CMS proposed physician payment rule 2023

[Multimodal]

Any guesses on how this would be implemented if it goes through?

CMS Proposes Physician Payment Rule to Expand Access to High-Quality Care | CMS

The Centers for Medicare & Medicaid Services (CMS) today issued the Calendar Year 2023 Physician Fee Schedule (PFS) proposed rule, which would significantly expand access to behavioral health services, Accountable Care Organizations (ACOs), cancer screening, and dental care — particularly in...

www.cms.gov

“CMS is also proposing to bundle certain chronic pain management and treatment services into new monthly payments, improving patient access to team-based comprehensive chronic pain treatment. Lastly, CMS is proposing to cover opioid treatment and recovery services from mobile units, such as vans, to increase access for people who are homeless or live in rural areas.”

So this seems like a huge cut on top of the other cuts that CMS is proposing. I think we're getting closer to a point where we have to start limiting medicare patients if this goes through. looks like a 50% cut vs a standard 99214. has anyone else seen this ? goes from an RVU around 3.8 to 1.45. not feeling great about our future

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[Pain Applicant1]

So this seems like a huge cut on top of the other cuts that CMS is proposing. I think we're getting closer to a point where we have to start limiting medicare patients if this goes through. looks like a 50% cut vs a standard 99214. has anyone else seen this ? goes from an RVU around 3.8 to 1.45. not feeling great about our future

Limiting Medicare? I bet the commercials will follow the Medicare lead. Unless you're part of a big institution, I don't think you have much power to negotiate the rates. I could be very wrong in this assumption as I know someone (pinchandburn) who was able to negotiate great rates.

 

[drusso]

So this seems like a huge cut on top of the other cuts that CMS is proposing. I think we're getting closer to a point where we have to start limiting medicare patients if this goes through. looks like a 50% cut vs a standard 99214. has anyone else seen this ? goes from an RVU around 3.8 to 1.45. not feeling great about our future

Limiting Medicare will be a necessity absent any juice on the SOS.

 

[callmeanesthesia]

So this seems like a huge cut on top of the other cuts that CMS is proposing. I think we're getting closer to a point where we have to start limiting medicare patients if this goes through. looks like a 50% cut vs a standard 99214. has anyone else seen this ? goes from an RVU around 3.8 to 1.45. not feeling great about our future

I thought the G code was an add-on to the office visit?

 

[drrosenrosen]

I still don't understand how they plan to enforce this. How will they know if you're doing "chronic pain management" or not? Do these codes only apply to pain specialists? Using G89.4 code? What if see a patient for "chronic pain" follow up, but then recognize that they're having an MI and send them directly to the ER? (that happened to me 6 months ago) How do I bill for that encounter?

 

[drusso]

I still don't understand how they plan to enforce this. How will they know if you're doing "chronic pain management" or not? Do these codes only apply to pain specialists? Using G89.4 code? What if see a patient for "chronic pain" follow up, but then recognize that they're having an MI and send them directly to the ER? (that happened to me 6 months ago) How do I bill for that encounter?

Separate code for a separate diagnosis.

 

[Multimodal]

correct me if I'm wrong, but it looks like they are trying to replace our E/M codes. any chance this is an addon code to an E/M visit ? otherwise, I have no idea how these new rates will incentivize more providers to take part in seeing CMS patients as they state as part of the reason for this change.

Per the ASA, these new codes are modeled after chronic care management codes (CCM).

Anesthesiologists Face Additional Payment Cuts as CMS releases its 2023 Physician Fee Schedule and Quality Payment Program Proposed Rule

www.asahq.org

I have never used any other CCM codes as an outpatient like these

Chronic Care Management

Learn how to get paid for the new Medicare chronic care management fee.

www.aafp.org

 

[IAmTheOne1]

Yeah if that code is to replace the E/M codes - we literally wouldn't have a choice but to drop Medicare entirely. That's a >50% cut, would literally lose money on every patient encounter.

