August 18, 2022

The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Attention: CMS-1770-P
P.O. Box 8016
Baltimore, MD 21244-8016
Submitted online via www.regulations.gov

Re: File Code CMS-1770-P Medicare and Medicaid Programs; CY 2023 Payment Policies Under the
Physician Fee Schedule and Other Changes to Part B Payment Policies
Dear Administrator Brooks-LaSure:

The American Association of Oral and Maxillofacial Surgeons (AAOMS) represents more than 9,000
oral and maxillofacial surgeons (OMSs) in the United States. AAOMS appreciates the opportunity tocomment on the proposed 2023 revisions to the Payment Policies Under the Physician Fee
Schedule and Other Changes to Part B Payment Policies, published in the July 29, 2022, Federal
Register (Vol. 87, No. 145, pages 45860-46843).

AAOMS commends CMS on efforts to improve access to high-quality and affordable health care,notably on the proposals aimed at ensuring Medicare beneficiaries have access to medicallynecessary and essential dental services. However, AAOMS also has concerns that certain aspects ofthe proposed rule exacerbate the uncertainty faced by Medicare providers under the current
payment system.
CY 2023 Physician Fee Schedule (PFS) rate setting and Medicare conversion factor

Medicare providers stand to face another round of significant payment cuts beginning January 1,
2023. In the proposed rule, CMS estimates that the CY 2023 PFS conversion factor (CF) - the basic
starting point for calculating Medicare payments - will be $33.08, representing a nearly 4.5 percent
decrease from the $34.61 CF for 2022.

The Medicare payment system has been devalued through recurring and drastic payment cuts year
after year. The ongoing public health emergency continues to require physicians across all
specialties to take unprecedented steps to manage patient care, mitigate workforce shortages,
navigate limited availability of critical supplies and rapidly respond to changes in patient needs andclinical protocols. CMS’ proposal fails to account for the economic factors that have dramaticallyincreased practice costs in the past year. The CY 2023 PFS proposed rule jeopardizes the alreadystrained financial stability of many physician practices, especially small independent practices.

The proposed payment cuts, combined with the pending threat of the 4 percent PAYGO reduction
and recent termination of the 2 percent sequestration moratorium have created a financial
environment for Medicare providers that is simply untenable, putting timely access to essential
healthcare services at risk. For these reasons, AAOMS urges CMS and HHS not to finalize theproposed payment cuts and to work with Congress to fundamentally reform the PFS toensure reimbursement stability for Medicare providers moving forward.
Proposals and request for information on Medicare Parts A and B payment for dental services

Oral and maxillofacial surgery is the surgical specialty of dentistry and one of the few dental
specialties whose members perform Medicare-covered procedures that range from the removing
cancerous tumors in the mouth/jaw area and the extraction of infected teeth to preparing apatient’s jaw for radiation cancer treatment to repairing tissue or bones in the facial area following
trauma. As such, our members have extensive experience with the Medicare program.

Currently, Medicare Benefit Manual provisions outline coverage for a limited number of dental
services and procedures, including those mentioned above, involving certain medicallycompromised patients. Codifying existing manual provisions would bring regulatory language inline with CMS manual provisions, affirming a Medicare beneficiary’s right to access these criticaloral and maxillofacial procedures. AAOMS supports CMS’ proposal to codify the existing dental
coverage policy and expand coverage for these services to inpatient or outpatient settings.

As CMS knows, section 1862(a)(12) of the Act generally precludes payment under Medicare Parts A
or B for any expenses incurred for services in connection with the care, treatment, filling, removal,
or replacement of teeth or structures directly supporting teeth (i.e., “dental services”). As stated in
the proposed rule, CMS’ current interpretation of section 1862(a)(12) has been called into question
as being “unnecessarily restrictive.”

For example, Medicare currently covers an oral exam for a patient prior to undergoing a Medicarecovered kidney transplant, but not any necessary dental treatment prior to the transplant to ensure
the success of the medical procedure. Further, an oral exam and treatment of diagnosed dental
infections are not covered for any other transplant procedures or for certain other medicallycovered procedures such as head and neck cancer, that rely on a healthy mouth for a successful
outcome. AAOMS appreciates CMS’ consideration to broaden the definition of medically necessary
dental services to better address the oral health needs of the Medicare population.

