- The proposed conversion factor is $32.75.
- Several proposed updates will help providers assess and address social determinants of health factors that may play a role in the overall health of beneficiaries.
- Proposals to pay for training for caregivers reflect the role these individuals play in providing successful care to Medicare beneficiaries.
Need help determining how the new CMS rules will affect your organization?
The Centers for Medicare & Medicaid Services (CMS) released its proposed rule related to the 2024 Physician Fee Schedule (PFS), including a decrease in the conversion factor. This won’t be welcome news for physicians considering the continuing high costs of practicing medicine.
The proposed new policy includes many changes, including some related to the hot topics of telehealth and social determinants of health. This regulatory advisor will summarize some of the key changes but does not include all provisions. To review the entire rule, visit the Federal Register.
Industry in context
Physician reimbursement cuts have long been an issue. First, it was the sustainable growth rate necessitating annual Congressional intervention. Now it’s the evolution of the Medicare Access and CHIP Reauthorization Act payment structure setting up a similar scenario where Congress has had to intervene in recent years.
CMS’s proposed rule decreases the conversion factor by 3.34% over the prior year. This is due to prior congressional relief expiring, as well as a budget neutrality adjustment. Statute requires CMS to offset any estimated increases of $20 million or more because of payment adjustments or addition of new services with cuts elsewhere. If the physician fee schedule is implemented as proposed, 2024 will be a reduction in reimbursements, which is at odds with the cost of practicing medicine, considering inflation, supply costs, and a tough labor market.
No one wants to revert to the annual congressional dance of stopping cuts, which is why many are advocating for a longer-term solution. Given the current political climate and financial impact a fix could have, that fix will likely not occur this year.
CMS proposes a $32.75 conversion factor
The proposed conversion factor reflects a 3.34% decrease over the 2023 factor.
Practice expense determination
CMS has undertaken a multi-year effort to update methodology used to determine practice expense (PE). In the 2023 rule, CMS issued a request for information to receive public comment on potential strategies to update PE data collection and methodology. CMS continues to request comment on this subject, as well as ask more specific questions:
- Should CMS consider aggregating data for certain specialties to create indirect allocators so practice expense calculations based on PPIS data would be less likely to over or under allocate indirect PE to a set of services, specialties, or practice types? If so, how should CMS approach establishing these aggregations?
- Does aggregation of services represent a “fair, stable, and accurate” means to account for indirect PEs across specialties or practice types?
- Should CMS balance factors that influence indirect PE inputs when these factors are likely to be driven by a difference in geography or setting of care? If so, how should CMS approach this?
Caregiver training services
Historically, CMS has taken the position that codes describing services provided to caregivers without the patient present are not covered services. However, in response to public comment in recent years regarding the empirical support for training parents, guardian, and caregivers, in specific patient circumstances CMS proposes an active payment status for the following codes:
|96202||Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); initial 60 minutes|
|96203||Multiple family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); each additional 15 minutes (list separately in addition to code for primary service)|
|9X015||Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding problem solving, safety practices) (without the patient present), face-to-face; initial 30 minutes|
|9X016||Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., ADLs, IADLs, transfers, mobility, communication, swallowing, feeding problem solving, safety practices) (without the patient present), face-to-face; each additional 15 minutes (list separately in addition to code for primary service)|
|9X017||Group caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (e.g., ADLs, IADLs, transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face with multiple sets of caregivers)|
In addition, CMS proposes to define “caregiver” for the purpose of caregiver training services as “an individual who is assisting or acting as a proxy for a patient with an illness or condition of short or long-term duration (not necessarily chronic or disabling); involved on an episodic, daily, or occasional basis in managing a patient’s complex health care and assistive technology activities at home; and helping to navigate the patient’s transitions between care settings.” CMS is seeking comment on this definition and is particularly interested in whether any additional elements of a caregiver should be incorporated.
Recognizing and addressing social determinants of health
As a result of increasing recognition within healthcare that it is essential to consider social determinants of health (SDOH) when providing services, CMS proposes to establish a new stand-alone G code, GXXX5 (administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5 – 15 minutes, not more often than every six months). The risk assessment would be required to be administered on the same day as an evaluation and management (E/M) visit, have been validated through research, and include food insecurity, housing insecurity, transportation needs, and utility difficulties. Other areas may be assessed if applicable within the practitioner’s community.
