Medicare Physician Fee Schedule
Read and review summaries of the direct impacts of recent Medicare Physician Fee Schedule (MPFS) rules on obstetrician-gynecologists’ practices.
2023 Medicare Physician Fee Schedule
The calendar year (CY) 2023 Medicare Physician Fee Schedule (PFS) final rule is one of several rules that reflect a broader Administration-wide strategy to create a more equitable health care system that results in better accessibility, quality, affordability, and innovation. Released by the Centers for Medicare and Medicaid Services (CMS) annually, updates the standards for physician reimbursement and policies related to the delivery of health care. While the fee schedule and regulations are for services for Medicare beneficiaries, Medicaid programs and private insurers utilize them as standards for their own payment rates and coverage policies.
Calendar Year 2023
CMS is finalizing a series of standard technical proposals involving practice expenses, including the implementation of the second year of the clinical labor pricing update. With the budget neutrality adjustments, which are required by law to ensure payment rates for individual services don’t result in changes to estimated Medicare spending, and the expiration of 3% supplemental increase to PFS payments for CY 2022, the final CY 2023 PFS conversion factor is $33.89, a decrease of $0.72 to the CY 2022 PFS conversion factor of $34.61. This reflects action taken by Congress in December 2022 to mitigate the cuts initially set in the 2023 Medicare Physician Fee Schedule.
Below is a breakdown of change in payment for common obstetrician-gynecologist procedures. This payment rate only reflects changes in the conversion factor and does not include any additional payment cuts instituted by legislative action such as Medicare sequestration.
CPT Code Description 2022 RVUs 2022 Payment 2023 RVUs
2023 Payment* % Change
Colpopexy, extra-peritoneal approach
Colpopexy, intra-peritoneal approach
Conization of cervix
Laparoscopy, total hysterectomy
Laparoscopy, hysterectomy, resection of malignancy
Ligation of fallopian tubes
*Please note that these values do not reflect any changes to the payment rate due to legislative action.
The annual ACOG Coding Manual includes RVUs for all codes used by obstetrician-gynecologists, as well as coding rules related to procedures billed on the same day. CMS also publishes RVUs and payment rates in its online fee schedule look-up tool.
For CY 2023, CMS has finalized a year-long delay of the split (or shared) visits policy that was proposed in 2022. This policy requires the E/M visit to be billed based on time only and allocates payment by the physician or qualified health professional (QHP) who spends more than half of the total time with the patient. For 2023, clinicians who furnish split (or shared) visits will continue to have a choice of history, or physical exam, or medical decision making, or more than half of the total practitioner time spent to define the “substantive portion” instead of using total time to determine the substantive portion. The new split (or shared) visits policy will be implemented on January 1, 2024.
Additionally, CMS finalized the creation of three new G-codes to describe prolonged services for hospitals, nursing facilities, and home visits. By doing this, it would also make CPT codes 99358 and 99359 invalid to avoid confusion and duplicative billing.
For CY 2023, CMS is finalizing several policies related to Medicare telehealth services, including extending the duration of time that services are temporarily included on the Medicare Telehealth Services List during the public health emergency (PHE) for at least a period of 151 days following the end of the PHE, including telephone visits. Doing this will allow additional time for data collection that may support their inclusion as permanent additions to the Medicare Telehealth Services List in the future. ACOG continues to advocate for permanent addition of these services, either via audio-only or two-way audio-video communication, to the Medicare Telehealth Services List even after the end of the PHE to improve access to high-quality, patient-centered care regardless of where patients live and access their specialists.
Similarly, CMS is extending the availability of mental health telehealth services through 151 days after the end of the PHE. CMS also finalized a proposal to allow physicians and practitioners to continue to bill eligible mental health telehealth services furnished via audio-only communication with the place of service (POS) indicator that would have been reported had the service been furnished in-person through the end of the year the PHE ends or 2023, whichever comes later. These claims will require the modifier “95” to identify them as services furnished as telehealth services. For those services furnished in a facility as an originating site, POS 02, may be used, and the corresponding facility fee can be billed, per pre-PHE policy, beginning the 152nd day after the end of the PHE.
In the CY 2022 PFS final rule, CMS discussed the electronic prescribing for controlled substances (EPCS) policy, exceptions, and a compliance threshold. In order to be exempted from EPCS requirements, physicians will need to prescribe 100 Medicare Part D prescriptions or less in a given evaluation year. For 2023 exceptions determinations, CMS has finalized changing the year from which Prescription Drug Event (PDE) data is used from the preceding year to the current evaluated year. For example, 2023 PDE data would be used to determine exceptions for CY 2023 EPCS compliance. This was done because it is recognized that prescriber practices may change from year to year, and it is believed to be inconsistent to evaluate exceptions and compliance based on PDE data from the preceding year as opposed to the year under evaluation.
Additionally, CMS finalized extending the sending of notices to noncompliant prescribers to 2024.
CMS is also delaying implementation of penalties for noncompliant prescribers to 2024. In the future, CMS is planning to propose alternative, more burdensome penalties that would apply to non-compliant prescribers rather than issuance of noncompliance notices.
