Recent rulings from the CMS offer an opportunity to reevaluate specialty mixes, surgical offerings and professional practice offerings against existing managed care contracts to ensure revenue cycle health.
At a November webinar sponsored by National Medical Billing Services, National Medical’s Kylie Kaczor, MSN, Senior Vice President of Clinical and Regulatory Affairs, and Paul Cadorette, Director of Training and Education for Coding, discussed CMS rulings and coding changes for 2023.
Three key takeaways were:
- Two CMS rulings increase reimbursement rates and expand service coverage. The Outpatient Prospective Payment System (OPPS) and ASC payment system final rulings will result in an increase in reimbursement for ASCs beginning in 2023.
Several years ago, CMS moved ASCs off the consumer pricing index and onto the Hospital Market Basket for rate increases, which better aligned ASC reimbursement with the cost of providing care. In calendar year (CY) 2023, the Hospital Market Basket rate is 4.1 percent. After adjusting for productivity by 0.3 percent, that brings the final ASC reimbursement increase to 3.8 percent. CMS also added four codes to the ASC covered procedure list for: mastectomy, retrieval of intravascular vena cava filter, biopsy or excision of lymph node(s) and laparoscopic removal of band and revision laparoscopic sleeve gastrectomy.
- The MPFS final ruling extends service availability but decreases reimbursement rates. The Medicare Physician Fee Schedule (MPFS) final ruling resulted in a decrease in physician reimbursement rates from $34.61 in CY 2022 to $33.06 in 2023, despite significant protest from stakeholders.
However, CMS extended availability of several temporary telehealth services through CY 2023 to collect further data that may support the permanent addition of these services. CMS also extended the duration of time that services are temporarily included on the telehealth services list. Practitioners are permitted to continue billing telehealth services with a place of service code that would be used if a telehealth service had been furnished in person through the end of CY 2023 or the end of the year in which the public health emergency ends, whichever is later.
The MPFS final ruling expands Medicare coverage for certain colorectal cancer screening tests by reducing the minimum age from 50 to 45 years old and by expanding the definition of colorectal cancer screening test. "This is an arena that has been advocated for quite some time, so this is believed to be a very positive change," Ms. Kaczor said.
CMS also finalized and adopted most of the AMA CPT changes in coding and documentation for "other" evaluation and management (E/M) visits, effective January 1, 2023. In addition, CMS finalized the proposal to maintain current billing policies that apply to the E/M visit; however, CMS is considering potential revisions in future rulemaking.
- There are five key coding changes for 2023:
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- Lumbar disc arthroplasty. The primary procedure, 22857, has an add-on code for 2023, +22860 for patients up to 60 years old and other add-on codes for increasing numbers of interspace lumbars.
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- Minimally invasive SI joint fusions. Both transfixing devices and intra-articular implants are used in minimally invasive SI joint fusions. Transfixing devices are covered under code 27279. In 2023, intra-articular implants will be reported as Category III code 0775T, and 27279 will be reimbursed at about $19,600, while 0775T will be only $15,680. "It is vitally important that you understand the types of device being used," Mr. Cadorette said.
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- Repair of nasal vestibular stenosis. In 2023, the new code 30469 is valued as a bilateral procedure, meaning the physician needs to perform the service on both sides. If the service is only performed on one side, it must be reported with the modifier 52.
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- Intragastric balloons. There are two new codes: 43290 for EGD transoral with placement of the intragastric balloon and 43291 for removal of the gastric balloon. As procedural requirements are attached to both codes to qualify for reimbursement, it is recommended that physicians clearly review the code details along with any required modifiers.
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- Hernia repairs. In 2023, epigastric, incisional, ventral, umbilical and spigelian hernias repaired by any approach, initial or recurrent, were combined into a single group, with variation in codes based on the length of the defect and whether the hernia is incarcerated or strangled. For parastomal hernias repaired by any approach, initial or recurrent, a new code 49621 will be available, with incarcerated or strangulated parastomal hernias reported as 49622. Review the CPT manual for the changes to these codes, as there are detailed required guidelines for defect measurement and reporting.
The coding changes listed apply across the board and do not always mean maximum reimbursement. The difference in how they are paid depends on the fee schedules and reimbursement rates of specific payers. It is important to stay up to date on rulings to be prepared and ready to go as new measures become active and mandatory.
Note: The details provided here are a summary of the information shared in the webinar, but this summary is not to be relied on for coding or billing.
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