The Medicare Physician Fee Schedule for 2024 was revealed by the Centers for Medicare & Medicaid Services (CMS) on November 2, 2023. This finalized rule outlines modifications slated to begin on January 1, 2024. These changes largely mirror the proposals made in July, with a focus on adjustments pertinent to urology. This article will spotlight these relevant alterations and offer further insights into the final rules that were recently disclosed.
Medicare Physician Fee Schedule Forecasts
The 2024 Medicare Physician Fee Schedule forecasts a reduction of around 3.37% in the conversion factor (CF), dropping from $33.89 in 2023 to $32.74. This decline stems from multiple factors: a 0% statutory update, a 2.17% decrease for budget neutrality, and an additional 1.25% reduction due to the absence of an increase outlined in the Consolidated Appropriations Act of 2023. The CF’s decrease is partly influenced by the reintroduction of the add-on code G2211, which will be explored further in this article. Prior to January 1, 2024, there’s anticipation for Congress to intervene and mitigate this CF decrease.
Effective January 1, 2024, changes to evaluation and management (E/M) services will occur, incorporating the implementation of the add-on code G2211. This code delineates the inherent complexity of visits linked to ongoing care for comprehensive health needs or for a patient’s singular serious or complex condition.
Initially proposed by CMS in 2021, code G2211 aims to compensate physicians for the added efforts in coordinating care for intricate or serious conditions. However, Congress mandated its implementation delay until January 1, 2024. The proposed 2024 implementation of the code involved several revisions addressing previously identified issues. Despite mixed reviews, CMS decided to proceed with the code’s implementation along with the proposed revisions, offering some guidance for its use. While attempts will be made to identify potential issues, it’s anticipated that further clarification from CMS might be necessary if Congress doesn’t act to block the code’s implementation through subsequent measures.
Code G2211 serves as an add-on code to E/M service codes and necessitates an E/M code for the same date of service for reporting. Furthermore, CMS has incorporated code G2211 into the approved list of telehealth services, encompassing both audio-only services, allowing its addition to E/M visits conducted via synchronous audiovisual means and the time-based audio-only codes 99441, 99442, and 99443.
In the 2024 regulations, CMS does not anticipate the add-on code to be reported initially with more than 38% of all billed E/M codes; however, CMS foresees an eventual increase in its utilization to be billed with approximately 54% of all E/M codes over time (Please note: This usage expectation may significantly vary among different specialties).
CMS has outlined specific encounters where the add-on complexity code G2211 is not reimbursable and should not be reported.
• If an E/M service includes a payment modifier, CMS specified in the final rule that the office/outpatient (O/O) E/M visit complexity add-on code isn’t expected to be used when the O/O E/M visit incorporates payment modifiers like modifier -25, indicating separately billed visits alongside another visit or procedure. Thus, if modifier -25 is necessary to report the E/M service due to performing a procedure or service, refrain from using the add-on code G2211.
• Instances where care provided during an office/outpatient E/M visit is delivered by a professional with a discrete, routine, or time-limited relationship with the patient are not appropriate for reporting the add-on code G2211. This encompasses situations like mole removal or referral, treatment for straightforward issues such as a simple virus, counseling for seasonal allergies, initial onset gastro-esophageal reflux disease, fracture treatment, instances lacking co-morbidities or unaddressed co-morbidities, or when the billing practitioner hasn’t taken consistent responsibility for ongoing medical care for that particular patient or doesn’t plan to maintain ongoing medical care consistently for that patient.
CMS anticipates that Add-On Code G2211, representing visit complexity inherent to evaluation and management services integral to comprehensive healthcare or part of ongoing care for a patient’s singular, serious, or complex condition, will be reported in addition to an E/M service for the following scenarios:
1. An E/M visit linked to medical care acting as the ongoing focal point for necessary healthcare or part of ongoing care for a patient’s singular, serious, or complex condition.
2. When the practitioner-patient relationship signifies that the practitioner will oversee all necessary patient care consistently, irrespective of the specific visit’s purpose. This encompasses considering the long-term relationship, even if the visit addresses a transient or short-term problem.
3. For E/M encounters where the practitioner-patient relationship indicates ongoing care responsibility for a single, serious, or complex condition, regardless of the specific visit’s purpose. Again, this requires considering the long-term relationship, even if the visit addresses a transient or short-term issue.
Based on the current directives in the final rule, initial guidance for code G2211 in 2024 is as follows:
• Do not report G2211 if modifier -25 should be appended to the E/M code.
• Report G2211 only when an E/M code is reported for the same date of service.
• Avoid reporting G2211 for encounters involving patients not under your ongoing care for a separate single, serious condition, or a complex condition related to a transient or potentially transient problem (e.g., initial visit for flank pain, urinary tract infection, stone).
• Report G2211 for an E/M visit where total patient care for a single, serious condition, or a complex condition is managed (e.g., benign prostatic hyperplasia, cancer, incontinence).
• Report G2211 for an E/M visit related to a transient or temporary problem (e.g., UTI, stone, flank pain) if there’s an established relationship for ongoing longitudinal care, even if it’s unrelated to the transient problem being treated.
Reimbursement for code G2211 with geographic modification is set at $16.04. Documentation requirements entail support for three general types of visits eligible for reporting code G2211:
1. Documentation for an E/M visit focused on total patient care or ongoing care for a single, serious condition or a complex condition should demonstrate clear direction and a care plan indicating patient return and continued care.
