2022 Year-End Physician Payment and Coverage Advocacy Highlights

Jan 12, 2023

Medicare Inpatient Hospital Rule 
On August 1, the Centers for Medicare and Medicaid Services (CMS) issued the final Medicare Hospital Inpatient Prospective Payment System rule. Of interest and supported by ASH was the decision to implement new International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for von Willebrand disease (VWD). These new codes were originally proposed by ASH in December 2020 and presented at the March 2021 ICD-10 Coordination and Maintenance Committee Meeting. Prior to this change, there was only one diagnosis code for VWD and all subtypes (D68.0), but as of October 1, 2022, there are now 10 separate codes for VWD and its subtypes. These new codes will help to accurately document, diagnose, and in turn, appropriately treat the different subtypes of VWD.

Medicare Physician Fee Schedule
On November 1, CMS released the calendar year (CY) 2023 Medicare Physician Fee Schedule final rule (MPFS) outlining changes that were implemented on January 1. The rule finalized the approximately 4.5% cut to the Medicare conversion factor which dictates payment rates for 2023. ASH along with the American Medical Association and the broader health care community advocated for Congress to prevent the payment reductions, and Congress acted by reducing the cuts to 2% in the final FY 2023 Omnibus package.  The rule also finalized revisions to evaluation and management (E/M) inpatient and observation visits, bringing them in line with the changes previously made to office/outpatient E/M visits. ASH’s comment letter to CMS on the draft CY 23 MPFS rule is available here.

Clinical Practice Provisions in FY 2023 Spending Bill 
In late December, Congress passed a $1.7 trillion spending bill, which included the following provisions that ASH advocated for over the past year:

  • The legislation partially addresses the significant cuts to Medicare payments in 2023; rather than facing the 8.5 percent cut originally planned, physicians will see a 2 percent cut to Medicare payments beginning in January.  ASH joined many others in the medical community to advocate that these cuts be fully waived and while the Society is pleased that Congress took action, it is disappointing that physicians will are seeing a cut.
  • Since the beginning of the COVID-19 public health emergency (PHE), ASH advocated a number of telehealth flexibilities be made permanent.  The bill includes a two-year extension (through December 31, 2024) of a number of these flexibilities that have been allowed under the PHE, including waiving the originating site and geographic restrictions (i.e., allowing patients to use telehealth from their homes) and continuing coverage and payment for audio-only telehealth services. 
  • ASH continually advocated for increased diversity in clinical trials for blood diseases and disorders.  The omnibus contains provisions related to clinical trial diversity and modernization. For example, clinical trial sponsors will be required to submit diversity action plans and the U.S. Food and Drug Administration must release guidance on the use of decentralized clinical trials.

Coverage for Allogeneic Hematopoietic Cell Transplantation for Primary Refractory or Relapsed Hodgkin's and Non-Hodgkin's Lymphoma with B-cell or T-cell Origin
As a result of ASH’s advocacy with the American Society for Transplantation and Cellular Therapy (ASTCT), a new Local Coverage Determination (LCD) approved by Medicare contractor Palmetto GBA allows Medicare beneficiaries to receive allogeneic hematopoietic cell transplantation (allo-HCT) for primary refractory or relapsed Hodgkin’s and Non-Hodgkin’s lymphoma with B-cell or T-cell origin for whom there are no other curative intent options. As a follow up to this decision, ASH and ASTCT sent letters to all Medicare Administrative Contractors (MAC) formally requesting the timely creation of an LCD in their respective regions. The letter encourages MACs to refer to Palmetto GBA LCD (DL 39270), supported by ASH and ASTCT. This fall, Noridian, WPS Government Health Administrators, and CGS Administrators released draft LCDs based off the Palmetto LCD. ASH and ASTCT submitted comments to each contractor. Final LCDs from these regions are expected to be released in early 2023.  The LCD is necessary as the Medicare National Coverage Determination for Allogeneic Stem Cell Transplantation does not specifically include lymphoma as a covered indication, leaving Medicare beneficiaries with lymphoma without nationally consistent access to this potentially curative treatment and creating a different standard of care under Medicare than what is afforded to patients with commercial insurance.

AMA, CPT Coding, RUC, and Medicare Payment Policies for Hematology-Specific Services 
ASH members attended the American Medical Association (AMA) House of Delegate (HOD) meetings virtually in June 2022, and in person in November 2022. ASH has two delegates, Drs. Chancellor Donald and Amar Kelkar, and two alternate delegates, Drs. Kelsey Martin and Ellen Fraint. Two delegates can attend each meeting, and vote on resolutions, which help to shape AMA policy positions. ASH also has representation in the AMA Women Physicians Section (WPS) by Drs. Margaret Ragni and Ariella Marshall.

ASH also remains active in the AMA Current Procedural Terminology (CPT) meetings and the AMA RVS Update Committee (RUC) meetings.  Dr. Sam Silver represents ASH for both the CPT and RUC with Dr. Chancellor Donald serving as an alternate for the CPT and Dr. Jamile Shammo serving as an alternate for the RUC.

Medicare Contractor Advisory Committee Meeting
In June, ASH hosted the Hematology Carrier Advisory Committee (CAC) Network Meeting.  ASH was excited to see the return of in-person networking between CAC representatives and Medical Directors for the first time since 2019.  The meeting focused on an assortment of issues such as ASH’s efforts to secure coverage for stem cell transplant for individuals living with lymphoma, design and Medicare coverage of clinical trials, post-transplant vaccination coverage under Medicare, and coverage of COVID-19 therapies under the Public Health Emergency.

Sickle Cell Disease 
ASH continues to work on a number of advocacy issues related to payment for and coverage of therapies and treatments used for sickle cell disease (SCD).  Please see the 2022 ASH Advocacy Efforts Related to SCD for more information about this advocacy.