News July 07, 2022

Anesthesiologists Face Additional Payment Cuts as CMS releases its 2023 Physician Fee Schedule and Quality Payment Program Proposed Rule

On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) has released its CY 2023 Medicare Physician Fee Schedule (PFS) proposed rule which includes proposals related to Medicare physician payment and the Quality Payment Program (QPP). Within the fee schedule, CMS proposed Medicare payment cuts to the Anesthesia Conversion Factor and the bundling of certain procedure codes that will only compound the financial strain that anesthesia groups are already facing. The proposed rule has a 60-day comment period and is expected to be published in the federal register on July 11, 2022. Final regulations will be issued on or around November 1 and unless otherwise noted, policies will be effective January 1, 2023.

ASA opposes these additional Medicare payment cuts included in the CY 2023 PFS proposed rule. The proposed rule underscores how the Medicare payment system is broken, especially during a time when anesthesia groups are faced with inflation pressures and the COVID-19 pandemic. ASA has urged and will continue to advocate to legislative stakeholders and regulatory agencies to minimize and reverse these cuts that negatively impact anesthesiologists.

Fee Schedule Provisions:

The 2023 proposed anesthesia conversion factor (CF) is 20.7191, representing a decrease of 3.91% from the 2022 anesthesia CF of $21.5623. The 2023 proposed RBRVS CF is 33.0775. This represents a decrease of 4.42% from the 2022 CF of 34.6062. The CFs are proposed to decrease because of two factors:

There is a 0% update scheduled for the PFS in CY 2023. The Medicare Access and CHIP Reauthorization Act of 2015 established a 0% update for PFS services through 2025. Beginning in 2026, clinicians identified as qualified participants in an Advanced Alternative Payment Model will receive an annual 0.75% update, and all other clinicians will receive a 0.25% annual update.
This negative adjustment also results from a statutorily mandated budget neutrality adjustment to account for changes in work RVUs. This means spending in one year needs to be balanced by reductions and CMS cannot increase or decrease expenditures by more than $20 million without triggering automatic budget neutrality adjustments. A funding patch passed by Congress at the end of CY 2021 expires at the end of CY 2022. This patch delayed a 3% cut to physician payment which was driven largely by updates to evaluation and management (E/M) services that were implemented in 2021.

	2022 CF	Proposed 2023 CF	Percent Change
Anesthesia	$21.5623	$20.7191	-3.91%
RBRVS	$34.6062	$33.0775	-4.42%

Specialty Impact on Anesthesia and Pain Medicine

Actual payment rates are impacted by a range of proposed policy changes related to physician work, practice expense, and malpractice RVUs. CMS summarized these changes in Table 138 in the proposed rule. Impact by practice will vary based on service mix. Specialty impacts ranged from -4% for Interventional Radiology, to +5% for Infectious Disease. The table indicates that the impact of policies in the proposed rule will have a -1% impact on anesthesiology and on interventional pain management.

Specialty	Allowed Charges (mil)	Impact of work RVU Changes	Impact of PE RVU Changes	Impact of Malpractice	Combined Impact
Anesthesiology	$1,741	-1%	0%	0%	-1%
Nurse Anesthetist/ Anesthesiologist Assistant	$1,116	-1%	0%	0%	-1%
Interventional Pain Management	$924	-1%	-1%	0%	-1%

*Note: Combined Impact may not equal the sum of work, PE and malpractice due to rounding.
Source: Table 138, CY 2023 Proposed PFS, display copy

Pain Medicine Code Updates

Pain medicine physicians are likely to see a decrease in certain payments based upon an emerging trend to bundle payments for procedures with imaging. CPT codes 64415, 64416, 64417, 64445, 64446, 64447 and 64448 describe only injection of an anesthetic agent in the area of the peripheral nerve and/or catheter placement for postoperative pain management. In recent years these codes are frequently reported (over 75% of the time) with imaging (76942 ultrasound imaging). Due to the frequent reporting of imaging, these codes were identified by the CPT Editorial Panel and the RVS Update Committee (RUC) to be revised and imaging was bundled into the procedure codes. These codes will be effective January 1, 2023, and CMS has proposed new values for these services.

ASA is reviewing these proposals and will advocate on behalf of members to CMS that pain medicine services are appropriately and fairly-valued.

The table below reflects CMS’s proposed reduced work RVUs for the new bundled codes as compared to when the procedure and imaging are billed separately.

