Breaking Down the 2024 CMS Physician Final Regulations

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CMS 2024 Final Rule Find out What CMS has
Finalized from the Proposed Rules
Jan Rasmussen PCS, CPC, ACS-OB, ACS-GI
Professional Coding Solutions 715.595.4278
janrpcs_at_aol.com
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2024 PFS Rate Setting

• CMS states overall physician payments must be
  budget neutral
• CMS cant improve payment in any area of the fee
  schedule without cutting it somewhere else.
• The conversion factor may be reduced to offset
  CPT codes with increases and newly introduced
  codes.
• CMS is proposing significant increases in payment
  for primary care and other kinds of direct
  patient care.

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2024 Conversion Factor

• CY 2024 PFS conversion factor is 32.74
• Decrease of 1.15 to the CY 2023 PFS conversion
  factor of 33.89.
• Final rule includes implementation of policies
  mandated by Congress in the Consolidated
  Appropriations Act, 2023.

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G2211

• Originally introduced in CY 2021 and delayed
  until this years final rule.
• Encourage holistic, patient-centered care that
  involves collaboration and coordination across
  specialties and provides continuity and
  consistency in patient care. 
• Establish meaningful relationships with patients
  and address their health care needs with
  consistency and continuity.
• Stronger clinician-patient relationships can lead
  to improved functional health for patients
• Not limited to any specific specialty but must
  have ongoing medical relationship with patients
  care

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Split Shared Care

• Services billed using the physicians NPI are
  paid at a 100 of the PFS rate
• 15 reduction of PFS rate for services billed by
  QHP
• CMS requirements for split shared care in 2024
  were supposed to be based on total time to
  determine the substantive portion.
• Significant change under the 2024 final rule.
• Substantive portion now either 50 of the
  total practitioner time or substantive portion of
  medical decision making.

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Maternity Services

• Increased RVUs for global maternity codes 59400,
  59410, 59510, 59515, 59610, 59614, 59618, 59622)
  to allow for previous increases in values of
  office/outpatient E/M services
• Global codes that provide a single payment for
  almost 12 months of services include a relatively
  large number of E/M visits performed along with
  delivery services and imaging

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Caregiver Training (CTS)

• Caregiver adult person who helps care for
  someone who is ill, disabled, or aged.
• Recognize and pay for two existing CPT codes
  which are currently considered bundled.
• 96202 Multiple-family group behavior
  management/modification training for 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
• Requires full 60 minutes before billing add on
  service
• 96203each additional 15 minutes

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New Auxiliary Services

• Three new types services that may be provided by
  auxiliary personnel incident to the billing
  physician or practitioners professional
  services, and under the billing practitioners
  supervision, when reasonable and necessary to
  diagnose and treat the patient
• Social Determinants of Health Risk Assessment
  (SDOH)
• Community Health Integration Services
• Principal Illness Navigation

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SDOH Risk Assessment

• Implemented a new code to separately identify and
  value a SDOH risk assessment furnished in
  conjunction with an E/M visit.
• G0136, Administration of a standardized,
  evidence-based Social Determinants of Health Risk
  Assessment, 5-15 minutes, not more often than
  every 6 months
• Review of the individuals SDOH or identified
  social risk factors that influence the diagnosis
  and treatment of medical conditions
• Work RVU of 0.18
• Permanently added to telehealth list including
  audio only

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Community Health Integration

• Two new G codes describing CHI services performed
  by certified or trained auxiliary personnel
  incident to the professional services and under
  the general supervision of the billing
  practitioner.
• G0019 Community health integration services
  performed by certified or trained auxiliary
  personnel, including a CHW, 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
• RVU 1.00
• G0022each additional 30 minutes
• RVU 0.70

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Principle Illness Navigation

• Services to help people with Medicare who are
  diagnosed with high-risk conditions e.g.,
  cancer, mental health conditions, substance use
  disorder (SUD) etc identify and connect with
  appropriate practitioners and providers in a
  timely manner for care and support resources
• CMS believes most important when a patient is in
  the initial stage of treatment as delay in care
  could be detrimental/deadly to the patient