In the CY 2023 PFS final rule, CMS finalized changes to reverse recent trends in the Medicare Shared Savings Program (MSSP): in recent years growth in the number of beneficiaries assigned to accountable care organizations (ACOs) has plateaued; higher spending populations are even more underrepresented in the program since the change to regionally-adjusted benchmarks; and access to ACOs appears inequitable as shown by data indicating that Black, Hispanic, Asian/Pacific Islander, and American Indian/Alaska Native beneficiaries are far less likely to be assigned to an MSSP ACO than their Non-Hispanic White counterparts. Based on feedback from health care providers, upfront capital is required to make investments to succeed in accountable care arrangements and may also need additional time under a one-sided model before transitioning to performance-based risk. This is especially important for physicians caring for underserved and vulnerable populations. CMS finalized policies to provide advance shared savings payments to low revenue ACOs. As finalized, these advance investment payments (AIPs) would increase when more beneficiaries who are dually eligible for Medicare and Medicaid or who live in areas with high deprivation (measured by the area deprivation index (ADI)), or both, are assigned to the ACO. These funds would be available to address the social needs of people with Medicare, as well as health care provider staffing and infrastructure. These AIPs would eventually be recouped once the ACO begins to achieve shared savings in the current agreement period or in their next agreement period, when possible.
Additionally, CMS finalized a health equity adjustment of up to 10 bonus points towards an ACO’s quality performance score to continue encouraging high ACO quality performance, transition ACOs to all-payer eCQMs/MIPS CQMs, and support those ACOs serving a high proportion of underserved beneficiaries while also encouraging all ACOs to treat underserved populations.
CMS finalized several new updates for the 2023 Merit-Based Incentive Payment System (MIPS) program performance year (PY). Firstly, CMS finalized increasing the positive payment adjustment threshold to 75 points and the data completeness threshold to 75 percent. CMS noted that 80 percent of those who do not submit any data and are subject to a penalty of up to 9 percent are clinicians in small practices. In total, approximately 16,614 out of 20,810 clinicians who do not engage in MIPS reporting are small practices. These updated performance category scoring thresholds will potentially lead to negative impacts on small practices already struggling to meet these requirements. CMS is also adding the Screening for Social Drivers of Health measure to the MIPS quality reporting program. This measure seeks to assess whether a hospital implements screening for patients on various health-related social needs (HRSNs) (food insecurity, housing instability, transportation needs, utility difficulties, and interpersonal safety). It is also the same measure included in the 2023 Hospital Inpatient Quality Reporting program as finalized in the CY 2023 Inpatient Prospective Payment System final rule.
For the currently included measure QID#309 Cervical Cancer Screening, CMS is finalizing an update to the initial patient population (IPP) to include women 24 to 64 years of age by the end of the measurement period with a visit during the measurement period in order to change the “age anchor” to the be more consistent with implementation across programs. Patients receiving screening at 21 years of age will still be appropriate for the measure population.
CMS is finalizing their proposal to not require CMS-frequency limits for the COVID-19 vaccine. Given to continuing impact of the COVID-19 PHE on practices, physicians, and patients, ensuring that life-saving vaccines are available to Medicare beneficiaries is critical. Frequency limits typically are required for a preventive test, immunization or vaccine to be an exception from physician self-referral law’s referral and billing prohibitions. By removing this requirement for COVID-19 vaccines, CMS in ensuring that there is no impediment on vaccine availability for beneficiaries. This remains important as variants emerge in the patient population and potential booster vaccinations are required for many patients.
CMS is finalizing two proposed updates to expand Medicare coverage policies for colorectal cancer screening. In the first update, CMS is expanding Medicare coverage for specific colorectal cancer screening tests by lowering the minimum age payment and coverage limitation from age 50 to age 40. In the second update, CMS is expanding the regulatory definition of colorectal cancer screening tests to include a complete colorectal cancer screening, where a follow-on screening after a Medicare covered non-invasive stool-based colorectal cancer screening test returns a positive result. For many beneficiaries, cost sharing will not apply for initial stool-based test or the follow-on colonoscopy. These policy updates push forth efforts to expand access to quality care and improve health outcomes for patients through prevention and early detection services.
Based on the seriousness of needs for patients diagnosed with opioid used disorder (OUD) and receiving services in the opioid treatment program (OTP) settings, CMS is finalizing a proposal to alter the payment rate for the non-drug aspect of the bundled payments for episodes of care in order to base the rates from the current crosswalk to CPT code 90832, which describes a 30-minute session, to a crosswalk to CPT code 90834, which describes a 45-minute session. Overall, this is intended to more accurately reflect a 50-minute therapy session as received by patients in the first few months of treatment at an OTP. This will push for efforts to increase overall payments for medication-assisted treatment and other treatments for OUD, increasing the length of therapy sessions that are normally required.
CMS has finalized updates to the payment amount for preventative vaccine administration under the Medicare Part B vaccine benefit, which includes the influenza, pneumococcal, hepatitis B, and COVID-19 vaccine as well as their administration. CMS has finalized the proposal to ensure annual updates to the payment amount for vaccine administration services based on the increases in the MEI and to take into consideration geographic locality based upon the geographic adjustment factor (GAF) for the PFS locality in which the vaccine was administered. In addition to these updates, CMS has also finalized the proposal for the continuation of additional payments for at-home COVID-19 vaccinations for CY 2023.