Medicare Physician Fee Schedule for Calendar Year 2023: Beneficiary-Oriented Updates for Social Workers

By Chris Herman, MSW, LICSW Senior Practice Associate–Aging

The Medicare Physician Fee Schedule (PFS) for calendar year (CY) 2023,[i] released by the Centers for Medicare & Medicaid Services (CMS) in November 2022, addresses Medicare payment policies for physicians and other Medicare providers between January 1 and December 31. These federal regulations reflect input provided by NASW[ii] and other stakeholders (including Medicare beneficiaries, beneficiary advocates, and providers) during a two-month public comment period for a corresponding proposed rule.[iii]

Social workers are trusted sources of information for Medicare beneficiaries and play an integral role in helping clients access health care services. Consequently, an understanding of Medicare payment policies enables social workers to serve beneficiaries more effectively. This publication addresses topics in the final rule (each listed with a corresponding section number) that are most pertinent to social workers who serve Medicare beneficiaries in roles other than mental health and substance use disorder services. (A separate NASW resource[iv] summarizes the topics in the final rule that are pertinent to clinical social work services.)

Caregiver Behavior Management Training [Section II.E.4(29)]

The final rule included extensive discussion of how Caregiver Behavior Management Training could foster equitable access to reasonable and necessary medical services for Medicare beneficiaries. As explained in the final rule, Caregiver Behavior Management Training constitutes face-to-face time providing group training to caregivers or guardians of beneficiaries. “Although the patient does not attend the group trainings, the goals and outcomes of the sessions focus on intervention aimed at improving the patient’s daily life,” CMS explained in the final rule (p. 69521). The rule continued:

During the face-to-face service time, caregivers are taught how to structure the patient’s environment to support and reinforce desired patient behaviors, to reduce the negative impacts of the patient’s diagnosis on the patient’s daily life, and to develop highly structured technical skills to manage patient behavior. (p. 69521)

However, CMS explained in the final rule that it interprets Medicare law to limit “Medicare coverage and payment to items and services that are reasonable and necessary for the diagnosis or treatment of an individual Medicare beneficiary’s illness or injury or that improve the functioning of a malformed body member” (p. 69521). For that reason, CMS explained, it is not paying for such services in CY 2023. Nonetheless, CMS summarized comments it had received regarding three topics:

• how a patient (beneficiary) may benefit when a caregiver learns strategies to modify the patient’s behavior
• how current Medicare policies regarding Caregiver Behavior Management Training services may impact the health of Medicare beneficiaries
• how Caregiver Behavior Management Training services might be bundled into Medicare-covered services as incident to services or as practitioner work that is part of some care management codes

The final rule stated that “most commenters recommended that CMS pay for caregiver behavioral management training services” (p. 69521) and that many (such as NASW) had provided examples of ways in which caregiver education about strategies to modify beneficiary behavior directly affects beneficiary health, quality of life, and quality of care.

In response to these comments, CMS stated:

Based on public comments, we believe there could be circumstances, captured in the medical record, where separate payment for these services may be appropriate. We will continue to consider and contemplate which circumstances or services and for which beneficiaries it would be appropriate to furnish and receive payment for these types of services in future notice and comment rulemaking. (pp. 69522–69523)

CMS concluded that it would reassess payment for Caregiver Behavior Management Training services during the CY 2024 rulemaking process.

NASW appreciates CMS’s recognition that family caregivers[v] play an integral role in maximizing the health, well-being, and safety of Medicare beneficiaries and commends the agency on its commitment to reassess Medicare payment for Caregiver Behavior Management Training services during the CY 2024 rulemaking process. NASW will continue to advocate for the social work role in providing these services.

Medicare Parts A and B Payment for Dental Services [Section II.L]

CMS finalized its proposals to cover “medically necessary” dental treatment for Medicare beneficiaries in certain situations:

• As of January 1, 2023, Medicare Parts A and B is paying for dental services, such as dental examinations and necessary treatment, performed as part of a comprehensive work-up before organ transplant surgery, cardiac valve replacement, or valvuloplasty procedures.
• Effective CY 2024, Medicare Parts A and B will pay for dental services, such as dental examinations and necessary treatments, performed as part of a comprehensive work-up before treatment for head and neck cancers.