AAOMS supports efforts to expand Medicare coverage for certain oral and maxillofacial surgery
services 1 that the association considers to be “medically necessary” or “essential” because they areintegral to a patient’s overall health. Such services include the evaluation and definitive treatment
of infections of the head and neck and the extraction of teeth prior to transplant surgery, valve
replacement and cardiac surgery. AAOMS considers “definitive treatment” to include the extractionof source teeth and incision and drainage procedures for treatment of severe dental infections. If
1 Essentials of Oral and Maxillofacial Surgery Services.

https://www.aaoms.org/docs/govt_affairs/advocacy_white_papers/essentials_oms.pdf. Accessed August 9,2022.

left untreated, severe oral and dental infections could lead to sepsis, deterioration of the jaw, heartcomplications or death. As such, AAOMS supports CMS’ proposal to expand Medicare coverageand payment for necessary dental examinations and treatment for oral infections, prior toorgan transplant surgery, cardiac valve replacement or valvuloplasty procedures.
Coverage of services in inpatient and outpatient settings, including ASCsAAOMS believes that access to procedures described above is often critical to successful
outcomes for patients with certain conditions. As OMSs routinely evaluate and safely treat
patients ranging in complexity across a variety of care settings, AAOMS supports CMS’
proposal for coverage of these services in either the inpatient or outpatient setting. AAOMS
also requests CMS extend coverage of such services when rendered in ambulatory surgery
centers (ASCs) as well as in oral and maxillofacial surgery practices. Lack of and/or limited
hospital-based OR access is further magnified by medical staffing shortages, industry-wide inflationand the residual backlog of cases spurred by the COVID-19 pandemic. Other challenges exist forpatients unable to access hospital facilities because of geographic or transportation limitations.
AAOMS believes that ASCs and oral and maxillofacial surgery practices have the potential tomitigate many of these external pressures. Indeed, industry research indicates the health caresystem as a whole benefits when procedures migrate to the office or ASC from more costly caresettings.
Request for clarification on the proposal on the administration of anesthesia as a covered service
ancillary to covered dental procedures

CMS has further proposed that payment could also be made, under the applicable payment system,
for the services considered ancillary to those dental services that would be deemed medicallynecessary and thus not be subject to the preclusion for payment under the Act, if finalized. CMS has
proposed such ancillary services may include x-rays, the administration of anesthesia and facility
costs including the use of the operating room. AAOMS supports CMS’ proposal to allow Medicare
payment for services that are ancillary to or provided in conjunction with dental services
that are inextricably linked to, and substantially related and integral to the clinical successof, covered medical services such as X-rays, administration of anesthesia, use of theoperating room and other facility services as such services represent necessary diagnostic,
clinical and procedural considerations that must be determined by the surgeon on a case-bycase basis.
OMS anesthesia delivery includes the administration of deep sedation or general anesthesia forprocedures performed on pediatric, adult and geriatric patients in the office and ASC settings. OMSs
undergo extensive clinical training emphasizing perioperative evaluation of all patients, risk
assessment, anesthesia and sedation techniques, monitoring and the diagnosis and management ofcomplications. AAOMS has supported the administration of moderate sedation and generalanesthesia, provided by OMSs, when done in conjunction with a separate procedure as medicallynecessary and essential for the control of pain and anxiety, when clinically appropriate.
Currently, Medicare bundles payment for general anesthesia with payment for the surgical service
when both are rendered by the operating surgeon, including an OMS. Although, neither CPT nor
CDT coding guidelines mention moderate sedation, deep sedation or general anesthesia as being
inclusive to a procedure. In fact, coding guidelines specifically state that only the administration ofa local anesthetic is inherent to the procedure. It is the position of the AAOMS that an oral andmaxillofacial surgeon who performs both surgery and administers moderate sedation, deepsedation or general anesthesia with his or her anesthesia team, should be reimbursed for both if heor she has the requisite education, training and required state license and/or permits to performthese services. Under current Medicare policy, a separate provider is required to administer the
deep sedation/general anesthesia for separate payment to be allowed. Given this, AAOMS seeksclarification from CMS on the consideration of the administration of deep sedation/generalanesthesia as a covered service ancillary to or provided with covered dental services thatare inextricably linked to, and substantially related and integral to the clinical success of, theother covered medical services, specifically whether CMS interprets this to include theadministration of anesthesia by the operating surgeon in an office-based setting and an ASC
for coverage under this proposal.
Other clinical scenarios for dental services integral to other covered medical services
In addition to those scenarios outlined above, AAOMS agrees with CMS that there are likely otherclinical scenarios in which certain dental services, such as examinations and/or medicallynecessary diagnostic and treatment services would be inextricably linked to, and medicallynecessary for, the clinical success of other covered medical services.