In addition, CMS proposes the creation of two new G codes to better recognize work done by non-physician personnel in recognizing and addressing SDOH risk factors. The codes are as follows:
|GXXX1||Community health integration services performed by certified or trained auxiliary personnel, including a community health worker, under the direction of a physician or other practitioner; 60 minutes per calendar month, in the following activities to address social determinants of health (SDOH) need(s) that are significantly limiting ability to diagnose or treat problem(s) addressed in an initiating E/M visit:
|GXXX2||Community health integration services, each additional 30 minutes per calendar month (list separately in addition to GXXX1)|
In addition, CMS proposes the following G codes for Principal Illness Navigation (PIN) services:
|HCPCS G Code||Descriptor|
|GXXX3||PIN services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator or certified peer specialist; 60 minutes per calendar month, in the following activities:
|GXXX4||PIN services, additional 30 minutes per calendar month (list separately in addition to GXXX3)|
CMS additionally seeks comment on the typical amount of time practitioners spend monthly providing services to address SDOH needs that may be obstacles to the diagnosis and treatment of issues addressed within an E/M visit to determine whether a frequency limit may be relevant.
Remote therapeutic monitoring
CMS proposed several clarifications to remote therapeutic monitoring (RTM) and remote physiologic monitoring (RPM), including:
- 16-day data collection minimums apply to RPM and RTM code families in CY 2024
- While RPM and RTM can be billed concurrently with carious care management services, RPM and RTM may not be billed together, so that no time is counted twice by billing for concurrent services
CMS additionally requests commentary on the proposed clarifications as well as general feedback on further developing RTM and RPM payment policies.
Evaluation and management visits
In the 2021 PFS final rule, CMS refined the office/outpatient E/M visit complexity add-on code:
HCPCS Code G2211— Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)
The Consolidated Appropriations Act, 2021 placed a moratorium on Medicare payment for HCPCS code G2211 that expires December 31, 2023. CMS proposes to change the status of the code, effective January 1, to make it separately payable by assigning the “active” status indicator. In addition, CMS is proposing several refinements, including that HCPCS code G2211 would not be payable when the E/M visit is reported with payment modifier -25, indicating a separately billable E/M visit provided on the same day of a procedure or other service by the same practitioner.
In addition, CMS proposes to delay the implementation of the revised definition of the “substantive portion” as more than half of the total time of a split/shared E/M visit through at least December 31, 2024.
Payment for vaccine administration
CMS proposes continuing additional payments established during the COVID-19 public health emergency (PHE) for in-home COVID-19 vaccine administration, as well as extending the additional payments to the in-home administration of pneumococcal, influenza, and hepatitis B vaccines. Effective January 1, 2024, the in-home administration payment amount for all four vaccines would be identical.
Expanding behavioral health payment
Section 4121 of the Consolidated Appropriations Act, 2023 (CAA, 2023) provides for Medicare Part B coverage and payment for services of marriage and family therapists (MFTs) and mental health counselors (MHCs) when billed. CMS will implement this change in 2024, proposing that MFTs and MHCs be allowed to enroll in Medicare after the final 2024 PFS rule is published.
In addition, CMS proposes an updated descriptor to HCPCS code G0323 to reflect these changes. The proposed descriptor reads: “Care management services for behavioral health conditions, at least 20 minutes of clinical psychologist, clinical social worker, mental health counselor, or marriage and family therapist time, per calendar month. (These services include the following required elements: Initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, coordination with and/or referral to physicians and practitioners who are authorized by Medicare to prescribe medications and furnish E/M services, counseling and/or psychiatric consultation; and continuity of care with a designated member of the care team.)”
CMS additionally solicits comment on any other HCPCS codes that may require updating to allow MFTs and MHCs to bill for services included in the HCPCS code description.
Expanding Medicare payment for dental services
In the CY 2023 PFS final rule, CMS specified certain clinical cases where payment for dental services is permitted under both Medicare parts A and B. These cases involve conditions where the successful treatment of a covered procedure or treatment is inextricably linked to the treatment of dental conditions, such as infection. CMS is proposing several technical changes to enhance the clarity of the regulation text, as well as additional policies to permit payment for dental services. In particular, CMS identifies the following situations where dental services are inextricably linked to the success of covered treatments and as a result the dental exclusion would not apply:
- Chemotherapy when used in cancer treatment
- CAR T-Cell therapy when used in cancer treatment
- Antiresorptive therapy when used in cancer treatment
Medicare Part B drug payments
The Inflation Reduction Act included several provisions involving Medicare payment for drugs. CMS is proposing conforming language, including limiting beneficiary spend for insulin to $35/month.