Code	Descriptor *	2022 wRVU (Procedure code + 76942)	2023 Proposed wRVU (Bundled Code)
64415	Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, including imaging guidance, when performed	2.02	1.35
64416	Injection(s), anesthetic agent(s) and/or steroid; brachial plexus, continuous infusion by catheter (including catheter placement) including imaging guidance, when performed	2.15	1.65
64417	Injection(s), anesthetic agent(s) and/or steroid; axillary nerve, including imaging guidance, when performed	1.94	1.31
64445	Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, including imaging guidance, when performed	1.67	1.28
64446	64446 Injection(s), anesthetic agent(s) and/or steroid; sciatic nerve, continuous infusion by catheter (including catheter placement) including imaging guidance, when performed	2.03	1.64
64447	Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, including imaging guidance, when performed	1.77	1.34
64448	Injection(s), anesthetic agent(s) and/or steroid; femoral nerve, continuous infusion by catheter (including catheter placement) including imaging guidance, when performed	2.08	1.68

*Updated code description for 2023 to include imaging

CMS Proposed Chronic Pain Management (CPM) Codes

In a follow-up to a request for information (RFI) in the CY 2022 PFS proposed rule, CMS is proposing the creation of two codes for chronic pain management. In acknowledgement of the importance to improve the care experience for individuals with acute and chronic pain, expand access to evidence-based treatments for acute and chronic pain and to address equity issues in this area, the agency has proposed for CY 2023 to create two HCPCS G-codes to describe monthly CPM services. These codes are designed similar to chronic care management codes.

Code	Descriptor *	2023 Proposed wRVU
GYYY1	Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care (e.g. physical therapy and occupational therapy, and communitybased care), as appropriate. Required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. (When using GYYY1, 30 minutes must be met or exceeded.)	1.45
GYYY2	Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month (List separately in addition to code for GYYY1). (When using GYYY2, 15 minutes must be met or exceeded.)	0.50

Anesthesiologists continue to face financial pressures beyond these reductions. Medicare payments, including physician services, are also subject to across-the-board cuts due to federal budget rules. Last year Congress passed legislation that defers until 2023 cuts of 4% that were otherwise scheduled to be implemented in 2022. Mandated by the “Pay-As-You-Go Act of 2010,” these cuts were meant to offset increases in the federal deficit. A 2% across the board cut to all Medicare payments known as “Medicare Sequestration” which were waived throughout most of the pandemic public health emergency have begun to be phased back in first at 1% on April 1 and then fully implemented to 2% on July 1. Absent Congressional action, the 2% reduction will continue in 2023. Congressional action is needed to reduce or fully waive all of these cuts.

ASA is committed to advocating for changes to the broken Medicare payment system and ensure that anesthesiologists and pain medicine physicians are paid fairly. ASA has supported an inflation adjustment to Medicare payments to allow for the compensation of our physicians and other clinicians to match rising cost of living across the country. ASA has also supported Congress and policymakers re-evaluating the budget neutrality clauses of the PFS that greatly restrict payment and cause continued decreases in CFs. ASA looks forward to advocating our position before Congress and in working with CMS and other government stakeholders on proposed solutions

Please contact [email protected] with any questions related to the Medicare Physician Fee Schedule.

Quality Payment Program Provisions:

CMS also released its 2023 Quality Payment Program (QPP) Proposed Rule. The proposed rule provides details on how CMS intends for eligible clinicians and groups to participate in the Merit-based Incentive Payment System (MIPS), Alternative Payment Models and other features of the QPP during the 2023 performance year.

Since the start of the COVID-19 pandemic, CMS has provided near blanket hardship exemptions to groups required to participate in the Merit-based Incentive Payment System (MIPS). Although blanket exemptions may provide widespread burden relief, they nonetheless discourage quality improvement at the local and national level. The continued use of hardship exemptions has resulted in far fewer positive payment adjustments, even for high-performing groups. Such actions have reduced the available payouts for groups exceeding the performance threshold. In recent years, groups performing well in MIPS have never seen a payment increase of more than 1.88%.

For the 2023 reporting year:

CMS is proposing to maintain the performance threshold at 75 points. Scoring above 75 points would allow an individual or group a payment bonus while scoring below 75 points would result in a payment penalty in 2025. The exceptional performance bonus is not available for the 2025 payment year.
By law, the quality performance category will be weighted at 30% and the cost performance category will be weighted by 30%. Promoting interoperability and Improvement Activities performance categories will maintain their respective 25% and 15% weights.
CMS proposes to increase the data completeness threshold to 75% for 2024 and 2025 performance periods. The threshold in the MIPS Quality Performance Category remains at 70% for 2023 performance year.
CMS has proposed to remove MIPS 76 (Prevention of Central Venous Catheter (CVC) – Related Bloodstream Infections) from MIPS and the Anesthesiology Measure Set. CMS has proposed the inclusion of a new measure, Screening for Social Drivers of Health in the measure set. No other change were made to the Anesthesiology Specialty Measure set.

Anesthesiologists will have the opportunity to report the Anesthesiology MIPS Value Pathway in 2023. MIPS Value Pathways, CMS believes, will alleviate some of the reporting burdens that anesthesiologists and other physicians encounter in the MIPS program.

For more information on the Quality Payment Program, please contact the ASA Department of Quality and Regulatory Affairs (QRA) at [email protected].

ASA leaders and staff will review the rule and submit comments by the deadline. Unless otherwise notes, finalized provisions will become effective January 1, 2023.

For more Information:

Proposed rule

Medicare PFS Proposed Rule fact sheet

QPP fact sheet