AAOMS has supported legislation to expand coverage to dental services that are medicallynecessary as a direct result of or will have a direct impact on treatments for all head and neckcancers, such as radiation therapy with or without chemotherapy, as well as for joint replacement
therapy. Additionally, AAOMS has supported the expansion of coverage to include the extraction ofproblematic teeth or incision and drainage of severe abscesses when a delay in surgical treatment
could result in the impairment of the patient’s condition or a delay in pending treatment thatshould be performed in a timely manner. AAOMS, for example, has supported the Medicare
Medically Necessary Dental Care Act (HR 5110) that would allow for coverage of dental services
that are furnished in conjunction with treatment relating to a prosthetic heart valve replacement,cancer of the head or neck, lymphoma, leukemia, or organ transplantation. AAOMS encourages
CMS to consider allowing payment under Medicare for dental services such as dental
examinations and the treatment of severe dental infections that are medically necessary as adirect result of, or will have a direct impact on treatments for all head and neck cancers,
such as radiation therapy with or without chemotherapy; as well as joint replacement
therapy.
AAOMS also acknowledges that significant policy changes, including the expansion of regulatory
language to include other clinical scenarios for coverage under the Medicare program, require a
calculated and stepped approach. To prioritize dental treatment of greatest need for Medicare
beneficiaries, AAOMS supports the expansion of dental coverage under the Medicare program
for the clinical scenarios addressed thus far and summarized as follows:•

Dental examinations and necessary dental treatment for severe dental infections
furnished as part of a comprehensive workup prior to any organ transplant surgery or
prior to cardiac valve replacement or valvuloplasty procedures, in either the inpatientor outpatient setting.

•Dental examinations and treatments of severe dental infections that are medicallynecessary as a direct result of or will have a direct impact on treatments for all headand neck cancers, such as radiation therapy with or without chemotherapy, as well as
for joint replacement therapy.

•The extraction of problematic teeth and incision and drainage when a delay in surgicaltreatment could result in the impairment of the patient’s condition or a delay inpending treatment that should be performed in a timely manner.

•

Services that are ancillary or provided in conjunction with dental services that are
inextricably linked to, and substantially related and integral to the clinical success of,covered medical services such as X-rays, administration of anesthesia, use of theoperating room and other facility services.

•

The administration of moderate sedation and general anesthesia, provided by thesurgeon, when rendered in conjunction with a separate procedure as medicallynecessary and essential for the control of pain and anxiety, when clinically appropriate.

AAOMS further supports CMS’ proposal to retain carrier pricing methodology for the dental
services for which payment is currently made under the PFS as well as for those dental
services that can be paid under the CMS proposals for CY 2023.
AAOMS recommends that CMS delay expanding additional dental benefits – outside of thosementioned above – to allow stakeholders and interested parties more time to determine thestandard of care that is clinically advisable to eliminate the source of dental infection prior
to proceeding with treatment, as well as to determine other clinical scenarios in which
dental treatment may be integral to or inextricably linked with, clinical success. Examples ofsuch may include the management of immunocompromised patients or those with a diagnosed
systemic disease such as diabetes.

