The Future is Unsure for the COVID-19 PHE

What is the likelihood that the COVID-19 public health emergency (PHE) will be extended through the end of 2022? In this blog we weigh in on what we think the near future holds, provide an update on the proposed 2023 Medicare Physician Fee Schedule and the monkeypox codes you should know.

Will the COVID-19 PHE be renewed again?

This summer, Health and Human Services (HHS) Secretary Xavier Becerra signed a tenth extension of the COVID-19 public health emergency, effective July 15 and lasting through October. But with COVID-19 cases leveling off – at least at the present, healthcare providers are anxious to see if the PHE will be extended yet again this month and last through the end of the year.

The current extension provided additional time for providers to continue to develop policies and workflows that make sense as COVID-19 shifts from pandemic to endemic. Throughout the pandemic, flexibility and regulatory waivers eased compliance burdens, but this situation won’t last forever.

What’s next? Will the government let the PHE expire following current trends, or will the unpredictability of flu season tip the feds toward another extension? The current 90-day extension, which expires on October 13 could mark the end of the PHE. If HHS decides on an eleventh extension, it’s likely to be 90 additional days based on uniformity with previous extensions.

In addition, the Biden administration has repeatedly said it will provide 60-days’ notice before ending the PHE. And at this time, the White House hasn’t given an indication that this will happen, especially since Secretary Becerra received a letter in May from the American Hospital Association, the American Nurses Association, and other professional and health groups urgeing HHS to “maintain the … PHE until it is clear that the global pandemic has receded, and the capabilities authorized by the PHE are no longer necessary. This will help prevent any future surges from threatening the health and safety of patients and the ability of health care professionals to care for them.”

The letter cites the rise in variant cases and urges the administration “to maintain the PHE until we experience an extended period of greater stability and, guided by science and data, can safely unwind the resulting flexibilities.”

These organizations also stated concern that the variants will take a greater hold on the country if the healthcare system lets its guard down. They also acknowledged the flexibilities and waivers allowed during the PHE are vital to caring for patients and enabling the healthcare system to adapt to tackle COVID-19 and its variants.

The Biden administration seems disposed to listen to such arguments, judging from the latest extension. And it’s likely to do so again for the next extension, which will fall just before midterm elections.

Experts predict that letting the PHE expire will mean healthcare coverage cliffs and a national healthcare system with laws or regulation to smooth the transition into a post-pandemic world, a world that will be worse for patients.

Next steps:

With the PHE’s exact end date undetermined, now is the time to prepare. Monitor changes in your state’s COVID-19 policies and evaluate how much your practice depended on these policies during the pandemic. Make a plan for when more stringent rules and compliance expectations return, so you and your staff will be ready and protected from potential liability of an expired regulatory policy.

Resource: Find the extension notice at https://aspr.hhs.gov/legal/ PHE/Pages/covid19-15jul2022.aspx

2023 Proposed Rule Features Conversion Factor Cut

Don’t expect another 3% boost for next year.

With COVID-19 still causing trouble and practice costs on the rise due to inflation, many assumed the feds would keep things status quo for the 2023 policymaking cycle. But their proposals indicate otherwise. Medicare providers may want to prepare now to tighten their belts and get ready for some compliance-related changeups.

Background: On July 7, the Centers for Medicare & Medicaid Services (CMS) issued its calendar year (CY) 2023 Medicare Physician Fee Schedule (MPFS) proposed rule, continuing its pandemic-inspired focus on health equity and access to safe, affordable healthcare for all. The fee schedule stands at 2,066 pages with suggested policy changes surrounding critical issues like mental health, telehealth, and chronic care management. The proposed rule is slated for publication in the Federal Register on July 29.

“At CMS, we are constantly striving to expand access to high quality, comprehensive health care for people served by the Medicare program,” says CMS Administrator Chiquita Brooks-LaSure in a release on the proposed rule. “Today’s proposals expand access to vital medical services like behavioral health care, dental care, and cancer treatment options, all while promoting access, innovation, and cost savings in the Medicare program.”

However, despite CMS’ rosy outlook on its CY 2023 proposals, the conversion factor (CF) decrease is cause for concern, experts warn. Industry leaders are already bemoaning the suggested cuts and calling for congressional input.

Here’s a Breakdown on the Proposed 2023 CF Cut

To fully understand what’s going on with the CY 2023 conversion factor (CF) changes, you have to look at last year’s changes, which were a byproduct of COVID and congressional input.

First: As part of the CY 2022 final rule, CMS reduced the conversion factor (CF) from $34.89 to $33.59. The combination of the mandated annual budget neutrality requirements, which included a $1.30 decrease to the CF, and the expiration of the Consolidated Appropriations Act, 2021 3.75 percent increase was not welcome news for Medicare providers.