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PIN-PS

• G0140 Principal Illness Navigation Peer
  Support by certified or trained auxiliary
  personnel under the direction of a physician or
  other practitioner, including a certified peer
  specialist 60 minutes per calendar month, in the
  following activities
• RVU 1.00, crosswalked to 99490, non complex
  chronic care management (first 20 minutes)
• G0146additional 30 minutes per calendar month
• RVU 0.70 crosswalked to 99439 (additional 20
  minutes) non complex CCM

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Telehealth

• Implemented several telehealth-related provisions
  of the Consolidated Appropriations Act, 2023
  (CAA, 2023),
• Temporary expansion of the scope of telehealth
  originating sites for services furnished via
  telehealth to include any site in the US where
  beneficiary is located at the time of the
  telehealth service, including an individuals
  home
• Finalizing refinements to process to analyze
  requests received for the addition of services to
  the Medicare Telehealth Services List
• Including determination on whether the requested
  services should be added permanently or
  provisionally. 

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Behavioral Health Services

• Implemented provisions from the Consolidated
  Appropriations Act, 2023 (CAA), which provides
  for Medicare Part B coverage and payment under
  the Medicare Physician Fee Schedule for the
  services of marriage and family therapists (MFTs)
  and mental health counselors (MHCs)
• Allow MFTs and MHCs to enroll in Medicare.
• Allow addiction counselors that meet all the
  applicable requirements to be an MHC to enroll in
  Medicare as MHCs.
• Taxonomy codes
• 106H00000X Marriage and Family therapists
• 101YM0800X Behavioral Health Social Services
• 101YA0400X Addiction Counselors
• Also applies to RHC and FQHC services

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Behavioral Health Services

• Health Behavior Assessment and Intervention
  (HBAI) CPT codes 96156, 96158, 96159, 96164,
  96165, 96167, and 96168, and any successor codes,
  may be billed by clinical social workers, MFTs,
  and MHCs, in addition to clinical psychologists
• Used to identify the psychological, behavioral,
  emotional, cognitive, and social factors included
  in the treatment of physical health problems.
• Allow for better integration of physical and
  behavioral health care,
• Behavioral health can significantly impact
  physical health illnesses.

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Preventive Vaccine Administration

• Additional payment for the administration of a
  COVID-19 vaccine in the home.
• Extend in-home additional payment to the
  administration of three preventive vaccines
  included in the Part B preventive vaccine benefit
  the pneumococcal, influenza, and hepatitis B
  vaccines
• Payment amount for the in-home administration of
  all four vaccines will be identical
• Limit additional payment to one payment per home
  visit, even if multiple vaccines are administered
  during the same home visit

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Diabetes

• Expand coverage of diabetes screening to include
  the Hemoglobin A1c (HbA1c) test.
• Expand diabetes screening frequency limitations
• Remove the specific clinical test criteria from
  the codified definition of diabetes for
  screening, MNT and DSMT

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Dental Oral Health Services

• Change 2023 finalized rule payment policy for
  dental services prior to, or during, head and
  neck cancer treatments, whether primary or
  metastatic. 
• Permit payment for certain dental services
  inextricably linked to other covered services
  used to treat cancer chemotherapy services,
  Chimeric Antigen Receptor T- (CAR-T) Cell
  therapy, and the use of high-dose bone modifying
  agents (antiresorptive therapy).
• Improve the success of cancer-related treatments
  and increase access to certain dental care.
• Seeking comment on additional circumstances where
  evidence supports dental services being integral
  to the clinical success of covered medical
  services.

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Discarded Drugs

• Final rule 2023 implemented rules requiring
  Manufacturers of Certain Single-dose Container or
  Single-use Package Drugs to Provide Refunds with
  Respect to Discarded Amounts
• Many drugs and biologicals payable under Medicare
  Part B are dosed in a variable manner such that
  the entire amount identified on the vial or
  package is not administered to the patient
• Often times, these drugs are available only in
  single-dose containers designed for use with a
  single patient as a single injection or infusion

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