The Medicare Part B Physician Fee Schedule is used for payment of certain services furnished by physicians and other clinicians that are not covered under Part A benefits. Under Medicare
SNF consolidated billing provisions, claims for all Medicare Part B physical and occupational therapy (PT, OT), and speech-language pathology (SLP) services to residents of the facility must be billed by the SNF.
Recently, the Centers for Medicare & Medicaid Services (CMS) announced an updated CY 2023 physician conversion factor (CF) of $33.8872. This change reflects a 2.5 percent positive adjustment from the initial CY 2023 physician CF of $33.0607 announced in the CY 2023 Medicare Physician Fee Schedule (PFS)
Final Rule. That initial physician CF represented a 4.47 percent cut from the CY 2022 CF of $34.6062, whereas the updated physician CF is a 2.08 percent cut. This rate update reflects provisions in the Consolidated Appropriations Act (CAA) of 2023, signed into law on December 29, 2022. The CAA also removed other Medicare Pay-As-You-Go Act of 2010 (PAYGO) cuts that could have resulted in an additional four percent across-the-board reduction in reimbursements in 2023.
Tony Marshall, former President and CEO of the Georgia Health Care Association and Georgia Center for Assisted Living, developed the AHCA CY 2023 Medicare Part B Physician Fee Schedule Rate Tables for AHCA/NCAL members and is
available here.
AHCA/NCAL Rate Tables Details
The 2023 therapy fees for each CPT/HCPCS Code in each geographic area are provided in the rate file and contains the following information:
- The 2023 Medicare Part B Fee Schedule for Outpatient Rehabilitation for each Carrier and Locality (Part B Fees)
- The 2023 Medicare Part B MPPR Fee Schedule for "Always Therapy Services (50% MPPR Factor) for each Carrier and Locality (MPPR Fees)
- The 2023 Relative Value Units for each Outpatient Rehabilitation Therapy Code (RVUs)
- The 2023 Geographic Practice Cost Indices by Medicare Carrier and Locality (GPCI)
- The Counties Included in 2023 Localities (GPCI Counties)
The Part B Fee Schedule amounts are calculated as follows:
((A1 x B1) + (A2 x B2) + (A3 x B3)) x Conversion Factor (Part B Fees), and
((A1 x B1) + ((A2 x B2) x (1-MPPR Factor) + (A3 x B3)) x Conversion Factor (MPPR Part B Fees), where:
A1 = Physician Work RVU
A2 = Non-Facility Practice Expense RVU
A3 = Malpractice RVU
B1 = Work GPCI
B2 = Practice Expense GPCI
B3 = Malpractice GPCI
Conversion Factor = $33.8872
MPPR Factor = 50%
Please note that the fees effective January 1, 2023, are calculated based upon the CY 2023 Payment Policies Under the Physician Fee Schedule (PFS) and Other Changes to Part B Payment Policies Final Rule (
CMS-1770-F) (
Transmittal 11708/Change Request 12982) (
MLN Matters article MM12982) published in the
Federal Register on November 18, 2022. This major final rule revises payment polices under the Medicare PFS and makes other policy changes, including the implementation of certain provisions of the Bipartisan Budget Act of 2018 (
BBA of 2018) (Pub. L. 115–123, February 9, 2018). Further, the Consolidated Appropriations Act, 2021 (
CAA 2021) (Pub. L. 116-260, December 27, 2020) modified the FY 2022 MPFS reinstating the Work GPCI floor through CY 2023. Additionally, as required by the ACA, the 1.5 work GPCI floor for Alaska and the 1.0 practice expense GPCI floor for frontier states are permanent, and therefore, applicable in CY 2022.
Per the PFS final rule, the CY 2023 PFS conversion factor was $33.0607 after applying the -1.60 percent Budget Neutrality adjustment under section 1848(c)(2)(B)(ii)(II) of the Act, the 0.00 percent update adjustment factor specified under section 1848(d)(19) of the Act, and the expiration of the 3.00 percent increase for services furnished in CY 2022, as provided in the CAA 2021. However, the final CY 2023 conversion factor is $33.8872 following application of the payment increases (reduction of cuts to 2.5 percent) provided by the Consolidated Appropriations Act, 2023 (
Pub. L. 117-328) signed into law on December 29, 2022.
The final rule continues the multiple procedure payment reduction (MPPR) policy for “always therapy” services. The MPPR policy required, effective April 1, 2013, a 50 percent reduction to be applied to the practice expense component of payment for the second and subsequent “always therapy” service(s) that are furnished to a single patient by a single provider on one date of service (including services furnished in different sessions or in different therapy disciplines). The MPPR worksheet lists those “always therapy” services subject to the MPPR policy and the reduced fee payment amounts.
Transmittal 11118/Change Request 12446 and MLN Matters article
MM12446 updates the therapy code list and associated policies for CY 2022 (no changes published for CY 2023). Codes for Remote Therapeutic Monitoring/Treatment Management (RTM CPT codes 98975, 98976, 98977, 98980, and 98981) services were designated as “sometimes therapy” to permit physicians and certain Nonphysician Practitioners (NPPs), including nurse practitioners, physician assistants, and clinical nurse specialists to furnish these services outside a therapy plan of care when appropriate. When furnished by therapists, these "sometimes therapy" services are “always therapy,” which means they must be accompanied by the appropriate therapy modifier (GP, GO or GN) to reflect that it is under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively.
The HCPCS CPT codes and short descriptors:
98975 Rem ther mntr 1st setup&edu
98976 Rem ther mntr dev sply resp
98977 Rem ther mntr dv sply mscskl
98980 Rem ther mntr 1st 20 min
98981 Rem ther mntr ea addl 20 min
The CTB CPT codes for telephone assessment services (98966, 98967, and 98968) added via CR 11791 as “sometimes therapy” codes remain effective for the duration of the PHE for COVID-19.
Further, please see the
2023 Part A MAC Update to download the 2023 Annual SNF Consolidated Billing HCPCS Updates that include the Major Category V Part B Therapy Inclusions.
Effective for January 1, 2018, Section 50202 of the BBA of 2018 repealed the application of the therapy caps and the therapy caps exceptions process while also retaining and adding limitations to ensure appropriate therapy. A separate provision of Section 50202 of the BBA of 2018 preserves the former therapy cap amounts as thresholds above which claims must include the KX modifier to confirm that services are medically necessary as justified by appropriate documentation in the medical record. Claims for therapy services above these amounts without the KX modifier are denied. These amounts are now known as the KX modifier thresholds and are a permanent provision of the statute, meaning that the statute does not specify an end date. Just as with the incurred expenses for the therapy cap amounts, there is one KX modifier threshold amount for physical therapy (PT) and speech-language pathology (SLP) services combined and a separate amount for occupational therapy (OT) services. The per beneficiary amounts are updated each year based on the Medicare Economic Index (MEI). For CY 2023, the KX modifier threshold amounts are: (a) $2,230 for PT and SLP services combined, and (b) $2,230 for OT services. The targeted medical review process, now-termed Medical Review threshold, amount remains at $3,000 for PT and SLP services combined and $3,000 for OT services until CY 2028. Please see the
MPFS Final Rule (page 69649 of the Federal Register) and
Transmittal 11626/Change Request 12923 for information on the KX modifier thresholds.
Resource links may be found below. Please contact
Dan Ciolek with any questions.
Resources: