Medicare Physician Fee Schedule and Hospital Outpatient Prospective Payment System Final Rules

Medicare Physician Fee Schedule and Hospital Outpatient Prospective Payment System Final Rules

By Matthew Kerschner

The 2022 Medicare Physician Fee Schedule (PFS) and 2022 Medicare Hospital Outpatient Prospective Payment System (OPPS) final rules were released on Tuesday, November 2. These final rules are effective starting on January 1, 2022. AHIMA submitted comments in response to both the PFS and OPPS proposed rules.

Medicare Physician Fee Schedule

Every year, the Centers for Medicare and Medicaid Services (CMS) issues policy updates for Medicare payments under the PFS. The stated aim of these policy changes is to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation. Each year, AHIMA submits comments in response to the PFS proposed rule to ensure that the health information perspective is accounted for by policymakers and to provide our subject matter expertise.

Conversion Factor

Due to budget neutrality requirements, and the expiration of the 3.75 percent temporary 2021 payment increase provided under the Consolidated Appropriations Act 2021, the 2022 PFS conversion factor is $33.59, a decrease of $1.30 from the CY 2021 PFS conversion factor of $34.89.


AHIMA supports the use of public policy to expand access to care, reduce costs, and improve convenience for patients through expanded access to telehealth. In alignment with our comments, AHIMA was pleased to see that CMS finalized several provisions in the PFS final rule that will promote access to telehealth services. Critical policies impacting telehealth include:

  • Certain services added to the Medicare telehealth services list for the duration of the COVID-19 Public Health Emergency (PHE) will remain on the list through December 31, 2023, allowing for additional time for the agency to evaluate evidence pertaining to whether those services should be permanently added to the Medicare telehealth services list. This policy will reduce uncertainty regarding the timing for adding services to the Medicare telehealth list in relation to the end of the PHE.
  • Removal of the geographic restrictions and addition of the home of the beneficiary as a permissible originating site for telehealth services furnished for the purposes of diagnosis, evaluation, or treatment of a mental health disorder. This is a significant permanent change to promote access to telehealth services.
  • Amendment of the definition of “interactive telecommunications system” for telehealth services to include audio-only communications technology when used for telehealth services for the diagnosis, evaluation, or treatment of mental health disorders furnished to established patients in their homes under certain circumstances. Audio-only services may only be provided by providers that have the capability to furnish two-way, audio/video communications, and audio-only technology is only used in cases in which the beneficiary is not capable of, or does not consent to, the use of two-way, audio/video technology for the service. This is a significant expansion of the definition of “interactive telecommunications system” and represents a major change in the agency’s thinking regarding the delivery of telehealth services.
  • Adoption of coding and payment for a longer virtual check-in service on a permanent basis. This policy will promote access to needed audio-only services.
Quality Payment Program

CMS has finalized a number of policies to substantially modify the Quality Payment Program including changes to the Merit-based Incentive Payment System (MIPS), the MIPS Value Pathways (MVP) program, and to Alternative Payment Models. Critical changes in the MIPS program include:

  • Increasing the performance threshold to 75 points and the exceptional performance threshold to qualify for bonus payments to 89 points.
  • Re-weighting of the performance categories to the following: 30 percent for the quality performance category, 30 percent for the cost performance category, 15 percent for the improvement activities performance category, and 25 percent for the promoting interoperability performance category.
  • Within the promoting interoperability performance category, CMS is revising reporting requirements for the Public Health and Clinical Data Exchange objective, adding an additional exclusion for the Electronic Case Reporting measure, requiring clinicians to attest to having conducted an annual assessment of the High-Priority Guide of the Safety Assurance Factors for EHR Resilience Guides (SAFER Guides), and modifying the Prevention of Information Blocking attestation statements to distinguish them from requirements established in the 21st Century Cures Act Final Rule.
  • In a significant victory for AHIMA advocacy, CMS is not moving forward with a proposal that would have required MIPS-eligible clinicians to ensure that patient health information remains available to be accessed indefinitely. AHIMA had significant concerns related to the potential burdens and security risks that the “indefinite” retention requirement would create. In the agency’s commentary explaining its decision to rescind this proposal, the agency cited several arguments made by AHIMA in our comment letter.
Hospital Outpatient Prospective Payment System

Each year, CMS issues updated policies pertaining to payment for hospital outpatient and Ambulatory Surgical Center services. CMS’ goal for this year’s policy changes is to address the health equity gap, fight the COVID-19 PHE, encourage transparency in the health system, and promote safe, effective, and patient-centered care. AHIMA regularly submits comments in response to the proposed rule to guide policymaking and ensure that the voice of the HI profession is heard.

Price Transparency

CMS is making modifications to the hospital price transparency regulations, with the aim of designed increasing compliance, due to initial reports of low levels of compliance with existing regulation. AHIMA supports the use of public policy to ensure that individuals have all the information they need to make informed choices about their healthcare. Starting on January 1, 2022, CMS is strengthening penalties so that the minimum civil monetary penalty of $300 per day will apply only to smaller hospitals with a bed count of 30 or fewer, and a new penalty of $10 per bed per day will be established for hospitals with a bed count greater than 30, with penalties not to exceed a maximum daily dollar amount of $5,500. Under this approach, for a full calendar year of noncompliance, the minimum total penalty amount would be $109,500 per hospital, and the maximum total penalty amount would be $2,007,500 per hospital.

CMS is also updating the regulation’s prohibition of certain activities that present barriers to access to the required publication of a machine-readable file with charge information for all items and services. Specifically, the agency is requiring that the machine-readable file be accessible to automated searches and direct downloads.

Inpatient Only List

In the 2021 final rule, CMS had previously finalized a policy to eliminate the inpatient only (IPO) list over a three-year period, removing 298 services from the IPO list in the first phase of the elimination. In a reversal of this pre-existing policy, CMS finalized a proposal to halt the elimination of the IPO list and add back to the IPO list the services removed in 2021, except for CPT codes 22630 (Lumbar spine fusion), 23472 (Reconstruct shoulder joint), 27702 (Reconstruct ankle joint), and their corresponding anesthesia codes.

Matthew Kerschner ( is director of regulatory affairs at AHIMA.

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