Next: Then last December, Congress pushed through, and President Biden signed, the Protecting Medicare and American Farmers from Sequester Cuts Act into law. The legislation offered Medicare providers a break with a 3 percent increase to the 2022 CF since many were reeling from COVID fallout.

Now: CMS proposes to cut the CF by $1.53 for CY 2023, reducing the rate from $34.61 to $33.08, the MPFS proposed rule suggests. “This conversion factor accounts for the statutorily required update to the conversion factor for CY 2023 of 0 percent, the expiration of the 3 percent increase in PFS payments for CY 2022 as required by the Protecting Medicare and American Farmers from Sequester Cuts Act, and the statutorily required budget neutrality adjustment to account for changes in Relative Value Units,” CMS explains in a fact sheet on the proposals.

Don’t Forget How the CF Impacts Medicare Pay

CMS utilizes a resource-based relative value scale (RBRVS) to determine how much practitioners are to be paid for the services they provide. In that capacity, the MPFS establishes different values for codes depending on the setting/site (facility or non-facility) in which the provider performs the service or procedure. For some services, the total relative value units (RVUs) for a given procedure are the same in a facility or a non-facility setting. In other situations, however, the two totals may differ.

How it works: The facility and non-facility total RVUs are the sum of three component RVUs:

• Physician work RVUs (to cover the cost of the physician or other qualified healthcare provider’s “work”)
• Practice expense RVUs (to cover the cost of supplies, equipment, etc.)
• Malpractice expense RVUs (to cover the cost of professional liability expenses)

Physician work RVUs and malpractice expense RVUs are the same, regardless of the setting (facility or non-facility.) Practice expense RVUs may vary by site of service, which accounts for the difference in facility and non-facility RVU totals for a given code.

Medicare fees also vary geographically; thus, each component RVU is multiplied by its own geographic practice cost index (GPCI) for the payment locality in which the service is rendered before the components are summed and multiplied by the dollar conversion factor that translates RVUs into fees.

See What Industry Insiders Think of the CF Cut

With the CF decrease expected to hit physicians hard in 2023, the American Medical Association (AMA) and the American College of Emergency Physicians (ACEP) are already advocating for legislators to get involved.

Resource: Peruse the proposed rule at https://public-inspection.federalregister.gov/2022-14562.pdf.

Coding Corner: New CPT® Codes for Monkeypox Texts and Vaccines

On July 26, 2022, the American Medical Association (AMA)added one new clinical lab test code and two vaccine codes for the virus for immediate use.

• 87593 Infectious agent detection by nucleic acid [DNA or RNA]; orthopoxvirus [e.g., monkeypox virus, cowpox virus, vaccinia virus.] Amplified probe technique, each

This code is for polymerase chain reaction (PCR) testing of a swab sample from a skin lesion obtained from a symptomatic patient.

The two new vaccine codes are product-specific:

• 90611 Smallpox and monkeypox vaccine, attenuated vaccinia virus, live, non-replicating, preservative free, 0.5 mL dosage, suspension, for subcutaneous injection

Use code 90611 for the JYNNEOS combined smallpox and monkeypox vaccine manufactured by Bavarian Nordic. The vaccine, also called Imvamune or Imnavex, has been FDA-approved for use in patients aged 18 and older. It requires administration of two doses 28 days apart.

• 90622 Vaccinia [smallpox] virus vaccine, live, lyophilized, 0.3 mL dosage, for percutaneous use

Use code 90622 for the ACAM2000 smallpox vaccine manufactured by Sanofi Pasteur Biologics Co. for patients 12 months and older. The FDA has approved the vaccine for use against monkeypox under expanded access Investigational New Drug (IND) application. It only requires administration of one dose.

Use one of the existing vaccine administration codes (90460, 90461, 90471 or 90472) in conjunction with the new vaccine product codes.

On August 4, 2022, the Secretary of Health and Human Services determined a national Public Health Emergency (PHE) exists as result of the outbreak of monkeypox across multiple states.

Industry Notes

UPDATE: New Cigna Policies Not Implemented

In the July 2022 edition, Experity published two new policies announced by Cigna:

• Policy M25 – Cigna had planned to require practices to submit medical records when an established E/M codes with modifier 25 is billed at the same time as a minor surgical procedure.
• Policy R38 – Cigna also planned to implement a new Unacceptable Principal Diagnosis Codes Reimbursement Policy for physician offices. Per the new policy, if an unacceptable principal diagnosis is the only diagnosis code used, the claim would deny.

Neither of these revisions are moving forward at this time.

UHC Discontinues Paper Refund Letters

Beginning September 23, 2022, overpayment notification letters from UnitedHealthcare will be sent via the UnitedHealthcare Provider Portal. Payers impacted include Medicare Advantage and commercial health plans. It does not apply to UHC Community Plan (Medicaid) health plans.

Interested in more urgent care tips, best practices, and industry updates? Check out our July and August installments.

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