 

[callmeanesthesia]

correct me if I'm wrong, but it looks like they are trying to replace our E/M codes. any chance this is an addon code to an E/M visit ? otherwise, I have no idea how these new rates will incentivize more providers to take part in seeing CMS patients as they state as part of the reason for this change.

Per the ASA, these new codes are modeled after chronic care management codes (CCM).

Anesthesiologists Face Additional Payment Cuts as CMS releases its 2023 Physician Fee Schedule and Quality Payment Program Proposed Rule

www.asahq.org

I have never used any other CCM codes as an outpatient like these

Chronic Care Management

Learn how to get paid for the new Medicare chronic care management fee.

www.aafp.org

It’s hard to tell from the descriptors but sure sounds like that would be inclusive of evaluation and management. I’m hoping though it will be something like the longitudinal care G code they were going to implement last year, where it’s an add-on:

The new Medicare G code: Everything you need to know to take advantage of it

On Dec. 21, Congress delayed implementation of the primary care add-on code, G2211, for three years as part of the 2020 Year End Funding Bill and COVID-19 Emergency Funding, and it applied the savings to increase Medicare base payments for all services and specialties by an additional 3.75%.

www.aafp.org

Still, I don’t foresee many of my patients where this would apply since I’m not seeing them for a half hour or more in a month. Even those of you with large med management panels probably aren’t really spending 30 minutes of doctor/midlevel time per month on them.

 

[IAmTheOne1]

If you code by time, it's still a huge loss vs a 99214 appt (RVU is drastically less). If you code by level of complexity where a level 4 is attainable with just 2 chronic problems and an Rx (doesn't have to be opiate) - then this is a MASSIVE loss.

 

[Drd105]

If you code by time, it's still a huge loss vs a 99214 appt (RVU is drastically less). If you code by level of complexity where a level 4 is attainable with just 2 chronic problems and an Rx (doesn't have to be opiate) - then this is a MASSIVE loss.

Can anyone make me feel better about this - I mean like, say it isn’t so? Or something.
Is it all a big misunderstanding ? 🤢

 

[oreosandsake]

As I mentioned in the other thread, these cuts every year are becoming unsustainable.

How is it remotely fair to cut our pay by 4% every year when our costs are increasing by double that amount or more every year?

And unfortunately patients on federal insurance, Medicare , tricare, and Medicaid don’t understand how poorly their plans pay.

My most annoying patients are rich patients on Medicare who behave as if they are paying cash for everything instead of the government paying us basically Medicaid rates.

I plan to soon limit my federal government patients of all types to just a few per day.

Time spent on federal patients is becoming charity care for all of them, not just Medicaid patients

I see rich patients on Medicaid. One guy flaunts his trips and spac deals while driving the nicest car in the parking lot..

 

[bedrock]

I see rich patients on Medicaid. One guy flaunts his trips and spac deals while driving the nicest car in the parking lot..

Lol. That is particularly common in California, NYC, Chicago.
In the Rockies and Midwest they have a bit more appropriate shame for the fact that they live off others taxes.

Still burns me up. I’d rather just see a few patients for free every month so they understand that what I’m doing for them is CHARITY, and they should be 1-grateful for their care, and 2- follow my directions as I’m trying to help them.

Seeing tons of Medicaid is one big reason I could never work for a hospital.

 

[callmeanesthesia]

Lol. That is particularly common in California, NYC, Chicago.
In the Rockies and Midwest they have a bit more appropriate shame for the fact that they live off others taxes.

Still burns me up. I’d rather just see a few patients for free every month so they understand that what I’m doing for them is CHARITY, and they should be 1-grateful for their care, and 2- follow my directions as I’m trying to help them.

Seeing tons of Medicaid is one big reason I could never work for a hospital.

