At the beginning of each calendar year, the CMS implements updates to numerous fee schedules. During the first quarter of 2023, this author received many questions about the Medicare Physician Fee Schedule (MPFS) for physicians and other qualified healthcare professionals (QHPs) and the Outpatient Prospective Payment System (OPPS) for work performed in hospital-owned outpatient wound/ulcer management provider-based departments (PBDs). The following are some of the frequently asked questions and answers.
MPFS QUESTIONS
Q: Last year, I was glad that the American Medical Association (AMA) and the CMS revised the guidelines for physicians and QHPs to select appropriate levels of evaluation and management (E/M) visits performed in offices or other outpatient settings. However, it was hard to simultaneously follow the 1995 and/or 1997 guidelines for E/M services that I performed in other places of service. For 2023, did the AMA and CMS implement the new E/M guidelines for other places of service?
A: Yes, effective January 1, 2023, physicians and QHPs will determine levels of E/M visits, provided in most places of service, based on medical decision-making or time; history and examination will no longer be used to determine the E/M level. The AMA also refined the descriptions of many E/M codes and revised medical decision-making guidelines for each category of E/M codes. Read the E/M sections in the 2023 Current Procedural Terminology (CPT.*) book1 that pertain to your places of service and update your E/M templates to reflect these welcomed changes.
The 2023 MPFS Final Rule adopted all the new E/M code descriptions and guidelines, except for other E/M prolonged services. The CMS created three new codes for those prolonged services, just as they did for office/outpatient prolonged services.2 Now wound/ulcer management physicians and QHPs who provide care to patients in hospitals, skilled nursing facilities, and/or their homes should use the new medical decision-making guidelines or time to determine the E/M levels that should be reported on their Medicare claims.
Q: I thought that CMS only released new Healthcare Common Procedure Coding System (HCPCS) codes for devices, drugs, and biologics in January of every year. However, I just learned that the CMS released HCPCS codes for new cellular and/or tissue-based products (CTPs) for skin wounds throughout 2022. Could you provide these new codes?
A: New codes were released in April, July, and October 2022 and January 2023 (Table 1). Note, in October 2022, the description for one code was changed (Table 2).
Q: Is it true that, effective January 1, 2023, the CMS packaged the payment for CTPs applied in a physician's office into the payment for their application?
A: No. Although the CMS proposed the packaged payment methodology for physician/QHP offices, it did not implement it in the 2023 MPFS Final Rule. Instead, on January 18, 2023, the CMS held a Skin Substitute Town Hall Meeting for the public to provide feedback on the proposed packaged payment and other proposed changes. All wound/ulcer management stakeholders should pay attention to, and provide written comments for, the 2024 MPFS proposed rule when it is released this summer.
OPPS QUESTIONS
Q: Are off-campus PBDs still required to append modifiers to services and procedures that they report to Medicare?
A: Yes, off-campus PBDs that are paid by the Medicare OPPS must report the appropriate modifier on their claims:
* PO: If they are an excepted off-campus PBD (NOTE: Excepted services must be performed in an off-campus practice location with an effective date prior to November 2, 2015).
* PN: If they are a nonexcepted off-campus PBD (NOTE: Nonexcepted services must be performed in an off-campus practice location with an effective date on or after November 2, 2015).
For clinic visits reported with G0463, these off-campus PBDs will be paid 60% of the OPPS allowable rate.
Q: Regarding the new CTP HCPCS codes that the CMS released January 1, 2023, did the CMS assign these CTPs to the high- or low-cost OPPS packaged payment group?
A: All four of the codes (Table 1) were assigned the OPPS status indicator "N", which means if a specific CTP is covered by the pertinent Medicare Administrative Contractor (MAC), payment for the CTP is packaged into the payment for its application. In addition, the codes were assigned to the low-cost packaged payment group. Therefore, PBDs should report applications of those CTPs with the appropriate application codes (C5271-C5278).
Q: For 2023, did CMS delete any HCPCS codes for CTPs?
A: Yes, CMS deleted HCPCS code C1849 Skin substitute, synthetic, resorbable, per square centimeter on December 31, 2022 because unique codes were assigned to each brand.
Q: Did CMS reassign any CTPs from the low-cost to the high-cost packaged payment group?
A: Yes, effective January 1, 2023, CMS assigned all the synthetic products and several other CTPs to the high-cost packaged payment group (Table 3; NOTE: To be moved from the low- to high-cost packaged payment group for calendar year 2023, the OPPS pricing data must show that the product cost is above either the mean unit cost of $47.00 or the per day cost of $837.00).
Q: Did any new CTPs receive OPPS device pass-through status for 2023?
A: No. Only one wound/ulcer management-related device still has device pass-through status: C1832 Autograft suspension, including cell processing and application, and all system components. The pass-through status for C1832 began on January 1, 2022 and will end on December 31, 2024.
Q: Our PBD used a CTP that has a HCPCS code and is assigned to the high-cost packaged payment group. All of our Medicare claims for that CTP were denied. Do you have any idea why that happened?
A: Only the MAC who processed your claims can provide a definitive answer to your question. However, I would guess that your MAC does not cover that particular CTP. You should verify if your MAC covers the CTP that was applied in your PBD. If not, your physician or QHP should request a peer-to-peer call with the MAC Medical Director to educate her/him about that particular CTP and its clinical evidence and request positive coverage.
Q: Were any wound/ulcer-related procedures added to the Inpatient-Only List for 2023?
A: One new wound/ulcer-related procedure was added to this list for calendar year 2023: 15778 Implantation of absorbable mesh or other prosthesis for delayed closure of defect(s) (ie, external genitalia, perineum, abdominal wall) due to soft tissue infection or trauma. Therefore, 15778 is not assigned to an Ambulatory Payment Classification group under the 2023 OPPS.
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