The 2023 Physician Fee Schedule finalized reporting requirements for single-dose container or single-use package drugs, including use of the JW modifier for reporting discarded amounts and JZ modifier to report drugs with no discarded amounts. CMS will begin editing for correct use of the modifiers October 1, 2023. However, because CMS believes it is unreasonable to require patients or caregivers self-administering drugs at home to provide data about discarded amounts, CMS proposes to require drugs separately payable under Part B furnished by a supplier who is not administering the drug be billed with the JZ modifier.
CMS proposes the initial refund report will be provided to manufacturers no later than December 31, 2024, then provide the second refund report no later than September 30, 2025. Subsequent reports will be released annually in September.
Appropriate use criteria for diagnostic imaging
The Protecting Access to Medicare Act of 2014 created a program to increase the rate of appropriate advanced diagnostic imaging, such as PET and MRI scans, provided under Medicare. The program required that when an order was placed for an advanced diagnostic imaging service, the provider would be required to use an electronic portal to assess acceptable use criteria (AUC).
The program was set to be fully implemented on either January 1, 2023. In response, concerns including inappropriate denial of claims, increase of provider burden, and the potential for beneficiaries to be financially liable for services were raised by stakeholders. In addition, value-based care incentives, including the Quality Payment Program and the Medicare Shared Savings Program, as well as electronic clinical quality measures have accomplished many of the goals of the AUC program.
In the 2024 proposed rule, CMS proposes to pause implementation of the AUC program and rescind current program regulations, as well as ending the educational and operations testing period.
The proposed Medicare telehealth originating site facility fee is $29.92.
During the COVID-19 PHE, CMS used a three-category system for adding new services to the Telehealth Service List. Category one included services like those already on the list while Category two included services not like those already on the list but where there was significant evidence telehealth services would improve diagnosis or treatment. Category three was created to encompass services added to the list during the COVID-19 PHE with insufficient evidence to be included in Category two.
In 2024, CMS proposes reverting to a two-category system for additions to the Telehealth Services List, designating additions as either permanent or provisional. CMS proposes codes currently included in the Telehealth Services List under Categories 1 and 2 will receive the permanent designation, while those included in Category 3 will be designated “provisional.” CMS also is proposing new steps for analysis of services under consideration for addition, removal, or change in status on the Medicare Telehealth Services List:
- Step 1 — Determine whether the service is separately payable under the PFS.
- Step 2 — Determine whether the service is subject to the provisions of section 1834(m) of the act.
- Step 3 — Review the elements of the service as described by the HCPCS code and determine whether each of them is capable of being furnished using an interactive telecommunications system as defined in code section 410.78(a)(3).
- Step 4 — Consider whether the service elements of the requested service match the service elements of a service on the list that has a permanent status described in previous final rulemaking.
- Step 5 — Consider whether there is evidence of clinical benefit analogous to the clinical benefit of the in-person service when the patient, who is located at a telehealth originating site, receives a service furnished by a physician or practitioner located at a distant site using an interactive telecommunications system.
Codes proposed to be added to the Telehealth Services List on a temporary basis for 2024:
- CPT Code 0591T (Health and well-being coaching face-to-face; individual, initial assessment)
- CPT code 0592T (Health and well-being coaching face-to-face; individual, follow-up session, at least 30 minutes)
- CPT Code 0593T (Health and well-being coaching face-to-face; group – 2 or more individuals, at least 20 minutes)
CMS proposes adding HCPCS code GXXX5 (administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes) to the Medicare Telehealth Services list permanently, contingent upon finalizing the service code description proposed.
Telehealth provisions in the Consolidated Appropriations Act, 2023
The CAA, 2023 included several provisions that affect telehealth policies finalized in the 2023 final rule, including:
- Delaying the requirement for an in-person visit with a physician or practitioner within six months prior to the initial mental health telehealth service, and again at subsequent intervals as the secretary finds appropriate. The in-person requirements will be effective on January 1, 2025.
- Expanding telehealth originating sites for any service on the Medicare Telehealth Services List to include any site in the U.S. where the beneficiary is located at the time of the service, including an individual’s home, through December 31, 2024.
- Requiring that qualified occupational therapists, physical therapists, speech-language pathologists, and audiologists continue to be included as telehealth practitioners through December 31, 2024. In addition, marriage and family therapists and mental health counselors will be recognized as telehealth practitioners effective January 1, 2024.