Such a policy shift is indicative of the increasing focus on whole person care, requiring intimate
collaboration across varying disciplines, including our cohorts outside of dentistry. Additional time
would help to ensure CMS has the best clinical data and medical evidence available, including
patient outcome measures, to facilitate CMS’ consideration of additional dental benefits in otherclinically relevant scenarios.
AAOMS also requests additional time for stakeholders and interested parties to consider thefollowing CMS requests for comment, as each requires considerable strategic development:•

The potential establishment of a process to facilitate recommendations within an annual
rulemaking cycle including: (1) relevant medical literature; (2) clinical guidelines or generally
accepted standards of care; (3) other supporting documentation to support CMS review andconsideration of other clinical scenarios involving dental services.

•

The establishment of payment models and concerns related to coordinating benefits with
Medicaid and other supplemental insurance coverage.

•

Whether existing care management codes adequately describe and account for time spentcoordinating with dentists and their clinical staff?

•

Whether the current policies for care management services make clear that time spent byphysicians or non-physician practitioners coordinating care with dentists regarding theperformance and outcomes of services as proposed in this proposed rule, may be counted for
purposes of applicable care management codes?

•

The impact of changes in how healthcare is delivered, specifically whether an increased
integration and coordination of care among healthcare providers should also be taken into
account in considering dental services that may be inextricably linked to, and substantiallyrelated and integral to the clinical success of, a primary medical service.

•

Whether, and to what extent, the proposed policies in this proposed rule would address any
inequitable distribution of dental services for Medicare beneficiaries?

AAOMS also wishes to reiterate our association’s continued support of the expansion of dental
benefits under Medicare Advantage as well as through state Medicaid programs. More specifically,
AAOMS has advocated in support of the Medicaid Dental Benefit Act (HR 4439/S 3166), which
would require state Medicaid programs to cover dental and oral health services for adults. Medicaid
as well as the Medicare Advantage programs provide access to oral healthcare for patients who
would otherwise not have access to oral healthcare under traditional Medicare. Patients with
Medicaid and Medicare Advantage dental benefits have access to networks of qualified dental
providers as well as cost savings from network rates and annual out-of-pocket limits. AAOMS
believes this, in combination with the proposals outlined here, will work to ensure the mostvulnerable of our nation’s population have access to high-quality, affordable and appropriate dental
and oral health care through all available avenues.

AAOMS looks forward to working with CMS to facilitate access to high-quality, medically necessaryand essential dental and oral health services for Medicare beneficiaries.
Global surgical package valuation

The OMS scope of practice encompasses a broad range of services, from diagnostic and therapeutic
to complex surgical intervention. AAOMS acknowledges that several factors have contributed to an
overall change in how healthcare services are delivered, not the least being advancements inmedical technology, an increasing focus on care coordination and the rapidly evolving healthcare
landscape.

In general, AAOMS supports improving the accuracy of physician payment as well as a more stableand predictable payment methodology under the PFS. However, given the incredibly diverse natureof the over 4,000 physicians’ services paid as global packages under the PFS, it seems unlikely that a
sweeping revaluation of global services would stabilize the Medicare payment system but rather
exacerbate existing sustainability concerns.
Currently, a mechanism exists that allows CMS, specialty societies and other interested parties to
identify potentially misvalued services. The American Medical Association (AMA)/Specialty Society
RVS Update Committee (RUC) Relativity Assessment Workgroup process continues to be an
objective and evidence-based approach for the detection and review of potentially misvalued
services. The process utilizes survey data from the practitioners furnishing these services to verify
the number, level and relative costs of postoperative visits included in the global packages. AAOMS
does not support across-the-board revaluation of services with global periods nor the broad
reduction in RVUs that would likely result. AAOMS encourages CMS to continue to rely on the
Relativity Assessment Workgroup process for the identification of potentially misvalued
services with global periods.

In previous rulemaking, CMS had proposed to transition all 010-day and 090-day global services to
000-day global services, effectively eliminating the concept of the surgical package under the PFS.
AAOMS would like to take this opportunity to reiterate the association’s concerns with thisapproach, should CMS seek to reconsider it.

