What’s happening: The Centers for Medicare & Medicaid Services’ (CMS) 2024 physician fee schedule final rule reduces Medicare payments to physicians by 1.23% compared to the prior year.
What else to know: The final 2024 physician fee schedule conversion factor is $32.74, a decrease of $1.15, or 3.4%, from 2023.
Key provisions of the rule include:
- Evaluation and Management Visits – Split Billing: For calendar year (CY) 2024, for purposes of Medicare billing for split (or shared) services, CMS defines “substantive portion” as more than half of the total time spent by the physician and non-physician practitioner, or a substantive part of the medical decision making as defined by Current Procedural Terminology.
- Evaluation and Management Visits – Add On Code: CMS implements Healthcare Common Procedure Coding System code G2211 to recognize the additional resource costs associated with evaluation and management visits for primary care and longitudinal care.
- Community Health Integration Services: CMS creates separate coding and payment for community health integration services. This includes planning, health system coordination, and facilitating access to community-based resources to address unmet social needs.
- Caregiver Training Services: CMS finalizes paying for caregiver training services in specified circumstances, so that practitioners are appropriately paid for engaging with caregivers to support people with Medicare in carrying out their treatment plans.
- Principle Illness Navigation: CMS finalizes payment for services to help patients navigate certain serious illnesses (e.g., dementia, HIV/AIDS, cancer). These services also include care involving other peer support specialists, such as peer recovery coaches for individuals with substance use disorders.
- Telehealth: CMS finalizes policies required by the Consolidated Appropriations Act (CAA) of 2023 that extend certain telehealth flexibilities through 2024. CMS also finalizes its policy to pay for telehealth services furnished to people in their homes at the higher non-facility physician fee schedule rate. This is designed to protect access to these services, recognizing the costs of maintaining both an in-person practice setting and a robust telehealth setting. In response to comments from CHA, CMS will not require practitioners who render telehealth services from home to report their home address on enrollment and claims forms, through the end of 2024, and solicits comments on this policy for future rulemaking.
- Remote Therapy Services: CMS finalizes a proposed policy that will continue to allow institutional providers to bill for outpatient therapy services furnished remotely to patients in their homes at least through the end of CY 2024. CMS modifies its proposal to clarify that these claims should include modifier 95 and to note specifically for outpatient hospitals that patients’ homes no longer need to be designated as provider-based entities.
- Behavioral Health Services: CMS finalizes policies to allow marriage and family therapists and mental health counselors, including addiction counselors, to enroll in Medicare and bill for their services beginning with CY 2024. The rule also increases payment for crisis care, substance use disorder treatment, and psychotherapy.
- Payment for Dental Services Prior to Cancer Treatment: The rule finalizes payment for certain dental services prior to and during certain cancer treatments, including chemotherapy, CAR-T, and antiresorptive therapy.
- Medicare Shared Savings Program (MSSP): The rule finalizes changes to the MSSP. The most significant changes include:
- Benchmarking methodology designed to encourage accountable care organizations (ACOs) to care for complex populations.
- Using assignment methodology to account for beneficiaries who receive primary care from nurse practitioners, physician assistants, and clinical nurse specialists. This change is designed to attribute more underserved beneficiaries to ACOs.
- Finalizes the adoption of Medicare CQMs as a new quality measure collection type for Shared Savings Program ACOs under the Alternative Payment Model Performance Pathway. A fact sheet specific to these policies is available on CMS’ website.
- Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Program: CMS formally pauses implementation of its AUC program, which had previously been referenced in sub-regulatory guidance.
- Clinical Laboratory Fee Schedule (CLFS) Private Payer Rate Reporting: As required by the CAA of 2023, CMS delays the CLFS private payer rate reporting period to Jan. 1-March 31, 2024; the data collection period remains Jan. 1-June 30, 2019. CMS also makes conforming changes to requirements for the phase-in of CLFS payment reductions so that payment may not be reduced by more than 15% as compared to the payment amount established for that test for the preceding year.
- Quality Payment Program (QPP): CMS finalizes several changes to the QPP program, including five new, optional merit-based incentive payment system (MIPS) value pathways. CMS also finalizes an increase to the performance threshold score that MIPS participants must achieve to earn positive payment adjustments but did not finalize an increase to the quality data completeness threshold as proposed. For the Advanced Alternative Payment Model track of the QPP, CMS will offer Advanced APM Incentive Payments in CY 2025 to those qualifying clinicians, as required by the CAA of 2023. A detailed fact sheet describes the QPP proposals.
CHA is currently reviewing the rule and will make a detailed summary available to members soon.