Where are you getting your info? I’m in CA, see a lot of Medicaid (in PP) through a good deal with the local carrier. Most of my patients are hardworking people with at least one job, but no benefits.

 

[SSdoc33]

Where are you getting your info? I’m in CA, see a lot of Medicaid (in PP) through a good deal with the local carrier. Most of my patients are hardworking people with at least one job, but no benefits.

I dont know about 'hardworking'. But yes, working with no medical benefits. Pretty common. Those who dont take medicaid cant really comment. Its different than it was 10 years ago. ? ACA and medicaid expansion?

 

[oreosandsake]

Lol. That is particularly common in California, NYC, Chicago.
In the Rockies and Midwest they have a bit more appropriate shame for the fact that they live off others taxes.

Still burns me up. I’d rather just see a few patients for free every month so they understand that what I’m doing for them is CHARITY, and they should be 1-grateful for their care, and 2- follow my directions as I’m trying to help them.

Seeing tons of Medicaid is one big reason I could never work for a hospital.

I’ve seen people who are considered at least higher middle class (executive chef, business owners, etc) in Cali on Medicaid. Not sure how they do their taxes to pull that off….

 

[drusso]

I’ve seen people who are considered at least higher middle class (executive chef, business owners, etc) in Cali on Medicaid. Not sure how they do their taxes to pull that off….

Joe and Fatima are on Medicaid in my state. When all your assets are dumped into an organic blue berry farm and you day trade, no W-2

 

[Ducttape]

I see none of these rich people on Medicaid. I am fairly willing to bet I see more Medicaid than almost everyone here.

1/3 of my Medicaid patients are the working poor.
1/3 tends to be the "I deserve it" crowd.
1/3 have legitimate medical issues that preclude work.

 

[bedrock]

I see none of these rich people on Medicaid. I am fairly willing to bet I see more Medicaid than almost everyone here.

1/3 of my Medicaid patients are the working poor.
1/3 tends to be the "I deserve it" crowd.
1/3 have legitimate medical issues that preclude work.

I think you do see more Medicaid than most of us.

I highly doubt that 1/3 have legitimate medical issues that prevent work. Virtually every Medicaid I’ve ever seen could work in an office answering phones etc, if they were properly motivated to work. (I.e. if the government handouts didn’t exist)

Just because some can no longer lift rocks/dig ditches, doesn’t mean they can’t work at all.

I would personally boot off 95% of the people currently on long term disability in the US.

As a physiatrist, I know what constitutes true disability, and 95% of these lazy people do not have it.

 

[runfastnow]

I see none of these rich people on Medicaid. I am fairly willing to bet I see more Medicaid than almost everyone here.

1/3 of my Medicaid patients are the working poor.
1/3 tends to be the "I deserve it" crowd.
1/3 have legitimate medical issues that preclude work.

I think you do see more Medicaid than most of us.

I highly doubt that 1/3 have legitimate medical issues that prevent work. Virtually every Medicaid I’ve ever seen could work in an office answering phones etc, if they were properly motivated to work. (I.e. if the government handouts didn’t exist)

Just because some can no longer lift rocks/dig ditches, doesn’t mean they can’t work at all.

I would personally boot off 95% of the people currently on long term disability in the US.

As a physiatrist, I know what constitutes true disability, and 95% of these lazy people do not have it.

Agree with ratio - see a fair amount of Medicaid myself.

Agree with bedrock on many people not fitting true disability. However - where I am in NW Arkansas you either have to work in a chicken farm, chicken processing factory, trucking company, or Wal-Mart. Many work these jobs until their 40s-50s then stuck dealing with a legitmately worn out body and someone without skills to work an office job + only so many low level non-physical jobs to go around. ... I agree they don't need to be on long term disability, but also don't know how to fix it in the communities my patients live in.