AAOMS notes the newly established CPT codes for the removal of sutures and/or staples not
requiring anesthesia effective for CY 2023; however, if postoperative care is unbundled, several
other services remain that inclusive to the global surgical package would need to be separately
reported:
•
•
•
•
•
•
•
•

Dressing changes
Local incision care
Removal of operative pack
Removal of lines, wires, tubes, drains, casts, and splints
Insertion, irrigation and removal of urinary catheters
Routine peripheral intravenous lines

Insertion, management, and removal of nasogastric and rectal tubes
Changes and removal of tracheostomy tubes

It is imperative for CMS to ensure physicians are accurately paid for these vital patient careservices, necessitating the creation of new CPT/HCPCS codes, or significant revision to existingcodes, as well as establishing distinct valuation for the physician work, practice expense andmalpractice risk for these services.

Unbundling postoperative services would significantly increase the administrative burden placedon Medicare providers, especially those in small, independent practices, as well as for Medicare
Administrative Contractors and CMS, given the separate submission, processing and payment for
postoperative services and supplies. Aside from the complexity such a change in policy may create
should it fail to be adopted industry-wide, it is not unreasonable to expect that this would shift
incentives back towards volume-based care, something CMS has notably worked to eradicate in the
Medicare program.

Importantly, the unbundling of postoperative services may also place increased financial strain on
patients, requiring them to make co-payments for not only their surgery, but also for eachsubsequent postoperative office visit or service. This will disproportionately impact patients witheconomic insecurities, perhaps working to provide a financial incentive to decline necessary
postoperative care. As such, AAOMS does not support the elimination of global periods under
the PFS.
Evaluation and management (E/M) visits

AAOMS is appreciative of CMS’ acceptance of the RUC’s work RVU recommendations for thehospital inpatient or observation codes, nursing facility codes, home or residence visit codes,
emergency department visits and prolonged services codes.

However, AAOMS is disappointed that CMS continues not to recognize the increased value of
postoperative E/M services included within the global period of surgical procedures, although the
Agency has historically done so. The failure to increase the E/M portion of global services will

foreseeably disrupt the congressionally-mandated relativity within the fee schedule and work tocreate specialty differentials that contradict Medicare statute. AAOMS echoes AMA and RUC
comments and recommends that CMS apply the office visit increases uniformly across allservices and specialties by increasing the relative values of surgical procedures accordingly
for all post-operative E/M services within a surgical global period to retain relativity within
the RBRVS.
If CMS is concerned about the accuracy of the number of postoperative visits included in global
surgical packages, CMS is encouraged to work with the RUC and affected specialty societies toconfirm and/or make new recommendations as specialty societies are most suitable for collecting
the actual resources, work and time associated with rendering surgical procedures.
Prolonged services

AAOMS appreciates the collaborative efforts of CMS and AMA that have resulted in the unified
adoption of a cohesive set of guidelines for reporting office and outpatient E/M services,
implemented in 2021. Effective January 1, 2023, the CPT Editorial Panel has redefined the “other”
E/M services to align with the revised office and outpatient E/M services, bringing the full family of
E/M services under the guidelines that currently govern office and outpatient visit codes. As
proposed for 2023, CMS’ general acceptance and adoption of the revised framework and guidancefor other E/M services seeks to further align coding conventions with current clinical practice andstreamline reporting for these critical and highly utilized services.

AAOMS is disappointed however that CMS has proposed not to accept the CPT coding and guidelinechanges related to prolonged services. Our association has concerns that a bifurcated system forreporting this subset of services will create administrative burden and undue confusion on the partof healthcare providers and coders. To ensure consistency and alleviate unnecessary claims
denials and reimbursement discrepancy for prolonged services, AAOMS encourages CMS towork with the CPT/RUC E/M workgroup to align CMS and CPT prolonged services policies.
Virtual direct supervision

Under Medicare Part B, certain types of services (e.g., many diagnostic tests, services incident tophysicians’ or practitioners’ professional services) must be furnished under the direct supervisionof a physician or practitioner. This requirement was temporarily changed with certain Public
Health Emergency (PHE) waivers to allow the supervising professional to be remote and use realtime, interactive audio-video technology. As many AAOMS members are educators who practice inacademic environments, our association does see the potential long-term benefits of the PHE
waivers for virtual direct supervision.