Place of service codes
During the COVID-19 PHE, many behavioral health services that would have been provided in person were provided via telehealth. This increase in utilization has been maintained even after the end of the PHE, and many practitioners maintain both office and telehealth visits — meaning their practice expenses are more like the non-facility rate.
As a result, CMS proposes claims billed with POS 10 (Telehealth Provided in Patient’s Home) will be paid at the non-facility PFS rate starting in CY 2024. Claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will maintain the PFS facility rate beginning January 1, 2024.
Removing frequency limitations on telehealth subsequent care services
When certain services were added to the Telehealth Services List in the past, the addition included frequency limitations to restrict how often a service could be provided via telehealth. During the COVID-19 PHE, these limitations were relaxed through December 31, 2023. CMS proposes to remove telehealth frequency limitations during CY 2024 for the following codes:
|99231||Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward or low level of medical decision making. When using total time on the date of the encounter for code selection, 25 minutes must be met or exceeded.|
|99232||Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 35 minutes must be met or exceeded.|
|99233||Subsequent hospital inpatient or observation care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 50 minutes must be met or exceeded.|
|99307||Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded.|
|99308||Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded.|
|99309||Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded.|
|99310||Subsequent nursing facility care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded.|
|G0508||Telehealth consultation, critical care, initial, physicians typically spend 60 minutes communicating with the patient and providers via telehealth.|
|G0509||Telehealth consultation, critical care, subsequent, physicians typically spend 50 minutes communicating with the patient and providers via telehealth.|
Rural Health Clinics and Federally Qualified Health Centers
In addition to the updates detailed below, CMS proposes making updates to reflect provisions in the CAA, 2023, including extending payment for telehealth services provided by RHCs and FQHCs through December 31, 2024, and delaying in-person requirements for mental health services provided via telehealth until January 1, 2025.
Updates to payment methodologies
CMS proposes to include licensed marriage and family therapists or mental health counselors as RHC and FQHC practitioners effective January 1, 2024. In addition, the following services can be considered an RHC or FQHC visit for Medicare payment:
- Transitional care management services
- Diabetes self-management services provided by a certified program
- Medical Nutrition Therapy sessions provided by a certified program
CMS proposes to allow RHCs and FQHCs to receive payment for RPM and RTM in addition to RHC inclusive rates and FQHC per visit payments. RPM and RTM services may be billed using HCPCS G code G0511, a general care management code.
To address increasing evidence that social determinants of health are key in successfully providing care to many populations, CMS proposes allowing RHCs and FQHCs to receive payment using HCPCS G codes GXXX1 and GXXX2, as discussed above. Proposed PIN G Codes GXXX3 and GXXX4 also apply to RHCs and FQHCs.
Medicare Shared Savings Program
CMS proposes several modifications to the Shared Savings Program:
- Revising quality reporting and performance requirements, including updating the APP measure set for Shared Savings Program Accountable Care Organizations (ACO), revising the health equity adjustment underserved multiplier calculation, and requiring Spanish language administration of the CAHPS for MIPS survey
- Revising policy for determining beneficiary assignment, including modifying the step-wise beneficiary assignment methodology
- Revising policies on benchmarking methodology, including modifying the calculation of the regional update factor used when updating the historical benchmark between benchmark year three and the performance year to provide more equitable treatment for ACOs
- Refining advance investment payment policies, including modifying AIP eligibility requirements to allow an ACO to choose to advance to a two-sided model level beginning with the third performance year of the five-year agreement in which the ACO received AIPs, as well as modifying termination policies to specify that AIPs would immediately terminate if an ACO voluntarily terminates from the Shared Savings Program
- Updating Shared Savings Program eligibility requirements, including removing the option for ACOs to request a shared governance requirement exception
Quality Payment Program
CMS proposes increasing the performance threshold from 75 to 82 points for all three MIPS reporting options.
MIPS Value Pathways
CMS is proposing five new MIPS Value Pathways:
- Focusing on Women’s Health
- Prevention and Treatment of Infectious Disease, including Hepatitis C and HIV
- Quality Care in Mental Health and Substance Use Disorders
- Quality Care for the Treatment of Ear, Nose, and Throat Disorders
- Rehabilitative Support for Musculoskeletal Care
In addition, CMS proposes revisions to several aspects of all MIPS pathways, including but not limited to quality measures, cost performance, and MIPS payment adjustments.
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