The Centers for Medicare and Medicaid Services (CMS) released its final rule updating the Medicare physician fee schedule for calendar year 2024 (Final Rule). Key proposals concerning the Medicare Physician Fee Schedule will impact allergy practices.
Cuts to Physician Reimbursement
The 2024 conversion factor for Physician Fee Schedule payments is $32.74 – a decrease of $1.15 (3.4%) from the 2023 conversion factor of $33.89. The decrease is calculated from the required budget neutrality adjustment, the expiration of the 2.5% payment increase for 2023, and the 1.25% increase for 2024.
This conversion factor decrease is expected to materially impact reimbursement to Medicare providers, including allergists. The 2024 reimbursement rates for allergy services will decrease under the Final Rule. Overall, allergists are expected to experience a -1.9% reimbursement impact due to the 2024 conversion factor. ACAAI continues to urge CMS to work with Congress to mitigate or eliminate the effects of these cuts and identify longer-term solutions to this annual issue.
Healthcare Common Procedure Coding System (HCPCS) Code G2211
The moratorium on Medicare payment for HCPCS code G2211 ended Dec. 31, 2023. This means that G2211 is now separately payable. HCPCS code G2211 is an add-on code used in conjunction with office/outpatient evaluation and management (E/M) services. This code describes “medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.”
HCPCS code G2211 is intended to compensate providers for costs associated with ongoing care in a longitudinal relationship between a practitioner and patient. To determine when billing code G2211 is appropriate, allergists should evaluate the relationship between the patient and the practitioner. The code is intended to compensate physicians for the trust-building that must occur in an ongoing relationship between patient and provider, and providers’ efforts to communicate health information to maintain the relationship.
HCPCS code G2211 cannot be reported with payment modifier 25, despite ACAAI’s advocacy to allow it. Because spirometry codes must be billed with a “25” modifier, allergists will have to choose between using a spirometry code or the new G2211 code. Notably, the reimbursement amounts for spirometry codes 94010 and 94060 are higher than the reimbursement rate for G2211. The Advocacy Council will provide additional guidance on G2211 in the future.
Medicare direct supervision rules require “incident to” services performed by clinical staff to be under the direct supervision of a physician, meaning the physician must be immediately available on site. These requirements are embedded in the reimbursement codes for allergen and venom immunotherapy. Since the COVID-19 public health emergency (PHE), direct supervision requirements have been relaxed to allow supervising physicians to be immediately available through a virtual presence via real-time audio and video technology.
Recognizing that physicians have established practice patterns around the ability to meet the direct supervision requirement via a virtual presence, CMS will continue this flexibility through the end of 2024. Through the end of 2024, allergists will not need to be physically present at the location where procedures were performed, provided that the allergist is immediately available through real-time audio and video technology. ACAAI has strongly urged CMS to make this flexibility permanent and will continue to advocate for the preservation of these flexibilities.
Remote Monitoring Services
CMS has provided clarification on the appropriate use of codes describing remote monitoring services. First, remote physiologic monitoring (RPM) services must be furnished only to an established patient. CMS clarified that patients who received initial remote monitoring services during the COVID-19 PHE are considered established patients.
Second, RPM and remote therapeutic monitoring (RTM) codes may not be billed together.
Third, for both RPM and RTM set-up and device codes 99453, 99454, 98976, and 98977, only one practitioner can bill the codes during a 30-day period, and only when at least 16 days of data have been collected on at least one medical device. CMS clarified that these restrictions do not apply to treatment management CPT codes 99457, 99458, 98980, or 98981.
CMS finalized maintaining certain telehealth flexibilities created during the PHE and extended by Congress through the Consolidated Appropriations Act of 2023. The following policies – among others – will remain in place until Jan. 1, 2025:
- Waiver of geographic restrictions and expanded scope of originating sites, meaning allergists can furnish telehealth services to patients in their homes.
- Coverage of select audio-only telehealth visits on the Medicare Telehealth Services list.
- Coverage and payment for items and services on the Medicare Telehealth Services List.
Social Determinants of Health
CMS established a new stand-alone code, HCPCS code G0136, to describe the administration of a standardized, evidence-based Social Determinants of Health (SDOH) Risk Assessment. G0136 can be billed no more than once every six months, with a duration of 5-15 minutes. Any standardized, evidence based SDOH risk assessment tool that has been tested and validated through research may be used to conduct the SDOH risk assessment. The tool must include the domains of food insecurity, housing insecurity, transportation needs, and utility difficulties.
The code can be billed in conjunction with an Annual Wellness Visit or outpatient E/M visit and can be provided via telehealth. At this time, providers are not required to have the capacity to furnish care management services or have partnerships with community-based organizations in order to bill the code.
Split (or Shared) Services
Split (or shared) services refer to E/M visits provided by both physicians and other nonphysician practitioners (NPP) in hospitals and other institutional settings. “Incident to” services are not available for services provided in a facility/hospital setting. For split (or shared) visits in the facility/hospital setting, the physician may bill for the services if the physician performs a substantive portion of the encounter.
For 2024, CMS revised the definition of substantive portion to mean more than half of the total time spent by the physician and NPP performing the split (or shared) visit, or a substantive part of the medical decision-making as defined by CPT.
- 2024 Medicare Physician Fee Schedule Final Rule
- For more information about 2024 changes to the Quality Payment Program, please refer to our recent Insider article.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.