2023 OBGYN Medicare Physician Fee Schedule

The release of the 2023 Medicare Physician Fee Schedule (PFS) final rule by the Centers for Medicare and Medicaid Services (CMS) brings significant updates to obgyn Medicare physician fee, reimbursement, and healthcare delivery policies. The aim of these changes is to create a more equitable and accessible healthcare system, with a focus on quality, affordability, and innovation. Although the Medicare ob gyn physician fee schedule primarily impacts services for Obgyn Medicare beneficiaries, it also serves as a benchmark for Medicaid programs and private insurers. Let’s explore the key highlights of the 2023 Medicare Fee Schedule.

In the 2023 PFS final rule, CMS introduces a series of standard technical proposals for practice expenses. These proposals include the implementation of the second year of the clinical labor pricing update. With the necessary budget neutrality adjustments and the expiration of a 3% supplemental increase to PFS payments for 2022, the conversion factor for the CY 2023 PFS is set at $33.89. This reflects a decrease of $0.72 compared to the CY 2022 conversion factor. These adjustments were made to mitigate the initial cuts set in the 2023 Medicare Fee Schedule.

The 2023 Medicare Fee Schedule brings changes in payment rates for common obstetrician-gynecologist procedures. The following table illustrates the RVUs (Relative Value Units), payment rates, and percentage changes for selected procedures:

The OBGYN Coding Manual, published annually, provides Relative Value Units (RVUs) for obstetrician-gynecologist codes, along with coding guidelines for procedures billed on the same day. Additionally, CMS offers an online fee schedule look-up tool that includes RVUs and payment rates.

CMS has finalized a year-long delay of the split (or shared) visits policy that was proposed in 2022. Under this policy, the E/M visit would be billed based on time only, and payment would be allocated to the physician or qualified health professional (QHP) who spends more than half of the total time with the patient. This policy will be implemented starting January 1, 2024.

Additionally, CMS has created three new G-codes to describe prolonged services for hospitals, nursing facilities, and home visits. This change aims to avoid confusion and duplicative billing by rendering CPT codes 99358 and 99359 invalid. OBGYN physicians should keep a close eye on E/M updates to avoid claim denials.

In CY 2023, CMS finalized several policies concerning Obgyn Medicare telehealth services. One significant policy is the extension of the inclusion of services on the Medicare Telehealth Services List, including telephone visits, for at least 151 days after the public health emergency (PHE) concludes. This extension allows for additional data collection to support potential permanent additions to the Obgyn Medicare Telehealth Services List. ACOG continues to advocate for the permanent addition of these services, including audio-only or two-way audio-video communication, to enhance access to high-quality, patient-centered care irrespective of patients’ locations.

Furthermore, CMS is also extending the availability of mental health telehealth services for 151 days after the PHE ends. Physicians and practitioners can continue billing eligible mental health telehealth services furnished via audio-only communication using the appropriate place of service (POS) indicator that would have been used for in-person services until the end of the year the PHE concludes or 2023, whichever comes later. To identify these services as telehealth, the modifier “95” is required. Starting from the 152nd day after the mentioned period, if services are provided at a facility as an originating site, you can utilize POS 02 and proceed to bill the corresponding facility Medicare physician fee, at the end of the PHE, following the pre-PHE policy.

Regarding the electronic prescribing of controlled substances (EPCS), CMS addressed the policy, exceptions, and compliance threshold in the CY 2022 PFS final rule. To qualify for an exemption from EPCS requirements, physicians will need to prescribe 100 or fewer obgyn Medicare physician Part D prescriptions in an evaluation year. CMS has made a final decision to use the current evaluated year’s Prescription Drug Event (PDE) data instead of the preceding year’s data for determining exceptions to EPCS compliance in 2023. This change recognizes that prescribing practices can vary from year to year and aims to ensure consistency in evaluating exceptions and compliance.

Furthermore, CMS has extended the timeline for sending notices to noncompliant prescribers until 2024. Implementation of penalties for noncompliant prescribers has also been delayed until 2024. In the future, CMS intends to propose alternative penalties that are more stringent and applicable to noncompliant prescribers, rather than relying solely on issuing non-compliance notices.

In the CY 2023 PFS final rule, CMS has implemented changes to address concerns and reverse recent trends in the Medicare Shared Savings Program (MSSP) for OBGYN. These trends include a plateau in the growth of beneficiaries assigned to accountable care organizations (ACOs), underrepresentation of higher spending populations due to regionally-adjusted benchmarks, and inequitable access to ACOs for certain racial and ethnic groups compared to Non-Hispanic White beneficiaries.

