On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) released its proposed rule for the 2023 Medicare Physician Fee Schedule (PFS) and updates to the Quality Payment Program (QPP). The Association for Clinical Oncology (ASCO) continues to analyze the full proposal, but based on a preliminary analysis, key provisions for the cancer care community include:
2023 Physician Fee Schedule
CMS has proposed a Calendar Year (CY) 2023 physician conversion factor of $33.0775. This represents a 4.4% reduction from the 2022 physician conversion factor of $34.6062. This reduction is largely a result of the expiration of the 3.0% increase in PFS payments Congress funded for CY 2022. Additionally, changes to several evaluation and management (E/M) code families are expected to result in an additional reduction of about 1.5% to the 2023 Medicare conversion factor due to statutory budget neutrality requirements.
CMS estimates a negative 1% overall impact for the hematology/oncology specialty and a negative 1% overall impact for the radiation oncology specialty in 2023. However, this estimate does not factor in the 3% reduction in the conversion factor. The actual impact on individual clinicians, however, will vary based on geographic location and the mix of Medicare services billed.
CMS is proposing to maintain the 2022 definition of the “substantive portion” of an E/M service performed by both a physician and a non-physician practitioner in a facility setting through 2023. Clinicians who furnish the split/shared visit will continue to have a choice of history, physical exam, medical decision making, or more than half of the total practitioner time spent to define the substantive portion to determine which practitioner will bill the visit.
Evaluation and Management Services
As part of the ongoing updates to E/M visits and related coding guidelines, the American Medical Association (AMA) CPT Editorial Panel approved revised coding and updated guidelines for Other (hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment) E/M visits, effective January 1, 2023. CMS is proposing to adopt most of these changes effective January 1, 2023, including:
- New descriptor times (where relevant)
- Revised interpretive guidelines for levels of medical decision making
- Choice of medical decision making or time to select code level (with several exceptions)
- Eliminated use of history and exam to determine code level
CMS is also proposing to create Medicare-specific coding for payment of Other E&M prolonged services, similar to what it adopted in CY 2021 for payment of Office/Outpatient prolonged services.
ASCO is working to update its E/M coding and billing resources and will share them with members as soon as they are available.
CMS is proposing to implement provisions of the Consolidated Appropriations Act, 2022 (CAA, 2022) that extend certain Medicare telehealth flexibilities adopted during the COVID-19 public health emergency (PHE) for 151 days after the end date of the PHE. The end date of the PHE is not yet known, but it could be as soon as October. These flexibilities include allowing telehealth services to be furnished in any geographic area and in any originating site setting, including the beneficiary’s home and allowing telehealth visits to be audio-only.
CMS has also made several updates to the Medicare telehealth services lists including additions to the Category 3 list (proposed services to be covered temporarily during the PHE, see Table 8 in the rule) and the Category 1 list (proposed services to be covered permanently, see table 9 in the rule). CMS’ proposal, in accordance with CAA, 2022, would continue to cover services temporarily added to the Medicare Telehealth Services List for 151 days after the end date of the PHE. Category 3 services will remain covered through 2023.
Colorectal cancer screening
CMS is proposing to reduce the minimum age requirement for certain colorectal cancer screening tests to 45 years. It is also proposing coverage for one follow-on screening colonoscopy after a Medicare covered, non-invasive, stool-based colorectal cancer screening test returns a positive result. No beneficiary co-pays would be required for these tests.
The Quality Payment Program
Merit-Based Incentive Payment System (MIPS) Performance Threshold
CMS is proposing to set the MIPS performance threshold at 75 points for 2023. The 2022 performance year (2024 payment year) is the final year that clinicians are eligible to earn either a 5% Advanced Alternative Payment Model (APM) incentive payment or a MIPS exceptional performance bonus.
