2023 MPFS and Quality Payment Program Final Rule Released


The conversion factor is down but certain public health emergency flexibilities will continue.

The 2023 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program final rule, released Nov. 1, allows Part B physician payment for behavioral healthcare, cancer screening, and dental care. But while the Centers for Medicare & Medicaid Services (CMS) continues its focus on promoting population health, Part B payment for participating physicians and other qualified healthcare practitioners (QHPs) continues to decline, making the payoff for joining an accountable care organization (ACO) more attractive than ever.

Behavioral Health and Substance Abuse

CMS says in the 2023 MPFS final rule that it “is strengthening access to vital behavioral health services” by:

  • Allowing behavioral health clinicians (e.g., licensed professional counsellors and licensed marriage and family therapists) to offer services under general (instead of direct) supervision of the Medicare physician or QHP under the incident-to rule.
  • Clarifying that any service furnished primarily for the diagnosis and treatment of a mental health or substance use disorder can be furnished by auxiliary personnel under the general supervision of a physician or QHP.
  • Paying opioid treatment programs (OTPs) that use telehealth with patients to initiate treatment with buprenorphine. The final rule clarifies that OTPs can bill for opioids use disorder treatment services provided through mobile units in accordance with Substance Abuse and Mental Health Services Administration (SAMHSA) and Drug Enforcement Administration (DEA) guidance. Locality adjustments for services furnished via mobile units would be applied as if the service were furnished at the physical location of the OTP registered with the DEA and certified by SAMHSA.
  • Revise the methodology for pricing the drug component of the methadone weekly bundle and the add-on code for take-home supplies of methadone. As proposed, CMS will base the payment amount for the drug component of HCPCS Level II 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.
  • Modifying the payment rate for the non-drug component of the bundled payments for episodes of care to base the rate for individual therapy on a crosswalk to a code describing a 45-minute session, rather than the current crosswalk to a code describing a 30-minute session.
  • Paying for clinical psychologists and licensed clinical social workers to furnish integrated behavioral healthcare as part of a primary care team and creating a new general BHI code describing a service performed by these clinicians to account for monthly care integration.
  • Allowing a psychiatric diagnostic evaluation to serve as the initiating visit for a new general BHI service.
  • Adding a new monthly bundled payment for comprehensive treatment and management services for patients with chronic pain. CMS is finalizing HCPCS Level II codes G3002 and G3003 for CPM, which includes diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and coordination between relevant practitioners furnishing care, such as physical and occupational therapy, complementary and integrative care approaches, and community-based care, as appropriate.

CMS is also finalizing its proposal to permit the use of audio-only communication technology to initiate treatment with buprenorphine and (in 2024) periodic assessments in cases where audio-video technology is not available to the beneficiary and all other applicable requirements are met.

Colon Cancer Screening

CMS is officially reducing the minimum age for colorectal cancer screening coverage under Medicare Part B from 50 to 45 years and adding coverage for a screening colonoscopy after a non-invasive stool-based test returns a positive result.

Dental Coverage

CMS is codifying current Medicare Parts A and B policies for dental services when integral to treating a beneficiary’s condition. CMS will pay for dental exams and treatments in certain cases such as to eliminate infection preceding organ transplant and certain cardiac procedures in CY 2023 and, beginning in 2024, prior to treatment for head and neck cancers. CMS says it will begin an annual process for reviewing public input on other circumstances when payment for dental services may be allowed.

Audiology Services

The final rule further codifies the recent policy to allow direct access to an audiologist without an order from a physician or QHP for non-acute hearing conditions unrelated to disequilibrium, hearing aids, or examinations for the purpose of prescribing, fitting, or changing hearing aids. Instead of a new HCPCS Level II G code, as proposed, CMS is creating a new modifier AB (for use with CPT® codes provided without an order). This benefit will be allowed once every 12 months.

Evaluation and Management Services

The CPT® E/M section underwent significant changes to the office/outpatient codes in 2021. Earlier in the year, the CPT® Editorial Panel further revised coding and guidelines for other E/M visits, effective Jan. 1, 2023. As with the changes to E/M coding in 2021, CMS has finalized “most” of the CPT® 2023 changes made throughout the E/M section. Where the difference occurs is mainly in coding for prolonged services. For Medicare, you will use three HCPCS Level G codes. The physician payment changes planned for split/shared billing, however, continue to be on hold until 2024.

Telehealth Services

CMS is making certain services currently listed under the temporary column in the Telehealth Code List available at least through 2023. Temporary codes will be covered for at least 151 days following the end of PHE for COVID-19, which was renewed for another 90 days on Oct. 13.

Physicians and QHPs will continue to bill with the place of service indicator that would have been reported had the service been furnished in person and append modifier 95 to the claim to identify non-telehealth services rendered via telehealth. This applies to the end of 2023 or the end of the year in which the PHE ends.

The Telehealth Originating Site Facility Fee (Q3104) for 2023 was not posted at the time of publication.

Skin Substitutes

CMS is putting its proposal on hold to change the terminology of skin substitutes to “wound care management products” and to treat and pay for these products as incident-to supplies beginning Jan. 1, 2024. CMS says it plans to hold a Town Hall to “strengthen proposed policies for skin substitutes in future rulemaking.”

Refunds for Discarded Drug Waste

CMS is finalizing its proposals for implementing section 90004 of the Infrastructure Investment and Jobs Act of 2021, including its definition of a refundable single-dose container or single-use package drug, exclusions to the definition, and when an increased applicable percentage of 35 percent would be appropriate for a drug. You’ll continue to use modifier JW to report discarded waste and modifier JZ will be required no later than July 1, 2023, in all outpatient settings for attesting that there were no discarded amounts. CMS says they will finalize the timing of the initial report to manufacturers or the date by which the first refund payments are due in future rulemaking, and will issue a preliminary report on estimated discarded drug amounts based on claims from the first two quarters of 2023 by Dec. 31, 2023.

Preventive Vaccinations

CMS will continue to allow an additional physician payment for at-home COVID-19 vaccinations for CY 2023.

CMS is clarifying the policies finalized in the CY 2022 PFS final rule regarding the administration of COVID-19 vaccine and monoclonal antibody products, to reflect that those policies will continue through the end of the calendar year in which the EUA declaration for drugs and biological products is terminated. Lastly, CMS is finalizing the proposal to permanently cover and pay for covered monoclonal antibody products used as pre-exposure prophylaxis for prevention of COVID-19 under the Medicare Part B vaccine benefit.

Part B Physician Payment Rates

Lastly, the MPFS final rule for CY 2023 sets the conversion factor for calculating physician payments at $33.06. This is a decrease of $1.55 from 2022. The Medicare economic index (MEI) update is finalized at 3.8 percent based on the most recent historical data available.

Additional policies were finalized for rural health clinics and federally qualified health centers for chronic pain management and behavioral health services, telehealth services, mental health visits, the RHC payment limit. The final rule also includes some policy changes to the Clinical Laboratory Fee Schedule, ground ambulance services, and the ambulance fee schedule.

For More Information:  86595 2023 medicare physician payment policies finalized