Based on feedback from healthcare providers, CMS recognizes the need for upfront capital and additional time under a one-sided model to succeed in accountable care arrangements, particularly for physicians caring for underserved and vulnerable populations. To support these providers, CMS has finalized policies to offer advance shared savings payments, known as advance investment payments (AIPs), to low-revenue ACOs. The number of AIPs will increase based on factors such as the number of beneficiaries who are dually eligible for Medicare and Medicaid or reside in areas with high deprivation according to the area deprivation index (ADI). These funds will be utilized to address the social needs of Medicare beneficiaries, as well as to enhance healthcare provider staffing and infrastructure. AIPs will eventually be recouped once the ACO achieves shared savings within the current or subsequent agreement periods, whenever possible.

CMS has introduced a health equity adjustment of up to 10 bonus points to an ACO’s quality performance score. This adjustment aims to incentivize high-quality performance by ACOs, facilitate the transition to all-payer electronic clinical quality measures (eCQMs) and MIPS clinical quality measures (CQMs), and support ACOs serving a significant proportion of underserved beneficiaries. The objective is to encourage all ACOs to prioritize the care of underserved populations while maintaining and improving overall quality.

CMS has recently finalized several updates for the 2023 Merit-Based Incentive Payment System (MIPS) program performance year (PY). These updates include adjustments to the positive payment and data completeness thresholds. The positive payment adjustment threshold has been increased to 75 points, while the data completeness threshold has also been set at 75 percent. CMS recognized that a significant number of clinicians in small practices, approximately 80 percent, who do not submit any data are subject to penalties of up to 9 percent. This impacts around 16,614 out of 20,810 clinicians who do not engage in MIPS reporting, posing potential challenges for small practices already struggling to meet these requirements.

Furthermore, CMS is introducing the Screening for Social Drivers of Health measure into the MIPS quality reporting program. This measure aims to evaluate whether hospitals are implementing screening protocols for patients regarding various health-related social needs (food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety). This measure aligns with the one included in the 2023 Hospital Inpatient Quality Reporting program, as finalized in the CY 2023 Inpatient Prospective Payment System final rule.

Regarding the existing measure QID#309 Cervical Cancer Screening, CMS has finalized an update to the initial patient population (IPP). The IPP will now include women aged 24 to 64 years by the end of the measurement period, with a visit during the measurement period, in order to align the “age anchor” consistently across programs. Patients receiving screening at 21 years of age will still be considered appropriate for the measure population.

CMS has made a final decision to eliminate the CMS-frequency limits for the COVID-19 vaccine. Recognizing the ongoing impact of the COVID-19 Public Health Emergency (PHE) on medical practices, physicians, and patients, it is crucial to ensure that Medicare beneficiaries have access to life-saving vaccines. Normally, frequency limits are imposed on preventive tests, immunizations, or vaccines to qualify for an exception from the referral and billing restrictions of the physician self-referral law. By removing this requirement specifically for COVID-19 vaccines, CMS ensures that there are no barriers hindering the availability of vaccines for beneficiaries. This remains significant as new variants arise within the patient population and the need for potential booster vaccinations arises for many individuals.

CMS has made final decisions to implement two proposed updates aimed at expanding Medicare coverage policies for colorectal cancer screening. The first update involves lowering the minimum age payment coverage and eligibility limitation from 50 to 40 years for specific colorectal cancer screening tests, thereby extending coverage to a younger population. As part of the second update, CMS is expanding the regulatory definition of colorectal cancer screening tests to encompass complete colorectal cancer screenings. This expanded definition now includes follow-up screenings that are conducted after a positive result is obtained from a Medicare-covered non-invasive stool-based colorectal cancer screening test. This change allows for a more comprehensive approach to colorectal cancer screening within Medicare coverage policies. For many beneficiaries, cost sharing will not be applicable for the initial stool-based test or the subsequent colonoscopy. These policy updates demonstrate CMS’s commitment to enhancing access to high-quality care and improving health outcomes by prioritizing prevention and early detection services.

Considering the critical needs of patients with opioid use disorder (OUD) receiving services in opioid treatment program (OTP) settings, CMS has finalized a proposal to revise the payment rate for the non-drug component of bundled payments for episodes of care. The rates will now be based on a crosswalk to CPT code 90834, which corresponds to a 45-minute therapy session, instead of the current crosswalk to CPT code 90832, representing a 30-minute session. This adjustment aims to more accurately reflect the typical 50-minute therapy session received by patients in the initial months of OTP treatment. The goal is to enhance payment levels for medication-assisted treatment and other OUD therapies while extending the duration of therapy sessions, which are typically necessary for effective treatment.

CMS has approved updates to the payment amount for preventative vaccine administration services under the Medicare Part B vaccine benefit. This includes vaccines such as influenza, pneumococcal, hepatitis B, and COVID-19, as well as their administration. The finalized updates ensure that the payment amount for vaccine administration services is annually adjusted based on increases in the MEI (Medicare Economic Index) and takes into account the geographic locality through the geographic adjustment factor (GAF) for the PFS (Physician Fee Schedule) locality where the vaccine was administered. Additionally, CMS has also confirmed the continuation of additional payments for at-home COVID-19 vaccinations for the calendar year 2023.