Breaking Down the CMS Physician Fee Schedule for 2024

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CMS Physician Proposed Rule 2024
Jan Rasmussen PCS, CPC, ACS-OB,
ACS-GI Professional Coding Solutions
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2023 Conversion Factor

• CY 2023 PFS conversion factor is 33.06
• Decrease of 1.55 to the CY 2022 PFS conversion
  factor of 34.61.
• Many E/M services had RVU reductions from 2022 to
  2023 due to category deletions and combining of
  categories

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2023 CPT E/M Changes

• Extended 2021 documentation guidelines to
  determine a level of E/M service to all
  additional EM services i.e., hospital inpatient,
  hospital observation, emergency department,
  nursing facility, consults, home services/
  residence services and cognitive assessment
• CMS accepted new documentation guidelines and E/M
  code changes except for prolonged services.
• Deleted several code categories in conjunction
  with new combined EM categories.
• Eliminated codes with same decision making
  levels.

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Deleted Codes and Categories

• Deleted Hospital Observation Services E/M codes
  99217-99220
• Deleted Domiciliary, Rest Home (e.g., Boarding
  Home/Assisted Living), or Custodial Care Services
  E/M codes 99324-99238, 99334-99337, 99339, 99340
• Deleted Consultations E/M codes 99241 and 99251

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Combined Categories

• Hospital Inpatient/Observation Care Category
• Codes 99221-99223 and 99231-99233 now include
  both inpatient and observation care
• Same day codes 99234-99236 also now apply to both
  inpatient or observation care
• New CMS add on code G0316 for inpatient/observatio
  n prolonged service to be reported in conjunction
  with 99223, 99233 or 99236
• Do not report G0316 for any time unit less than
  15 minutes
• Do not report G0316 on the same date of service
  as other prolonged services for evaluation and
  management codes 99358, 99359, 99418, 99415,
  99416)

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Combined Categories

• New Home/Residence Services category 99341-99342,
  99344-99345 (new pt) 99347- 99350 (est.pt)
• Consolidation of Domiciliary, Rest Home (eg,
  Boarding Home/Assisted Living) and Custodial Care
  Services combined into one category
• Deletion of Home or Residence Services E/M code
  99343 (moderate decision making) home visit.
• Overlaps with 99244 which also required moderate
  decision making

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Prolonged Services Changes

• New CMS add on code G0317 code for prolonged
  nursing facility service to be reported in
  conjunction with 99306 or 99310.
• Do not report G0317 for any time unit less than
  15 minutes
• Do not report G0317 on the same date of service
  as other prolonged services for 99358, 99359,
  9941

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Split Shared Care

• Split shared care may be billed by the provider
  that furnishes the substantive portion of a
  hospital or nursing facility visit.
• CMS requirements for split shared care in 2023
  remain the same as 2022.
• Clinicians who furnish split (or shared) visits
  will continue to have a choice of
  history, physical exam, or medical decision
  making, or more than half of the
  total practitioner time spent to define the
  substantive portion
• Initially intended to require time as the
  determining factor of substantive portion in
  2023

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Colorectal Cancer Screening

• Expanded Medicare coverage for certain colorectal
  cancer screening tests by reducing the minimum
  age payment limitation to 45 years.
• Expanded the regulatory definition of screening
  colorectal cancer tests to include a follow-up
  after a Medicare covered non-invasive stool-based
  colorectal cancer screening test, 82270
  (Cologuard) and 82272 (hemoccult) returns a
  positive result. 

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Telehealth

• Extended duration of time services are
  temporarily included on the telehealth services
  list during the PHE, but are not included on a
  Category I, II, or III basis for a period of 151
  days following the end of the PHE
• Category 1 Services that are similar to
  professional consultations, office visits, and
  office psychiatry services that are currently on
  the Medicare Telehealth Services List.
• Category 2 Services that are not similar to
  those on the current Medicare Telehealth Services
  List.
• Category 3. Services added to the Medicare
  Telehealth Services List during the PHE for which
  there is likely to be clinical benefit when
  furnished via telehealth, but not yet sufficient
  evidence available to consider the services for
  permanent addition under the Category 1 or
  Category 2 criteria.
• Continued through the end of CY 2023

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Chronic Pain Management

• No existing CPT code that specifically describes
  the work and potential resources of a clinician
  who performs comprehensive, holistic CPM.
• Chronic pain generally defined as persistent or
  recurring pain lasting longer than three months
• Often require longer office visit times, longer
  follow-up coordinating care with social workers
  and case managers, mental and behavioral health
  support, communications with emergency department
  physicians and nurses, and numerous medication
  adjustments
• Prompt more practitioners to welcome Medicare
  beneficiaries with chronic pain
• Expect most services to be billed by primary care
  providers

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Discarded Drugs

• FDA-approved labeling for a drug packaged in a
  single-dose container typically includes
  statements instructing users to discard unused
  portions
• When a provider must discard the amount of drug
  that was unused (that is, the discarded amount)
  from a single-dose container or other single-use
  package of a drug after administering a dose to a
  Medicare beneficiary, the program provides
  payment for the unused and discarded amount as
  well as the dose administered, up to the amount
  of the drug indicated on the vial or package
  labeling.
• JW modifier used to report the amount of a drug
  that is discarded and eligible for payment.

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RHC FQHC

• Now covered in RHC and FQHC chronic pain
  management (G3002) and behavioral health
  integration services (G0323) under G0511.
• When CPs and CSWs furnish the services described
  in HCPCS code G0323 in an RHC or FQHC, they can
  bill HCPCS code G0511.
• May be billed alone or with other payable RHC or
  FQHC services

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