Medicare Physician Fee Schedule
Read and review summaries of the direct impacts of recent Medicare Physician Fee Schedule (MPFS) rules on obstetrician-gynecologists’ practices.
The Medicare Physician Fee Schedule (MPFS) is the annual regulatory rule released by the Centers for Medicare and Medicaid Services (CMS) that 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.
Below are summaries of the direct impacts of recent MPFS rules on obstetrician-gynecologists' practices. For questions, please visit ACOG’s Payment Advocacy and Policy Portal.
Calendar Year 2022
Read ACOG’s public comments on the CY 2022 MPFS Proposed Rule.
Medicare reimbursement is calculated using relative-value units (RVUs) for each procedure multiplied by a conversion factor, then adjusted for geographic differences. The final CY 2022 conversion factor is $33.5848, a 3.75% decrease from the CY 2021 conversion factor of $34.8931. This decrease is due to legislatively imposed limitations to Medicare funding. The lower conversion factor impacts reimbursement rates for Medicare and Medicaid beneficiaries, and may impact private payer rates if they adopt CMS policies. Below is a sample of gynecologic surgery codes with 2021 and 2022 RVUs and the national payment rate based on the conversion factor. Please note that payment is also adjusted for geographic differences, so these rates do not represent the actual rates across the country.
CPT Code Description 2021 RVUs
2021 Payment 2022 RVUs
Colpopexy, extra-peritoneal approach
Colpopexy, intra-peritoneal approach
Conization of cervix
Laparoscopy, total hysterectomy
Laparoscopy, hysterectomy, resection of malignancy
Ligation of fallopian tubes
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.
CMS is finalizing a payment rate of $40 for administration of the COVID-19 vaccine through the end of the calendar year in which the COVID-19 PHE ends, and then $30 thereafter. This is in line with the American Medical Association (AMA) RVS Update Committee (RUC) recommendations detailed to CMS in May 2021, which ACOG supported.
In CY 2022, the RUC resurveyed the complex care management (CCM) code family, including Complex Chronic Care Management (CCCM) and Principal Care Management (PCM), and added five new CPT codes (see list below) each with a base code and an add-on code for a total of 10 new codes. The RUC recommended values for these 10 codes and CMS is finalizing the implementation of the RUC recommendations for the CCM code family.
- 99X21: Chronic care management services each additional 30 minutes by a physician or other qualified health care professional, per calendar month (List separately in addition to code for primary procedure)
- 99X22: Principal care management services for a single high-risk disease first 30 minutes provided personally by a physician or other qualified health care professional, each calendar month (List separately in addition to code for primary procedure)
- 99X23: Principal care management services for a single high-risk disease each additional 30 minutes provided personally by a physician or other qualified health care professional, each calendar month (List separately in addition to code for primary procedure)
- 99X24: Principal care management services for a single high-risk disease first 30 minutes of clinical staff time directed by a physician or other qualified health care professional, each calendar month
- 99X25: Principal care management services for a single high-risk disease each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, each calendar month (List separately in addition to code for primary procedure)
CMS is finalizing their proposal to further delay the electronic prescribing for controlled substances (EPCS) compliance date from January 22, 2022 to January 1, 2023 due to the continued effects of the COVID-19 PHE. The benefits of EPCS are broad and far-reaching, but its transition is not without logistical and administrative burdens practices and physicians may not be able to tackle currently. As discussed in prior sections, the impact of the COVID-19 PHE has left practices and physicians with less financial resources and capital to invest in technology-based infrastructures, including EPCS systems and training.
In the CY 2020 final rule, CMS finalized allowing Transitional Care Management (TCM) services to be billed concurrently with 14 codes previously considered to overlap TCM. CMS is now finalizing to extend this allowance of billing TCM services furnished for the same beneficiary during the same service period, provided all requirements for billing each code are met to rural health centers (RHCs) and federally qualified health centers (FQHCs).
During the Public Health Emergency (PHE), CMS lifted and added several regulations related to telehealth on a temporary basis. Some regulations are limited by federal law; others will be extended through the PHE and a few were made permanent.
In the CY 2021 MPFS final rule, CMS created a third category of criteria for adding services to the Medicare list of telehealth services on a temporary basis following the end of the COVID-19 PHE. The use of this category was extended through December 31, 2023. This will further facilitate continuity of care for recipients and data collection to inform future proposals.
CMS is also revising the regulatory definition of “interactive telecommunications system” to permit the use of audio-only communications technology for mental health telehealth services under certain conditions when provided to beneficiaries located in their home. Mental illness is often a leading cause of pregnancy-related deaths and plays a significant role in our country’s maternal mortality crisis. ACOG believes strengthening telehealth policies such as remote patient monitoring to advance maternal health from all angles. Expanding this definition will give patients who may not possess audio-visual technology, lack digital literacy skills, or do not feel comfortable utilizing video due to the sensitive nature of mental health information more readily available access to vital mental health services. Furthermore, CMS is finalizing their proposal to allow opioid treatment programs (OTPs) to provide counseling and therapy services via audio-only communication after the COVID-19 PHE.
ACOG and many of our medical specialty counterparts have been working to reduce burdens against obtaining treatment for opioid and substance use disorder (SUD). With these proposals finalized, we believe such changes will help promote better access to opioid, SUD, and mental health treatment for all patients.
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.
The COVID-19 PHE has had substantial impacts on practices and physicians, including reporting requirements for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program (MSSP). To mitigate these impacts and help participating physicians transition to these requirements, CMS is finalizing to allow ACOs to continue reporting through the CMS Web Interface through 2023 and to not require ACOs to report on at least one eCQM/MIPS CQM for performance year 2023.
Authorized by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), the Quality Payment Program (QPP) is an incentive program that includes two participation tracks: the Merit-Based Inceptive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). As the QPP evolves, CMS is implementing a new reporting mechanism called MIPS Value Pathways (MVPs) to reward high-quality of care for patients and increase opportunity for Advanced APM participation. These MVPs allow for a more cohesive participation experience by connecting activities and measures from the four MIPS performance categories that are relevant to a specialty, medical condition, or population. However, transitioning to MVPs and digital quality measurement, like other aspects of health care, has been impacted by the COVID-19 PHE. Despite this, CMS is finalizing a transition deadline to digital quality measurement in CY 2025 and subgroup reporting for multispecialty practices. Additionally, CMS is moving forward with a 75-point performance threshold for the 2024 MIPS performance year.
For more information on the Quality Payment Program, visit this new webpage that we will create sometime for QPP for Ob/GYNs.
Calendar Year 2021
View the Medicare Physician Fee Schedule for 2021