2. Documentation for an E/M visit unrelated or seemingly unrelated to total patient care should show patient return outside the longitudinal care provided, without necessarily addressing the long-term care issue.
3. Documentation for an E/M visit unrelated or seemingly unrelated to the care of a single, serious condition or complex condition should indicate patient return outside the longitudinal care provided, without specifically addressing the underlying long-term care issue.
The implementation of billing for code G2211 should be executed in a manner that doesn’t hinder the practice’s capacity to deliver services while also allowing the separate reporting of principal care management or chronic care management, which can still be reported. Within a urology office, the introduction of this code will necessitate adjustments for both the billing and clinical teams. Here’s a projected list of systems and areas that will likely need attention if the code is adopted as proposed:
• Clinical staff will probably bear the primary responsibility for reporting code G2211. Hence, developing training programs covering documentation requirements and effectively communicating the utilization of G2211 will be essential for the clinical team.
• Refinement of electronic health record templates and the development of communication strategies between billing and clinical aspects will be necessary.
• Education for the billing team concerning payer-specific reporting guidelines and handling situational reporting scenarios will need to be developed and delivered.
• Consideration should be given to updating practice management scrubbers, including modifier flags, and incorporating payer-specific rules into these systems.
• Establishing data review protocols can assist in medical billing processes by analyzing prior patient interactions and billing trends, providing checks to ensure appropriate use of the code.
• Development and implementation of compliance reviews, coupled with follow-up education, will be crucial to ensure adherence to regulations and standards.
Services Divided or Shared
CMS has decided to extend the postponement of the change that mandates the determination of split/shared services policy based solely on the qualified health professional spending the most time with the patient on the date of service for an additional year, now until 2025. A revised guideline for split/shared visits has been incorporated into the American Medical Association (AMA) Current Procedural Terminology 2024 Manual. This guideline outlines instructions where medical decision-making (MDM) or time defines the substantive portion of the visit. If both practitioners document E/M time spent, time may be used, and it must be used if time determines the reported service level.
In cases where MDM determines the service level, billing under the physician is considered appropriate if the physician thoroughly documents the presenting problem, reviews pertinent data used in formulating the care plan, and documents the care plan itself. Mere documentation of reviewing and agreeing with MDM will not suffice. CMS has agreed to adopt this guideline established by the AMA.
Index for Practice Cost Variations by Geography.
The mandated geographic practice cost index (GCPI) floor of 1.0, which was extended until 2023, is now scheduled to expire. Medicare annually provides a Geographic Adjustment Factor (GAF) to estimate how changes in the GCPI affect various locations. This GAF employs a formula considering past Medicare billing to adjust the impact on Work, Practice Expense (PE), and Malpractice (MP) GCPI changes. However, this projection might not accurately depict the GCPI changes specifically for urology or a particular practice. Nonetheless, it serves as a broad estimation, and the GAF acts as a reasonable starting point. For 2024, Medicare has allocated 109 different locations.
The elimination of the GCPI floor will affect Medicare payments across locations differently. Among these, 72 regions are expected to experience a decrease in Medicare reimbursement ranging between 0.1% and 2.6%, in addition to the decline caused by the CF decrease and any alterations in relative value units (RVUs) as previously mentioned. Conversely, five locations will not encounter changes for 2024, while 32 locations are projected to observe an increase in payment ranging between 0.1% and 2.6%. We encourage a thorough review of the GAF and GCPI addenda to better gauge the impact on individual practices.
Adjustments to Cost Relative Value Unit (RVU).
Medicare foresees that the alterations in RVUs for urology will lead to a 1% boost in the overall RVU output for a comparable range of services, incorporating the introduction of Add-on code G2211. While there will be multiple minor tweaks to RVUs in urology, the significant change lies in the post-void residual in the office setting, which will experience an increase or decrease of more than 5%, rising from a non-facility total of 0.32 in 2023 to 0.34 in 2024.
Even though the COVID-19 Public Health Emergency (PHE) has lapsed, the Consolidated Appropriations Act of 2023 mandated Medicare to extend telehealth coverage under PHE regulations until December 30, 2024. In its finalized rule, CMS confirmed that Medicare will uphold telehealth coverage next year as it currently stands. Additionally, CMS made the decision to pay for telehealth services delivered to patients at home at the non-facility rate in 2024. Consequently, using Place of Service Code 10 to report services provided, telehealth services administered while the patient is at home will receive payment equivalent to what would have been reimbursed to the physician had the patient been in the office.
CMS will persist in covering all services provided in the office setting by support staff “incident to” the physician if the physician is available via audio and visual remote connection during the service. Furthermore, CMS will continue covering telephone-only services 99441 through 99443 throughout 2024.
Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Merit-based Incentive Payment System (MIPS).
CMS has confirmed that the threshold for the Merit-based Incentive Payment System (MIPS) will stay at 75 points for 2024. Falling short of this benchmark incurs a penalty of -9% of Medicare payments for MIPS-eligible physicians. CMS attributed its decision not to implement the proposed increase to 82 points to factors such as the COVID-19 Public Health Emergency (PHE) and the absence of pre-pandemic data. Despite the majority of urology practices already meeting the threshold, the postponement of this alteration is seen as a positive development.