On July 13, 2023, CMS issued a proposed rule that identifies and seeks public comments on a broad array of proposed changes to the Medicare Physician Fee Schedule and Medicare Part B payments (the proposed rule). If finalized, the proposed changes would take effect January 1, 2024. The rule addresses a number of policies, especially in the telehealth space, and includes a 3.34% decrease in the conversation factor. Under the Fee Schedule, the conversion factor is the number of dollars assigned to the relative value unit, a key element in how CMS calculates payouts for physicians in Medicare.
Telehealth
In the proposed rule, CMS aims to make a number of policy extensions through 2024. The agency proposes adding health and well-being coaching services to the Medicare Telehealth Services List temporarily for 2024 and permanently for Social Determinants of Health Risk Assessments. The proposed rule also seeks to implement telehealth-related provisions of the Consolidated Appropriations Act of 2023. These changes include allowing telehealth originating sites to include any place where the patient is located, including their home; expanding the definition of telehealth practitioners to include qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists, and qualified audiologists; continuing payment for telehealth services provided by Rural Health Clinics and Federally Qualified Health Centers; delaying the requirement for an in-person visit with a practitioner within six months of initiating mental health telehealth services; and the continuing coverage and payment for telehealth services included on the Medicare Telehealth Services List until December 31, 2024.
CMS also proposes paying for telehealth services at the non-facility physician fee schedule rate for services provided to people in their homes. CMS’s goal is to protect access to mental health and other telehealth services first made available on an extended basis during the COVID-19 public health emergency. The agency further proposes to continue defining direct supervision to allow the supervising practitioner to be present through real-time audio and video interactive telecommunications through December 31, 2024.
Remote Patient Monitoring
CMS has paid for remote patient monitoring, also known as remote physiologic monitoring and remote therapeutic monitoring (RPM and RTM), outside of the statutory restrictions that must be applied to two-way audio/video visits since 2018. As this is a somewhat new development, CMS is still refining the codes and payment for RPM and RTM in each Fee Schedule. This Fee Schedule extended the ability to bill codes for this service to federally qualified health centers and rural health clinics, but did not address the concern many stakeholders have raised related to the requirement that 16 days of data be collected in a month in order to bill the service.
Evaluation and Management Visits
Starting January 1, 2024, CMS proposes a separate add-on payment for healthcare common procedure coding system (HCPCS) code G2211. The add-on code is designed to capture resource costs associated with evaluation and management visits for primary care and longitudinal care of complex patients. The add-on code will generally be available for outpatient office visits. CMS estimates that, if the add-on code is finalized, it will have redistributive effects for all other 2024 payments. CMS originally finalized this policy in 2021, but Congress suspended its use and prohibited CMS from implementing it before 2024.
Appropriate Use Criteria
Established in the Protecting Access to Medicare Act of 2014, the Appropriate Use Criteria (AUC) Program would have required practitioners to consult an AUC using a qualified clinical decision support mechanism before ordering an advanced diagnostic imaging service for a Medicare beneficiary. The program’s purpose was to require clinicians to check whether ordering an advanced imaging service was clinically appropriate in order to avoid ordering “unnecessary” services. Stakeholders have argued that this program would delay necessary care, add administrative burden, and be duplicative of other CMS initiatives that are aimed at reducing costs. CMS seemed to agree with these concerns and continued to delay the full implementation of this program for several years. In this year’s proposed rule, the agency intends to delay the program indefinitely.
Complex Drug Administration
CMS is requesting input from stakeholders regarding CMS “policies on the exclusion of coverage for certain drugs under Part B that are usually self-administered by the patient.” In particular, CMS is seeking feedback on coding and payment policies for complex non-chemotherapeutic drugs in order to “promote coding and payment consistency and patient access to infusion services.”
Physician Groups Unhappy
As reported by Medical Economics, health and physician groups responded negative to CMS’s announcement of the proposed Fee Schedule. Most of the objections focused on the proposed 3.34% reduction in the conversion factor—a major element in the formula used to determine reimbursement rates for specific procedures.
Groups spoke out, such as the Medical Group Management Association. In a release, Anders Gilberg, Senior Vice President of Government Affairs, said the following: “The proposed 2024 Medicare Physician Fee Schedule (PFS) raises significant concerns for medical groups related to its 3.4% reduction to the conversion factor, which further increases the gap between physician practice expenses and Medicare reimbursement rates. Medicare already largely fails to cover the cost of furnishing care to beneficiaries, and the proposed cut to the 2024 conversion factor compounds the problem. Implementation of a new add-on code (G2211) for complex patients highlights CMS’ flawed approach to addressing inadequate Medicare payments for primary care services using a budget neutral methodology. Congress must reexamine existing law to provide an annual physician payment update commensurate with inflation and do away with Medicare’s ‘robbing Peter to pay Paul’ budget neutrality requirements to provide much-needed financial stability for medical practices.”
It is not yet clear if Congress will act, but we will continue to monitor for updates.