Federal Register - July 13, 2021
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Source: Federal Register
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Federal Register / Vol. 86, No. 131 / Tuesday, July 13, 2021 / Rules and Regulations anesthesia conversion factor for each service code;
C For air ambulance services, calculate a median contracted rate for the air mileage service codes A0435
and A0436; and D Where contracted rates otherwise vary based on applying a modifier code, calculate a separate median contracted rate for each such service code-modifier combination;
iii In the case of payments made by a plan or issuer that are not on a fee-forservice basis such as bundled or capitation payments, calculate a median contracted rate for each item or service using the underlying fee schedule rates for the relevant items or services. If the plan or issuer does not have an underlying fee schedule rate for the item or service, it must use the derived amount to calculate the median contracted rate; and iv Exclude risk sharing, bonus, penalty, or other incentive-based or retrospective payments or payment adjustments.
3 Provider specialties; facility types.
i If a plan or issuer has contracted rates that vary based on provider specialty for a service code, the median contracted rate is calculated separately for each provider specialty, as applicable.
ii If a plan or issuer has contracted rates for emergency services that vary based on facility type for a service code, the median contracted rate is calculated separately for each facility of the same or similar facility type.
c Methodology for calculation of the qualifying payment amount1 In general. i For an item or service other than items or services described in paragraphs c1iii through vii of this section furnished during 2022, the plan or issuer must calculate the qualifying payment amount by increasing the median contracted rate as determined in accordance with paragraph b of this section for the same or similar item or service under such plans or coverage, respectively, on January 31, 2019, by the combined percentage increase as published by the Department of the Treasury and the Internal Revenue Service to reflect the percentage increase in the CPIU over 2019, such percentage increase over 2020, and such percentage increase over 2021.
A The combined percentage increase for 2019, 2020, and 2021 will be published in guidance by the Internal Revenue Service. The Department of the Treasury and the Internal Revenue Service will calculate the percentage increase using the CPIU published by the Bureau of Labor Statistics of the Department of Labor.
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B For purposes of this paragraph c1i, the CPIU for each calendar year is the average of the CPIU as of the close of the 12-month period ending on August 31 of the calendar year, rounded to 10 decimal places.
C The combined percentage increase for 2019, 2020, and 2021 will be calculated as:
CPIU 2019/CPIU 2018 CPIU
2020/CPIU 2019 CPIU 2021/
CPIU 2020
ii For an item or service other than items or services described in paragraphs c1iii through vii of this section furnished during 2023 or a subsequent year, the plan or issuer must calculate the qualifying payment amount by increasing the qualifying payment amount determined under paragraph c1i of this section, for such an item or service furnished in the immediately preceding year, by the percentage increase as published by the Department of the Treasury and the Internal Revenue Service.
A The percentage increase for any year after 2022 will be published in guidance by the Internal Revenue Service. The Department of the Treasury and Internal Revenue Service will calculate the percentage increase using the CPIU published by the Bureau of Labor Statistics of the Department of Labor.
B For purposes of this paragraph c1ii, the CPIU for each calendar year is the average of the CPIU as of the close of the 12-month period ending on August 31 of the calendar year, rounded to 10 decimal places.
C The combined percentage increase for any year will be calculated as CPI
U present year/CPIU prior year.
iii For anesthesia services furnished during 2022, the plan or issuer must calculate the qualifying payment amount by first increasing the median contracted rate for the anesthesia conversion factor as determined in accordance with paragraph b of this section for the same or similar item or service under such plans or coverage, respectively, on January 31, 2019, in accordance with paragraph c1i of this section referred to in this section as the indexed median contracted rate for the anesthesia conversion factor.
The plan or issuer must then multiply the indexed median contracted rate for the anesthesia conversion factor by the sum of the base unit, time unit, and physical status modifier units of the participant or beneficiary to whom anesthesia services are furnished to determine the qualifying payment amount.
A The base units for an anesthesia service code are the base units for that
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service code specified in the most recent edition as of the date of service of the American Society of Anesthesiologists Relative Value Guide.
B The time unit is measured in 15minute increments or a fraction thereof.
C The physical status modifier on a claim is a standard modifier describing the physical status of the patient and is used to distinguish between various levels of complexity of the anesthesia services provided, and is expressed as a unit with a value between zero 0 and three 3.
D The anesthesia conversion factor is expressed in dollars per unit and is a contracted rate negotiated with the plan or issuer.
iv For anesthesia services furnished during 2023 or a subsequent year, the plan or issuer must calculate the qualifying payment amount by first increasing the indexed median contracted rate for the anesthesia conversion factor, determined under paragraph c1iii of this section for such services furnished in the immediately preceding year, in accordance with paragraph c1ii of this section. The plan or issuer must then multiply that amount by the sum of the base unit, time unit, and physical status modifier units for the participant or beneficiary to whom anesthesia services are furnished to determine the qualifying payment amount.
v For air ambulance services billed using the air mileage service codes A0435 and A0436 that are furnished during 2022, the plan or issuer must calculate the qualifying payment amount for services billed using the air mileage service codes by first increasing the median contracted rate as determined in accordance with paragraph b of this section, in accordance with paragraph c1i of this section referred to in this section as the indexed median air mileage rate.
The plan or issuer must then multiply the indexed median air mileage rate by the number of loaded miles provided to the participant or beneficiary to determine the qualifying payment amount.
A The air mileage rate is expressed in dollars per loaded mile flown, is expressed in statute miles not nautical miles, and is a contracted rate negotiated with the plan or issuer.
B The number of loaded miles is the number of miles a patient is transported in the air ambulance vehicle.
C The qualifying payment amount for other service codes associated with air ambulance services is calculated in accordance with paragraphs c1i and ii of this section.
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