AAOMS understands and appreciates CMS' continued commitment to patient safety and agrees thata broad expansion of direct supervision via interactive audio-video communication technology may
not be warranted for all services. However, given the ongoing need to mitigate workforce shortages
and ensure the availability of physicians and healthcare providers, AAOMS does support thepermanent expansion of virtual direct supervision for those services demonstrated during
the PHE as safe and effective in the delivery of high-quality, appropriate care under thevirtual direct supervision of a physician working within their scope of practice.
Updates to practice expense data collection and the Medicare Economic Index

The Medicare Economic Index (MEI) serves as a proxy for the economic environment within thehealthcare space, aiming to represent the true cost of doing business across the industry. CMS has
proposed a rebasing of the Medicare Economic Index (MEI) for CY 2023, utilizing aggregate data
sources, including the 2017 data from the United States Census Bureau’s Service Annual Survey(SAS), to update the MEI weights. Although not proposed for implementation in 2023, the rebased
MEI would also be used to calculate updates to practice expense data.

AAOMS appreciates CMS’ intent to reflect current cost inputs more accurately for physician
practices and healthcare organizations, however the association has concerns over the proposed
MEI weights based on the new methodology and data sources. The aggregate data sources
proposed by CMS do not appear to capture data from physician practice owners, only from thosepractitioners considered employed physicians, requiring additional data manipulation on the partof CMS to understand practice owner costs. Therefore, the proposed values of physician work,
practice expense and professional liability insurance (47.3 percent, 51.3 percent and 1.4 percent,respectively) may not be representative of the true cost of physician work and PLI relative topractice expense.

Current MEI weights are based on 2006 data obtained from the AMA’s Physician PracticeInformation (PPI) Survey, last conducted in 2007/2008. CMS has a long-standing history ofcollaborating with the AMA and utilizing the data generated from AMA-led physician surveys forboth direct and indirect practice cost inputs. There has been acknowledgment on both sides thatthe data currently in use is outdated, with the AMA currently engaging in robust data collection for2022 inputs. Given CMS’ historical use of the PPI and the AMA’s current efforts, AAOMS
encourages CMS to continue to collaborate with the AMA in the data collection process andto delay applying updates to the MEI weights under the proposed methodology until the new
AMA survey data are available.
Changing the terminology of skin substitutes

CMS is proposing to replace the term “skin substitutes” with the term “wound management” or“wound management products” which, CMS asserts in the proposed rule, more accurately describe
the suite of products that are currently referred to as “skin substitutes.” CMS is of the belief theterm is misleading as skin substitute products are not a substitute for a skin graft because they do
not actually function like human skin that is grafted onto a wound but rather, these products areapplied to wounds to aid wound healing.

Under the CPT code set, the description of the family of codes that describe skin substitute grafts
accurately captures the procedures related to skin replacement surgery as well as tissue repairs.
Further, the description established by the CPT Editorial Panel clarifies the instances that are, andare not appropriate to report as the application of skin substitutes. From this definition, as well as
individual code descriptors, it is clear that skin substitutes are very specific and separately
reportable from wound dressings. AAOMS believes a change in terminology to “wound
management” would differ from CPT nomenclature and cause confusion and inconsistent reporting.

AAOMS would like to echo the concerns of the AMA RUC regarding the proposed change interminology and would encourage CMS to delay the implementation of such changes until
the matter may be considered by the CPT Editorial Panel.

Thank you for your consideration of these comments. Please contact Patricia Serpico, AAOMS
Director of Health Policy, Quality & Reimbursement, with any questions at 800-822-6637, ext. 4394
or pserpico@aaoms.org.
Sincerely,

J. David Johnson Jr., DDSAAOMS President