Last week, the Centers for Medicare and Medicaid Services (CMS) issued its final rule for the calendar year 2024 Physician Fee Schedule (MPFS). At over 2,700 pages, the final rule provides lengthy discussions of key policy changes to the MPFS. While CMS issued a helpful summary of the major changes in the fact sheet located at this link, the document does not explore key details about new policy in the rule. To better understand the changes, this edition of Insights InHealth summarizes a few of the key changes that will materially impact the operations of medical groups, with a focus on three areas: (1) the addition of key new current procedural terminology (CPT) codes, and (2) noteworthy changes to billing rules and policies. To facilitate your review of the rule in the federal register, we have provided page references in [brackets] throughout this document.
Before diving into the other changes, we highlight the new finalized conversion factor of $32.7442. The conversion factor represents a decrease of roughly 3.4% from the prior conversion factor of $33.8872. CMS anticipates that utilization of the new CPT codes will result in higher spending, which will partially offset the decrease, leading to an overall reduction in spending of 1.25% using the new conversion factor. Between specialties, primary care providers (e.g., family practice) are expected to see the most significant increase in reimbursement, mostly attributable to addition of the new office/outpatient evaluation/management visit complexity add-on CPT code (discussed further below). Procedure-driven specialties (e.g., interventional radiology) are expected to see the largest decreases in reimbursement. Overall, CMS is continuing its trend towards shifting reimbursement away from procedure-driven specialties to primary care specialties. This shift is being implemented in a “budget neutral” manner, though the wisdom of this approach in light of rampant inflation is beyond the scope of this article.
The most significant addition to the CPT roster is the new add-on code for O/O E/M visits intended to capture the complexity of a primary care physician serving as the focal point for all health services or for other physicians managing an ongoing serious medical condition (HCPCS code G2211). This code was introduced in 2021, but implementation was delayed until this final rule. The new code can be billed in conjunction with O/O E/M visits (e.g., 99202-5 and 99211-5), but not inpatient E/M services.
The following quote summarizes CMS’s view of the applicability of the add-on code to existing E/M services: “We note that the application of the add-on code is not based on the characteristics of particular patients…but rather the relationship between the patient and the practitioner.” [Emphasis added] The code is not intended to be billed in conjunction with E/M services that are related to care involving a discrete, routine, or time-limited nature (“longitudinal, non-procedural care”). Essentially, the code will apply to primary care services and services involved in the ongoing management of a serious condition (e.g., cancers requiring chemotherapy).
The add-on code will be assigned .49 relative value units (RVUs), of which .33 are work RVUs (wRVUs), .14 are non-facility practice expense RVUs (peRVUs), and .02 are malpractice RVU (mpRVUs). The code cannot be billed in conjunction with modifier -25 (service billed on the same day as a minor procedure or another E/M visit by the same practitioner). CMS estimates that roughly half of all E/M services will be eligible for the new code, resulting in a 2% increase in total Part B spending. This impact drove a substantial proportion of the decrease in the conversion factor.
As CMS has prioritized health equity as a key pillar of Medicare and Medicaid programs, the 2024 Final Rule contains new CPT codes intended to advance this objective. In order to better care for underserved populations, providers have a key role to play in addressing health-related social needs. Until the new final rule, this crucial work was not reimbursable by Medicare. The 2024 Final Rule adds seven key new CPT codes that pertain to these services. The table below summarizes the codes and their RVU amounts.
Here are some highlights related to the codes above:
Given the nature of these services, practices that have advanced capabilities in team-based care and data analytics related to value-based care stand to benefit from the additional reimbursement for activities essential to their care delivery models.
Given the critical role of caregivers in helping effectively treat underlying medical conditions, CMS finalized three new CPT codes for caregiver training provided by physicians or other qualified health professionals. The codes will reimburse for either individualized or group face-to-face training services provided to caregivers without the patient present. The caregiver training must be focused on facilitating a patient’s activities of daily living, reducing the impacts of a condition on a patient, and carrying out a treatment plan. The table below summarizes the codes and the RVU values.
The CPT code for group training (97552) is billed per person trained within the group.
As was the case in the 2023 Final Rule, CMS elected to postpone for another year their redefinition of what constitutes the “substantive portion” of a split/shared visit for the purpose of attributing credit to the visit to either the physician or advanced practice professional. For more background on split-shared billing rules, reference this prior Insight. This postponement will allow for split-shared visits to be attributed to the provider that performs the medical decision making associated with a visit, regardless of the distribution of face-to-face time associated with patient care. CMS is continuing to track utilization patterns associated with split-shared billing practices and may revisit its current position in future rulemaking.
A few notable changes were made regarding CMS’s telemedicine services policies. CMS added health and well-being coaching to the list of services eligible to be billed through telemedicine (CPT codes 0591T, 0592T, and 0593T). These services are provided by certified health and wellness coaches for the purpose of effecting the lifestyle changes needed to treat and manage conditions like diabetes, chronic pain, and depression without costly medical intervention. In addition, Medicare added the new CPT code, G0136, for SDoH assessment tool administration to the telemedicine services list. Of note, the CPT codes for CHI and PIN services do not typically require face-to-face interaction, so CMS indicated that those services could be billed similarly to other communications-based technology services (e.g., remote patient monitoring).
The 2024 Final Rule also codified significant changes to telemedicine policy that were originally proposed in the Consolidated Appropriations Act of 2023. These are summarized below:
The sum total of these changes will facilitate the financial viability of telemedicine providers that serve Medicare beneficiaries, at least through the end of 2024. In particular, the final two changes are essential for improving access to professional care through telemedicine given the costs associated with such services and the ability for physicians to simultaneously supervise care team staff spread over multiple geographic locations.
Similar to the telemedicine policy changes and in keeping with the Biden administration’s focus on improving mental health, CMS finalized a number of important changes to Behavioral Health Services, as summarized below:
As with the changes to telemedicine policy, these updates will increase access to care, as well as reimbursement for behavioral health services.
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