The Centers for Medicare and Medicaid Services (CMS) on Nov. 2 released the 2022 Medicare Physician Fee Schedule (PFS) final rule, addressing Medicare payment and quality provisions for physicians in the next fiscal year. Under the rule, the conversion factor will decrease by $1.30 on Jan. 1, 2022, going from $34.89 to $33.59. CMS estimates payments to cardiologists will decrease by about 1% from 2021 to 2022 through updates to work, practice expense and malpractice relative value units (RVUs). This estimate is based on the entire cardiology profession and can vary widely depending on the mix of services provided in a practice. Highlights from the final rule include:

2022 Medicare Physician Fee Schedule:

• A revised and finalized plan to update clinical staff labor inputs in the direct practice expense formula, which takes into account some comments from the ACC and other groups, will be phased in over four years, starting in 2022. Increases for the cost of clinical staff in the office setting require reductions elsewhere in the formula to supplies and equipment. The ACC and others expressed concerns about the severity of the cuts at a time when clinicians are needed on the front lines of the COVID-19 pandemic. As a result of the phased-in approach, office-based services with high supply costs (lower-extremity revascularization) and equipment (imaging) are estimated to see reductions of roughly 1% to 6% in 2022 and 4% to 24% after full implementation absent changes in future rulemaking.
• Updates to work and/or practice expense (PE) values for new/revised codes describing exclusion of left atrial appendage, harvest of upper extremity artery, external cardiovascular device monitoring, electrophysiological (EP) evaluation, endovascular repair of aortic coarctation, 3D imaging of cardiac structures, percutaneous cerebral embolic protection, cardiac catheterization for congenital defects, and cardiac ablation services bundling.
• Work RVU proposals for EP ablation services were not revised from the proposal to maintain the existing work RVUs for 93653 and 93656 despite bundling of related services. This change results in significant reductions due to the shorter procedure times reported in two different RVU surveys. CMS says it will consider additional information from the second survey in future rulemaking.
• The rule finalizes a number of refinements to current policies for split (or shared) evaluation and management (E/M) visits, critical care services, and services furnished by teaching physicians involving residents. Critical care split (or shared) visits must be billed by the physician or advanced practice practitioner (APP) who spends the majority of the time with the patient, starting in 2022. For other facility E/M services, the clinician who spends more than half the time, or performs the history, exam, or medical decision-making can be considered to have performed the substantive portion during a transition year in 2022. The previously proposed definition based on total time will take effect for 2023.
• Finalized details regarding telehealth services, physician assistant services, opioid treatment program policy, rural health clinics and federally qualified health centers, electronic prescribing of controlled substances, drug pricing information reporting, pulmonary rehabilitation, Medicare Shared Savings Program, Open Payments Financial Transparency Program, and Medicare Provider Enrollment, among other topics.
• Removal of two national coverage determinations (NCDs), including PET NCD 220.6 that includes myocardial PET, based on the criteria developed in last year's final rule addressing outdated NCDs.
• Delayed implementation of the Appropriate Use Criteria (AUC) Program penalty phase until Jan. 1, 2023, or the Jan. 1 following the end of the COVID-19 Public Health Emergency (PHE), whichever is later. This will allow CMS time to address implementation and claims processing issues as part of future rulemakings and also takes into account the continued impact of COVID-19.

Medicare Telehealth and Other Services Involving Communications Technology

• A decision to allow certain services added to the Medicare telehealth list to remain through Dec. 31, 2023, allowing time to evaluate whether the services should be permanently added to the telehealth list following the COVID-19 PHE.

2022 Quality Payment Program Performance Period

As clinicians across the country continue to respond to COVID-19, the rule finalizes some significant changes to the Quality Payment Program (QPP) in 2022. Highlights include:

• A finalized implementation timeline for the Merit-Based Incentive Payment System (MIPS) Value Pathways (MVPs) and Alternative Payment Model (APM) Performance Pathway (APP) in the 2023 performance period. CMS finalized an initial set of MVP clinical areas, including rheumatology, stroke care and prevention, heart disease, chronic disease management, lower extremity joint repair (e.g., knee replacement), emergency medicine, and anesthesia.
• MIPS-eligible clinicians can report the APP as a subgroup beginning with the 2023 performance year. CMS will require multispecialty groups to form subgroups to report MVPs beginning in 2026.
• MVP reporting will be voluntary as CMS continues to consider sunsetting traditional MIPS by the end of the calendar year (CY) 2027 performance period/CY 2029 MIPS payment year; however, no date for mandatory MVP participation or traditional MIPS sunsetting is established.
• MVP participants or subgroups will register for the MVP between April 1 and Nov. 30 of the performance year or a later date as specified by CMS.
• The CY 2022 performance threshold is 75 points, using the mean final score from the 2017 performance period/2019 MIPS payment year data. The additional performance threshold is set at 89 points, the 25th percentile of actual 2017performance period/2019 MIPS payment year data.
• Performance category weights are 30% for the Quality performance category, 30% for the Cost performance category, 15% for the Improvement Activities performance category, and 25% Promoting Interoperability performance category.
• Equal weighting of the Cost and Quality Performance categories at 30% for traditional MIPS (Individuals, Groups, Virtual Groups), as required by statute.
• After consideration of the comments received, the Risk-Standardized Acute Unplanned Cardiovascular-Related Admission Rates for Patients with Heart Failure measure was not included. CMS will continue to consider how to implement condition-specific measures in the future.
• Continued reliance on historical benchmarks as opposed to performance period benchmarks for the CY 2022 performance period/2024 MIPS payment year.
• The 10-point complex patient bonus is revised to better target clinicians who treat a higher caseload of more complex and high-risk patients, starting in CY 2022.
• The transition to accountable care organizations (ACO) eCQM/MIPS CQM quality measure reporting, which requires all-payer data, is lengthened by extending the CMS web interface as an option for two years for ACOs.
• Finalized updates to quality measure scoring to remove end-to-end electronic reporting and high-priority measure bonus points, as well as the three-point floor for scoring measures (with some exceptions for small practices), and the addition of five new episode-based cost measures categorized as procedural, acute or chronic.
• The Improvement Activities inventory is updated by adding new activities about health equity and standardizing language related to equity across the improvement activities inventory.
• Under the Promoting Interoperability performance category, CMS revised reporting requirements for the Public Health and Clinical Data Exchange objective to support the COVID-19 recovery processes and future health threats, as well as requiring attestation for annual SAFER guide assessments for cybersecurity.
• Beginning in the 2023 performance year, CMS will require all third-party intermediaries [e.g., Qualified Clinical Data Registries (QCDR), qualified registries and health IT vendors] to support MVPs relevant to the specialties they support, as well as subgroup reporting.
• A requirement for a QCDR measure to be fully tested at the clinician level, beginning with the 2022 performance period, in order to be included in an MVP.

ACC staff is reviewing the final rule to identify additional topics of interest to members. More information will be available in the Advocate newsletter and on ACC.org in the coming days. Additional CMS fact sheets are available here and here and here.

Clinical Topics: Cardiovascular Care Team, COVID-19 Hub, Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Centers for Medicare and Medicaid Services, U.S., COVID-19, Public Health, Electronic Prescribing, Drug Costs, Rural Health, Medicare, Fee Schedules, Physicians, Heart Failure, Telemedicine, Critical Care, Physician Assistants, Stroke, Cardiac Catheterization, Disease Management, SARS-CoV-2, ACC Advocacy

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