding the application for the new MEI cost-share rates to adjust the payment rates and make changes to the GPCI within PFS. PFS within the next few years.
We have completed the proposed and revised revision of the base on 2017. MEI with a few technical modifications to the methodology proposed in response to public feedback. Final update for CY 2023 of MEI. MEI will be 3.8 percent from the most recent historic records available. In the previous paragraph, it was mentioned that the updated and modified MEI weights were not used in determining PFS rate setting for CY 2023 PFS rates
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
Chronic Pain Management and Behavioral Health Services
CMS is in the process of finalizing the integration of chronic care management as well as behavioral health services into G0511, the RHC as well as the FQHC specific general care management HCPCS code G0511, that is aligned with changes in the PFS for CY 2023. The requirements for chronic pain control and the behavioral integrated health services is comparable to the requirements for general management of services offered through RHCs as well as FQHCs (which are currently the only services available to RHCs and FQHCs can utilize HCPCS codes G0511) the rates for payment of HCPCS G0511 is expected to be the median of the national non-facility PFS rates for RHC as well as FQHC health management as well as general health code (CPT numbers 99484, 999487, 99490 as well as 99491) and PCM codes (CPT codes 99424 and 99425) The payment rates will be reviewed each year based on PFS numbers for the codes. This is the way in which these updates are being implemented currently.
Telehealth Services
We announced that we are implementing the telehealth provisions in the Consolidated Appropriations Act, 2022 (CAA, 2022) via program instruction or other subregulatory guidance to ensure a smooth transition after the end of the PHE. The CAA, 2022 extends certain flexibilities in place during the PHE for 151 days after the PHE ends, including allowing payment for RHCs and FQHCs for furnishing telehealth services as distant site practitioners (though note that mental health visits can be furnished virtually on a permanent basis) under the payment methodology established for the PHE, allowing telehealth services to be furnished in any geographic area and in any originating site setting, including the beneficiary’s home, and allowing certain services to be furnished via audio-only telecommunications systems. The CAA, 2022 also delays the in-person visit requirements for mental health visits via telecommunications technology, including those furnished by RHCs and FQHCs, until 152 days after the end of the PHE.
Conforming Technical Changes to the In-Person Requirements for Mental Health Visits
We finalized conforming regulatory text changes in accordance with section 304 of the CAA, 2022 to amend paragraph (b) ( 3) of 42 CFR 405.2463, “What constitutes a visit,” and paragraph (d) of 42 CFR 2469, “FQHC supplemental payments,” to include the delay of the in-person requirements for mental health visits furnished by RHCs and FQHCs through telecommunication technology under Medicare until the 152nd day after the COVID-19 PHE ends.
Specified Provider-Based RHC Payment Limit Per-Visit
Subsequent to the publication of the CY 2022 PFS final rule, which implemented changes to the RHC payment limit as required by the Consolidated Appropriations Act, 2021, interested parties requested clarification regarding the timing of cost reports used to set the RHC payment limit. We finalized the clarification that a 12-consecutive month cost report should be used to establish a specified provider-based RHC’s payment limit per visit. We believe 12-consecutive months of cost report data accurately reflects the costs of providing RHC services and will establish a more accurate base from which the payment limits will be updated going forward.
Clinical Laboratory Fee Schedule (CLFS):
In accordance with section 4(b) of the Protecting Medicare and American Farmers from Sequester Cuts Act, we are finalizing certain conforming changes to the data reporting and payment requirements at 42 CFR part 414, subpart G. Specifically, we are finalizing revisions to § 414.502 to update the definitions of both the “data collection period” and “data reporting period,” specifying that for the data reporting period of January 1, 2023 through March 31, 2023, the data collection period is January 1, 2019 through June 30, 2019. We are also finalizing revisions to § 414.504(a)( 1) to indicate that initially, data reporting begins January 1, 2017 and is required every 3 years beginning January 2023. In addition, we are finalizing conforming changes to our requirements for the phase-in of payment reductions to reflect the amendments in section 4(b) of this law.
Specifically, we are finalizing revisions to § 414.507(d) to indicate that for CY 2022, payment may not be reduced by greater than 0% as compared to the amount established for CY 2021, and for CYs 2023 through 2025, payment may not be reduced by greater than 15% as compared to the amount established for the preceding year. Additionally, after examination of public comments and further analysis, we are finalizing an increase to the nominal fee for specimen collection based on the Consumer Rate Index for all Urban Consumers (CPI-U). Therefore, for CY 2023, the general specimen collection fee will increase from $3 to $8.574 and as required by PAMA, we will increase this amount by $2 for those specimens collected from a Medicare beneficiary in a SNF or by a laboratory on part of an HHA, which will result in a $10.57 specimen collection fee for those beneficiaries.
In addition, we are finalizing a policy to update this fee amount annually by the percent change in the CPI-U. We are also finalizing our proposals to codify and clarify various laboratory specimen collection fee policies in § 414.523(a)( 1 ). This is because the policies implementing the statutory requirements under section 1833(h)( 3 )(A) of the Act for the laboratory specimen collection fee, which are currently described in the Medicare Claims Processing Manual Pub. 100-04, chapter 16, § 60.1., did not have corresponding regulations text and a few of the manual guidance is no applicable. Lastly, in light of questions we have received from interested parties, we are finalizing as proposed to codify in our regulations, and make certain modifications and clarifications to, the Medicare CLFS travel allowance policies. We are finalizing the addition of § 414.523(a)( 2) “Payment for travel allowance” to reflect the requirements for the travel allowance for specimen collection. Specifically, in accordance with section 1833(h)( 3 )(B) of the Act, we are finalizing to include in our regulations the following requirements for the travel allowance methodology: (1) a general requirement, (2) travel allowance basis requirements, and (3) travel allowance amount requirements.
Medicare Ground Ambulance Data Collection System
CMS is completing a series of revisions that will affect the Medicare Ground Ambulance Data Collection System. We are first completing our proposal to revise our regulations to SS 414.626(d)(1) as well as (e)(2) to give the necessary flexibility to determine how ground ambulance providers must submit hardship exemption requests as well as request for informal reviews, which include the portal on our website once it is operational.
CMS also finalizing our proposal for changes as well as adding clarifications of this Medicare Ground Ambulance Data collection instrument. The modifications and clarifications are designed to ease the burden for respondents, increase the quality of data or both. We have grouped the changes and clarifications under four general categories. changes to the editorial structure to ensure consistency and clarity as well as updates that reflect the system’s web-based interface and clarifications in response to comments by interested parties and tests as well as typos and technical corrections.
Origin and Destination Requirements Under the Ambulance Fee Schedule
CMS is completing the interim policy (85 FR the 19276) that expanded the list of destinations covered for ground ambulance transportation was in effect for the duration of COVID-19PHE. The destinations are but are not limited to, any site which is an alternative location that is deemed by the CMS to belong in a hospital crucial access hospital(CAH)or skilled nursing facility (SNF) Community medical centers for mental illness, federally accredited health centers rural health clinics, doctor offices and urgent care centers or ambulatory surgical centers. any other location that provides dialysis services outside of an end-stage kidney condition (ESRD) facility, if there is no ESRD center is not accessible as well as the home of the beneficiary.
After the COVID-19 PHE expires our regulations will reflect the existing ambulance coverage that covers the locations listed below only: hospital or SNF; CAH; the home of the beneficiary and dialysis center for the ESRD patient that requires dialysis. In addition to these covered locations rural hospital emergency facilities (REH) will also be allowed to be a location in accordance with the Consolidated Appropriations Act, 2021 that will be in effect with the start of services beginning on or the 1st of January, 2023.
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