CMS released the 2023 Medicare Physician Fee Schedule (MPFS) and Quality Payment Program (QPP) Proposed Rule on July 7. In many ways, this article could be a copy-paste from last year’s edition, as the theme of decreasing reimbursement rates and increasing difficulty of the Merit-Based Incentive Payment System (MIPS) seems to be stuck on repeat for policymakers.

For 2023, CMS estimates an overall impact of the MPFS changes to radiology to be a 3% reduction in reimbursement, while IR would see a decrease of 4%, nuclear medicine would see a 3% decrease, and radiation oncology and radiation therapy centers would see a 1% decrease if the provisions within the proposed rule are finalized. These reimbursement cuts result from continued implementation of clinical labor pricing updates and revisions to evaluation and management code families, including hospitals, emergency medicine, nursing facilities, and home visits. If Congress does not intervene to extend the $3 billion infusion to the MPFS budget provided by the Protecting Medicare and American Farmers from Sequester Cuts Act, the percent decreases described above will be greater for 2023.

All is not lost, however. CMS is proposing to update the prices for several supply items, including “towel, paper (Bounty) (per sheet),” which is found in the practice expense of several radiology codes. In an act of what can only be considered goodwill to paper towel-wielding clinicians, CMS proposes to increase the price by 114%, from $0.007 to $0.015.

Paper product sarcasm aside, there were a few positive highlights for radiologists. No radiology codes were nominated by CMS or public stakeholders as potentially misvalued. Additionally, CMS accepted most of the recommended relative value unit (RVU) values for imaging codes brought before the AMA/Specialty Society RVS Update Committee (RUC) in this calendar year cycle. The ACR RUC team is currently working on a response to CMS defending the recommended values for the remaining codes in our comment letter to the proposed rule. In addition, the ACR and the AMA identified potential errors in CMS’ calculation of professional liability insurance RVUs that adversely impacted radiology. We are hopeful that CMS will work with us to identify and correct the errors, which would result in a smaller reimbursement decrease than projected. 

CMS did not propose major changes to MIPS for 2023, instead focusing on further development of MIPS Value Pathways (MVPs) and advancing health equity across CMS programs and policies. Nonetheless, the impact of previous years’ policies will likely be more palpable this performance year. Most notably, the removal of bonus points and further constriction of quality measures available to radiologists remain significant barriers for radiology practices. The performance threshold (below which clinicians are subject to a financial penalty) is proposed to remain at 75 points for 2023. The maximum penalty and bonus amounts remain at the statutorily mandated levels of +/–9% of Medicare Part B payments. There will no longer be an additional bonus for exceptional performance starting in 2023.

CMS is maintaining the six-point small practice bonus included in the Quality Performance category and continues to award small practices three points for submitted quality measures that do not meet case minimum requirements or lack a benchmark. The agency proposes to raise the data completeness threshold to 75%, beginning with the 2024 performance year. Specific to radiology, CMS proposes an updated version of the 2021 MIPS Measure #145: Exposure Dose Indices or Exposure Time and Number of Images Reported for Procedures Using Fluoroscopy, in accordance with changes proposed by the ACR. To meet performance for this measure, exposure dose indices must be provided; exposure time and number of images will no longer be sufficient. If the proposed changes are finalized, we expect this measure to be removed from the list of topped-out measures capped at seven points.

CMS added five proposed MVPs for 2023, bringing the total MVPs available for voluntary reporting to 12. The ACR continues to engage CMS in discussions about the challenges of creating MVPs that are applicable to radiologists.

The 2023 proposed rule represents the continuation of a disconcerting trend — the confluence of Conversion Factor decreases, the statutory cuts on the horizon from sequestration and Pay-As-You-Go policies, and a 0% payment update that fails to account for significant inflation practice costs creates long-term financial instability in the Medicare physician payment system. The increasing difficulty of MIPS and an ever-decreasing pool of available quality measures further disadvantages radiologists. Working with other medical societies, the ACR was able to preempt some of these cuts last year. The 2023 MPFS proposed rule makes clear the need to redouble our efforts to ensure that patient access to Medicare-participating physicians and imaging services is not threatened.