Likewise, CMS finalized amendments to Medicare regulation in two respects:

• to provide that dental services that are inextricably linked to, and substantially related and integral to the clinical success of, a certain covered medical service(s) are not subject to the exclusion under Section 1862(a)(12) of the Social Security Act
• to provide that payment can be made under Medicare Parts A and B, under the applicable payment system, for such dental services that occur within the inpatient hospital and outpatient setting, as clinically appropriate

Moreover, CMS established a process by which stakeholders may submit additional dental services that are inextricably linked, substantially related, and integral to the clinical success of other covered medical services.

These changes will enable many beneficiaries who cannot afford oral health care to receive the dental services necessary to prevent complications associated with medical treatments. The changes also constitute a critical first step toward a comprehensive oral health care benefit in Medicare—a benefit for which NASW is advocating as a member of the Medicare Oral Health Coalition[vi] and which was recommended by a 2017 interprofessional oral health forum[vii] in which NASW participated.

Expansion of Coverage for Colorectal Cancer Screening and Reducing Barriers [Section III.D]

CMS finalized two changes in relation to colorectal cancer screening (CRC) for Medicare beneficiaries:

• reducing the minimum age from 50 to 45 years of age for certain Medicare-covered CRC screening tests (specifically, screening fecal-occult blood tests and screening flexible sigmoidoscopy)
• expanding coverage of CRC screening tests to include a follow-on screening colonoscopy after a noninvasive stool-based test returns a positive result

Both changes took effect on January 1, 2023. These changes, CMS noted, were consistent with the May 2021 recommendation[viii] of the U.S. Preventive Services Task Force. As a result of these changes—both of which NASW had supported in its comments on the proposed rule—many beneficiaries will be able to obtain an initial noninvasive screening stool-based test and a follow-on screening colonoscopy test with no out-of-pocket cost. NASW concurs with CMS’s statement in the final rule that these changes “will expand access to quality care and improve health outcomes for patients through prevention, early detection, more effective treatment and reduced mortality,” especially for African American beneficiaries and for beneficiaries of all races and ethnicities who live in rural communities (pp. 69766–69767).

In its comments on the proposed rule, NASW had also encouraged CMS to “maintain coverage for a screening colonoscopy as the first step in CRC screening when determined appropriate by the beneficiary and their health care professional” (p. 10). CMS responded to this comment and similar concerns in the final rule: “We clarify that our provision for a complete colorectal cancer screening does not change the coverage or payment requirements for screening colonoscopy as an optional first step in the patient screening process” (p. 69766). Furthermore, the final rule affirmed that screening colonoscopies continue to not have a minimum age limitation in CY 2023 (another provision NASW supported in its comments).

Medicare Shared Savings Program [Section III.G]

Medicare beneficiaries can be assigned to (enrolled in) an Accountable Care Organization (ACO) without their knowledge. ACO assignment not only affects the extent to which a beneficiary’s claims data are shared among providers, but also can have health and economic consequences[ix] for beneficiaries.

As a result of the final rule, the following changes regarding beneficiary notification of ACO enrollment have taken effect for CY 2023:

• ACOs and ACO participants (health care practitioners and offices) are now required to post beneficiary notification signs in all facilities, regardless of whether the facility provides primary care services. In its comments on the proposed rule, NASW had supported this change, consistent with the social work profession’s commitment to provider transparency and clients’ informed decision making.
• ACOs and ACO participants are required to make standardized written notices available upon request in all settings in which beneficiaries receive primary care services. NASW had also supported this change.
• ACOs are only required to send information notices to beneficiaries about their assignment to an ACO once per agreement period (which may be as long as five years) rather than once every year. In proposing this change, CMS had provided two rationale: (1) that sending annual written notices to beneficiaries was burdensome for ACOs and (2) that beneficiaries were confused by the notices. In its comments on the proposed rule, NASW had disagreed with this proposed change, stating: 
  • Decreasing communication with beneficiaries is not an effective strategy to reduce confusion about ACO enrollment. Instead, NASW strongly urges CMS to retain the current notification requirements for ACOs while collaborating with beneficiaries, family caregivers, health care professionals, ACOs, and other stakeholders to improve the quality of communication about the health and economic implications of ACO enrollment for beneficiaries. (p. 9)

In the final rule, CMS stated that, effective CY 2023, it is requiring ACOs to issue a follow-up beneficiary communication “to promote beneficiary comprehension of the standardized written notice and occurring no later than 180 days following the date that the standardized written notice was provided to the beneficiary” (p. 69779), while leaving the method of follow-up communication to each ACO’s discretion.

