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What's New in the 2022 Physician Fee Schedule?

Article In Brief

The 2022 Physician Fee Schedule does not bring major changes in reimbursement but several new medical coding rules will enable neurologists to be paid for work that was previously not covered for reimbursement.

This year's Physician Fee Schedule brought some new policies to neurology and continued others expanded at the start of the pandemic, experts told Neurology Today. And several new coding rules will help reimburse for services not previously covered.

Two new medical coding rules that went into effect January 1—one pertaining to services for high-risk patients and one for critical care services—allow neurologists to be paid for work that heretofore may have gone unreimbursed.

Four new codes are available to bill for principal care management services (PCM) to a patient for a single high-risk chronic condition that requires significant monitoring and management and care coordination with other providers.

“This means several different specialists dealing with different conditions can report these on the same patient,” said Neil A. Busis, MD, FAAN, a clinical professor in the department of neurology at NYU Grossman School of Medicine.

Previously, specialists could only bill for care management services if they were managing at least two conditions. For that reason, they typically deferred to primary care physicians. Under the new rule, a neurologist, nurse practitioner, or physician assistant who spends at least 30 minutes on PCM services for a patient in a calendar month can use the new codes to bill for their total time serving that patient as well as clinical staff time provided by nurses and other members of the care team.

Speaking at an AAN webinar about the 2022 Medicare Physician Fee Schedule in December, Dr. Busis said the PCM codes might be appropriate for neurologists treating patients with epilepsy, movement disorders, severe headaches, dyskinesias, and many other conditions in which patients are at significant risk of hospitalization, decompensation, functional decline, or death. The new rules apply only to care provided for Medicare beneficiaries unless a state Medicaid program or private insurer adopts them as part of their coverage policy.

In another recognition of the importance of specialty care, the 2022 fee schedule allows critical care services to be provided by multiple specialists on the same day. Previously, a critical care code could only be used once a day for a given patient and neurologists typically deferred to intensivists.

Under the new rule, an intensivist managing a patient's ventilator and a neurologist managing their status epilepticus, for example, can each bill for critical care services individually.

“That is really wonderful because it recognizes the value that both of those individuals bring to the patient and to the team,” Nassim Zecavati, MD, MPH, FAAN, director of epilepsy at Children's Hospital of Richmond, said in the webinar.

That said, the use of the new codes will require neurologists to adjust their thinking because they may be used to forgoing reimbursement for care management or critical care to avoid conflict with other physicians who relied on certain billing codes to make a living.

“We generally didn't do the chronic care management codes because we didn't want to offend our referring physicians, and we didn't try to use critical care codes because we didn't want to offend the critical care physicians,” Dr. Busis said. “But now that we have parallel reimbursement tracks for individual conditions in the outpatient sphere with PCM and for individual critical care illnesses in the ICU, you can bill without worrying about any of the medical politics. It's actually a very big deal.”

What to Do Now

Success with the new PCM codes will require physician training and careful documentation, said Jose M. Rocha, director of the central business office for FirstChoice Neurology, the nation's largest neurology group with more than 41 facilities in Florida.

His practice will pilot use of the new codes with a small number of patients in early 2022 to gain experience, but certain steps are clear.

Make sure proper documentation—most likely, more details than physicians are used to—is recorded in the electronic health record. The time that clinical staff members spend coordinating infusion services or confirming that a patient is complying with treatment plans must be recorded. Likewise, even though many care management tasks may occur via telephone or remote monitoring, the brief “spoke to patient” notes that may have sufficed in the past will not support the use of PCM codes.

“You are going to have to actually record what you spoke to the patient about and how long you spoke to the patient,” he said.

At the end of each month, someone must go through the patient's record to tally how much time was spent on care management and, thus, which codes will be used to bill. Beyond that, those details will be essential if CMS asks for documentation to support the PCM reimbursement, Rocha said.

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“It is in some ways a success that it is only 2.75 percent and not much more. This is a challenge we face every year and the best way that we can prevent cuts is to support the AANs advocacy efforts and consider participating in Neurology on the Hill” in May.—DR. NASSIM ZECAVATI

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“Its a great way to take a lot of these things that we have to do and combine them in a way that makes sense. There is going to be a lot of nuances of how to engage with this process, how to make it work and how to decide if this makes more sense than sticking with traditional MIPS reporting.”—DR. DANIEL J. ACKERMAN

Other Billing Updates

Among other billing updates in 2022, neurologists should expect to see incremental cuts–0.75 percent in January, 1 percent in April, and 1 percent in July–for a total 2.75 percent reduction in Medicare payment levels in 2022. The situation would have been much worse if not for Congressional action in December that avoided the plan to cut physician payments by 9.75 percent as of January 1. Dr. Zecavati attributed that vote to advocacy efforts by the AAN and other associations.

“It is in some ways a success that it is only 2.75 percent and not much more,” she said. “This is a challenge we face every year and the best way that we can prevent cuts is to support the AAN's advocacy efforts and consider participating in Neurology on the Hill” in May.

In another development, the CMS payment policy for telehealth services will continue through calendar year 2023, following rules in place since the beginning of the COVID-19 public health emergency. This gives the Centers for Medicare and Medicaid Services (CMS) time to review evidence about the efficacy of telehealth services that is currently being collected and analyzed, Dr. Busis said.

CMS will continue to allow behavioral health visits, including cognitive neurology visits, to be conducted via telephone as long as the patient has one in-person visit for those services every 12 months.

In addition, Medicare's Quality Payment Program will introduce a new “value pathway” for stroke care in 2023. The “Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes” pathway is a set of quality measures and improvement activities focused on stroke care that can be used to meet a neurologist's Merit-based Incentive Payment System (MIPS) reporting requirements.

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“We generally didnt do the chronic care management codes because we didnt want to offend our referring physicians, and we didnt try to use critical care codes because we didnt want to offend the critical care physicians. But now that we have parallel reimbursement tracks for individual conditions in the outpatient sphere with PCM and for individual critical care illnesses in the ICU, you can bill without worrying about any of the medical politics. Its actually a very big deal.”—DR. NEIL A. BUSIS

“It's a great way to take a lot of these things that we have to do and combine them in a way that makes sense,” said Daniel J. Ackerman, MD, FAAN, director of stroke and vascular neurology at St. Luke's University Health Network in Philadelphia, who worked with the AAN as it helped CMS develop the new pathway. “There is going to be a lot of nuances of how to engage with this process, how to make it work and how to decide if this makes more sense than sticking with traditional MIPS reporting.”

Link Up for More Information

• AAN resource on Medicare fee-for-service. AAN.com/view/MedicareNews. Accessed on January 14, 2022.