 

[RoloTomassi]

Bill to Avert Impending Conversion Factor with Cuts of 4.4% in 2023 to be Introduced - American Society of Interventional Pain Physicians

September 14, 2022 Great news! Representatives Larry Bucshon (R-Ind.) and Ami Bera (D-Calif.), are introducing a bill that would prevent a 4.4 percent Medicare physician fee payment cut from taking … Bill to Avert Impending Conversion Factor with Cuts of 4.4% in 2023 to be Introduced Read More »

asipp.org

 

[bedrock]

Agree with ratio - see a fair amount of Medicaid myself.

Agree with bedrock on many people not fitting true disability. However - where I am in NW Arkansas you either have to work in a chicken farm, chicken processing factory, trucking company, or Wal-Mart. Many work these jobs until their 40s-50s then stuck dealing with a legitmately worn out body and someone without skills to work an office job + only so many low level non-physical jobs to go around. ... I agree they don't need to be on long term disability, but also don't know how to fix it in the communities my patients live in.

I’m don’t know about your community but our office and many other doctors/dentists offices are always short/trying to hire more front desk staff and MAs.

Official MA training isn’t required by our office on many others.

All of these people could work those jobs easily if they weren’t given free healthcare/food/housing with our taxes.

 

[SSdoc33]

Very little financial difference between working at mcdonalds and not working at all. Many choose to be poor, have crappy lives, and not work than work and have marginally more money. Is the answer to pay the lower end jobs more or decrease the entitlements? In general, positive reinforcement works better than negative -- the carrot is stronger than the stock.

 

[runfastnow]

I’m don’t know about your community but our office and many other doctors/dentists offices are always short/trying to hire more front desk staff and MAs.

Official MA training isn’t required by our office on many others.

All of these people could work those jobs easily if they weren’t given free healthcare/food/housing with our taxes.

I agree with you that there is too many people on disability that is inappropriate (I am PM&R too) + we have the same issues with staffing.

BUT - 90+% of these type patients around my practice grew up in a culture of "have to work XYZ physically demanding job" and "I can't/won't work in an office because XYZ conspiracy theory" or they can't get an office job because they do not have the IQ/EQ/professionalism to work in MA/receptionist setting (at least the 5+ times we've tried at our office).

 

[bedrock]

I agree with you that there is too many people on disability that is inappropriate (I am PM&R too) + we have the same issues with staffing.

BUT - 90+% of these type patients around my practice grew up in a culture of "have to work XYZ physically demanding job" and "I can't/won't work in an office because XYZ conspiracy theory" or they can't get an office job because they do not have the IQ/EQ/professionalism to work in MA/receptionist setting (at least the 5+ times we've tried at our office).

If the choice was between starving or learning to bite their tongue (as we do all day long) they would learn to function.

 

[SSdoc33]

I agree with you that there is too many people on disability that is inappropriate (I am PM&R too) + we have the same issues with staffing.

BUT - 90+% of these type patients around my practice grew up in a culture of "have to work XYZ physically demanding job" and "I can't/won't work in an office because XYZ conspiracy theory" or they can't get an office job because they do not have the IQ/EQ/professionalism to work in MA/receptionist setting (at least the 5+ times we've tried at our office).

Sort mail

Security guard

Call center/ dispatcher

MA/CNA

Janitor

Cashier

Front desk at a hotel, apt building.

I could go on

 

[SSdoc33]

They can do these jobs. They just dont want to.

 

[runfastnow]

Again - I do not disagree. Plus - disability fraud seemed much more rampant when I trained in major city in northeast.

But until the Pain Forum runs for office and does away with current government benefits/handouts people in my region will work their physically demanding job farming/killing/processing chickens so our kids can eat their nuggets, trash their back/neck/knees/hips/shoulders, and then give up and wait for handouts because it is easier than change and entering the rest of society.

I don't give them disability - just try to keep them off opiates and unnecessary surgery with some injections here and there.

 

[deleted875186]

Universal basic income for everyone, get rid of all other government handouts, done.