Similarly, CMS is no longer requiring ACOs to submit marketing materials for review and approval before disseminating such materials to beneficiaries. Instead, ACOs are now required to submit marketing materials only upon request from CMS. NASW had disagreed with this proposal. CMS noted that it is retaining the requirement for ACOs to discontinue use of any marketing materials or activities that are disapproved.

Medical Necessity and Documentation Requirements for Nonemergency, Scheduled, Repetitive Ambulance Services [Section III.I]

This section of the final rule addressed access to nonemergency, scheduled, repetitive ambulance services for Medicare beneficiaries who are “bed confined” (as defined by CMS in the proposed rule and existing regulation) and for whom ambulance transportation is medically necessary, such as for dialysis, chemotherapy, or radiation treatments. Aiming to promote consistent application of payments for such ambulance services, CMS finalized the following proposals, all of which NASW had supported:

• retaining existing language stating that, in all cases, the provider or supplier must keep appropriate documentation on file and, upon request, present it to CMS
• maintaining the language that states that the ambulance service must meet all program coverage criteria, including vehicle and staffing requirements
• clarifying that the physician certification statement (PCS) and additional documentation from the beneficiary’s medical record may be used to support a claim that transportation by ground ambulance is medically necessary
• clarifying that the PCS and additional documentation must provide detailed explanations, consistent with the beneficiary’s current medical condition, that explain the beneficiary’s need for transport by an ambulance
• clarifying that coverage includes observation or other services rendered by qualified ambulance personnel

This information is particularly relevant to social workers, who may sign the nonphysician certification statement if the ambulance provider or supplier is unable to obtain the attending physician’s signature within 48 hours of the transport—a privilege granted to social workers in the PFS final rule for CY 2020.[x]

Medicare Provider and Supplier Enrollment [Section III.J]

This section of the final rule addressed amendments to the process for provider and supplier enrollment in Medicare. CMS stated in the final rule:

The overarching purpose of the enrollment process is to help confirm that providers and suppliers seeking to bill Medicare for services and items furnished to Medicare beneficiaries meet all applicable Federal and State requirements to do so. The process is, to an extent, a ‘‘gatekeeper’’ that prevents unqualified and potentially fraudulent individuals and entities from entering and inappropriately billing Medicare. (p. 69998)

Citing recent federal reports addressing the abuse of residents by nursing home staff and fraud or improper billing among nursing home owners or operators and multiple high-profile media reports of the same, CMS finalized its proposal to move all SNFs that are newly or initially enrolling in the Medicare program from a limited-risk designation to a high-risk designation. (The only other Medicare providers categorically designated at the high-risk screening level are newly or initially enrolling home health agencies; providers of durable medical equipment, prosthetics, orthotics, and supplies; Medicare diabetes prevention program suppliers; and OTPs.)

This change to a high-risk designation, which NASW supported in its comments on the proposed rule, institutes the following requirements for every SNF that is newly or initially enrolling in Medicare:

• CMS will conduct a site visit to every newly or initially enrolling SNF.
• All individuals with a 5 percent or greater direct or indirect ownership interest in the SNF must submit a set of fingerprints for a national background check.
• The Federal Bureau of Investigation’s (FBI’s) Integrated Automated Fingerprint Identification System will conduct a fingerprint-based criminal history record check on all individuals with a 5 percent or greater direct or indirect ownership interest in the SNF.

Similarly, CMS confirmed its proposal to categorize SNFs that are revalidating their Medicare enrollment at the moderate risk-screening level. This designation requires every revalidating SNF to undergo a site visit. Revalidating SNFs that are at the moderate-risk level do not need to submit fingerprints, nor does the FBI conduct a fingerprint-based criminal history record check. Nonetheless, the moderate-risk screening level will reduce the risk of resident abuse and financial fraud, waste, and abuse.

The preceding SNF enrollment requirements took effect on January 1, 2023.

Summary

The PFS final rule for CY 2023 includes multiple changes that will increase access to and quality of care for Medicare beneficiaries. NASW encourages social workers who serve Medicare beneficiaries to familiarize themselves with these changes and to educate beneficiaries and families (as defined by each beneficiary) accordingly.