MIPS Value Pathways (MVP)
For 2023, five new MVPs are proposed, including an oncology-specific MVP:
- Advancing Cancer Care
- Optimal Care for Kidney Health
- Optimal Care for Patients with Episodic Neurological Conditions
- Supportive Care for Neurodegenerative Conditions
- Promoting Wellness
CMS is proposing 11 MIPS quality measures and 2 Qualified Clinical Data Registry (QCDR) measures within the quality component of the Advancing Cancer Care MVP:
- Oncology: Medical and Radiation – Pain Intensity Quantified
- Oncology: Medical and Radiation – Plan of Care for Pain
- Appropriate Treatment for Patients with Stage I (T1c) – III HER2 Positive Breast Cancer
- RAS (KRAS and NRAS) Gene Mutation Testing Performed for Patients with Metastatic Colorectal Cancer who receive Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibody Therapy
- Patients with Metastatic Colorectal Cancer and RAS (KRAS or NRAS) Gene Mutation Spared Treatment with Anti-epidermal Growth Factor Receptor (EGFR) Monoclonal Antibodies
- Percentage of Patients Who Died from Cancer Receiving Chemotherapy in the Last 14 Days of Life (lower score – better)
- Percentage of Patients Who Died from Cancer Admitted to Hospice for Less than 3 days (lower score – better)
- Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy
- Oncology: Utilization of GCSF in Metastatic Colorectal Cancer
- Oncology: Mutation testing for lung cancer completed prior to start of targeted therapy
- Advance Care Plan
- Preventive Care and Screening: Screening for Depression and Follow-Up Plan
- CAHPS for MIPS Clinician/Group Survey
CMS is proposing 13 Improvement Activities for the Advancing Cancer Care MVP:
- Engagement of patients through implementation of improvements in patient portal
- Regularly assess patient experience of care and follow up on findings
- Engagement of patients, family and caregivers in developing a plan of care
- Financial navigation program
- Implementation of use of specialist reports back to referring clinician or group to close referral loop
- Patient navigator program
- Provide 24/7 access to MIPS eligible clinicians or groups who have real-time access to patient’s medical record
- Electronic submission of patient centered medical home accreditation
- Implementation of methodologies for improvements in longitudinal care management for high risk patients
- Implementation of episodic care management practice improvements
- Implementation of medication management practice improvements
- Advance care planning
- Use of decision support and standardized treatment protocols
Cost measures in the Advancing Cancer Care MVP will include the Total Per Capita Cost (TPCC) measure. Currently, no applicable episode-based cost measures are available, but CMS notes that one could be considered for future development.
In general, MVPs have the following reporting criteria (additional details are available for subgroup reporting):
- Quality Performance Category: MVP Participants will select four quality measures. One must be an outcome measure (or a high-priority measure if an outcome isn’t available or applicable). This can include an outcome measure calculated by CMS through administrative claims, if available in the MVP.
- Improvement Activities Performance Category: MVP Participants will select two medium-weighted improvement activities OR one high-weighted improvement activity OR participation in a patient-centered medical home if it is already included in the MVP.
- Promoting Interoperability Performance Category: MVP Participants will report on the same Promoting Interoperability measures required under traditional MIPS, unless they qualify for reweighting of the Promoting Interoperability performance category.
- Cost Performance Category: MVP Participants will be scored on the cost measures included in the MVP that they select and report.
- Foundational Layer (MVP-agnostic): Population Health Measures: MVP Participants will select one population health measure to be calculated on. The results will be added to the quality score.
For the 2023 performance period, CMS anticipates two population health measures available for selection:
- Hospital-Wide, 30-day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System Program (MIPS) Eligible Clinician Groups (finalized in CY 2021 PFS Final Rule)
- Clinician and Clinician Group Risk-standardized Hospital Admission Rates for Patients with Multiple Chronic Conditions (finalized in CY 2022 PFS Final Rule)
MVPs will be available beginning with the 2023 performance year. For the 2023, 2024, and 2025 performance years, MVPs may be reported by individual clinicians, single specialty groups, multispecialty groups, subgroups, and APM Entities. Subgroup reporting will be voluntary for the 2023, 2024, and 2025 performance years; however, beginning in 2026, multispecialty groups will be required to form subgroups to report MVPs.
CMS proposes revising the definitions of single specialty and multispecialty groups to identify Medicare Part B claims as the data source for determining specialty type. Specifically, a single specialty group is a group that consists of one specialty type as determined by CMS using Medicare Part B claims, and a multi-specialty group is a group that consists of two or more specialty types as determined by CMS using Medicare Part B claims.
Bookmark ASCO in Action for further analysis of the proposed rule as well as news, advocacy, and analysis on cancer policy.