 

[bedrock]

Very little financial difference between working at mcdonalds and not working at all. Many choose to be poor, have crappy lives, and not work than work and have marginally more money. Is the answer to pay the lower end jobs more or decrease the entitlements? In general, positive reinforcement works better than negative -- the carrot is stronger than the stock.

I think a lot more people would work if the choice was to either work or starve.

I agree that the $ to live each month can be similar between working at McDonald’s and SSDI.
But one level up on the pay scale ladder are plenty of jobs you listed that people could do if they weren’t given handouts and they would have the self respect of contributing to society and themselves.

 

[Ducttape]

I think you do see more Medicaid than most of us.

I highly doubt that 1/3 have legitimate medical issues that prevent work. Virtually every Medicaid I’ve ever seen could work in an office answering phones etc, if they were properly motivated to work. (I.e. if the government handouts didn’t exist)

Just because some can no longer lift rocks/dig ditches, doesn’t mean they can’t work at all.

I would personally boot off 95% of the people currently on long term disability in the US.

As a physiatrist, I know what constitutes true disability, and 95% of these lazy people do not have it.

disability is not just physical.

psychological, mental disease are probably a larger component than purely physical conditions

I think a lot more people would work if the choice was to either work or starve.

I agree that the $ to live each month can be similar between working at McDonald’s and SSDI.
But one level up on the pay scale ladder are plenty of jobs you listed that people could do if they weren’t given handouts and they would have the self respect of contributing to society and themselves.

you guys realize it is not a huge population that gets social security disability, right?

"in 2011, 2.4% of nonelderly adults received supplemental security for a disability"
"The disability-prevalence rate, adjusted for age and sex, was 4.5 percent in 2011."

The Facts on Social Security Disability Insurance and Supplemental Security Income for Workers with Disabilities

Social Security Disability Insurance and Supplemental Security Income provide critical lifelines for the roughly 12 million people with disabilities in the United States.

www.americanprogress.org

(i must note that this website has a left bias)

and, of note:
"According to a recent analysis by the Organisation for Economic Co-operation and Development, or OECD, the United States has the least generous disability-benefit system of all OECD member countries except Korea."

 

[deleted875186]

disability is not just physical.

psychological, mental disease are probably a larger component than purely physical conditions



you guys realize it is not a huge population that gets social security disability, right?

"in 2011, 2.4% of nonelderly adults received supplemental security for a disability"
"The disability-prevalence rate, adjusted for age and sex, was 4.5 percent in 2011."

The Facts on Social Security Disability Insurance and Supplemental Security Income for Workers with Disabilities

Social Security Disability Insurance and Supplemental Security Income provide critical lifelines for the roughly 12 million people with disabilities in the United States.

www.americanprogress.org

(i must note that this website has a left bias)

and, of note:
"According to a recent analysis by the Organisation for Economic Co-operation and Development, or OECD, the United States has the least generous disability-benefit system of all OECD member countries except Korea."

You don’t think 4.5% is a lot?

 

[SSdoc33]

I think a lot more people would work if the choice was to either work or starve.

I agree that the $ to live each month can be similar between working at McDonald’s and SSDI.
But one level up on the pay scale ladder are plenty of jobs you listed that people could do if they weren’t given handouts and they would have the self respect of contributing to society and themselves.

true....but then again, a lot more people would also starve.

 

[Ducttape]

You don’t think 4.5% is a lot?

compared to 95.5%?

fyi that 4.5% is specifically the disability prevalence rate, which is different from the total population.

 

[bedrock]

true....but then again, a lot more people would also starve.

I doubt it. Lack of food, air , etc creates a primal drive to do something.

They would have to learn to deal with daily frustrations and show up on time, just like the rest of us.

 

[pastafan]

2017 State Report for County-Level Data: Prevalence | Annual Disability Statistics Compendium

Much higher than 4.5%

 

[Ducttape]

there is a difference between disability and receiving government payments through SSI.