The Centers for Medicare and Medicaid Services (CMS) released a proposed rule updating the Medicare Physician Fee Schedule and Quality Payment Program for calendar year 2024 (Proposed Rule). This article summarizes key proposals concerning the Medicare Physician Fee Schedule (MPFS) that would impact allergy practices.
The Advocacy Council plans to submit comments on the 2024 proposed physician fee schedule by the Sept. 11 deadline.
Cuts to Physician Reimbursement
For 2024, CMS is again proposing to decrease the conversion factor. The proposed 2024 conversion factor is $32.7476, a decrease of $1.14 (3.36%) from the 2023 conversion factor of $33.8872. This reduction is primarily a consequence of budget neutrality requirements that will accompany another CMS proposal to implement a Healthcare Common Procedure Coding System (HCPCS) code: G2211 (described in further detail below).
The proposed cut to the conversion factor, in addition to other structural cuts, would materially impact reimbursement to providers across the Medicare program, including allergists. CMS’ policies in the Proposed Rule would result in an estimated -1.88% impact for the allergy/immunology specialty. This figure does not include other applicable Medicare payment cuts (e.g., sequestration).
The Advocacy Council developed a downloadable spreadsheet that compares the 2023 reimbursement rates and Relative Value Units (RVUs) for allergy codes to the ones proposed for 2024. (Note: these amounts do not account for geographic adjustments.)
Evaluation and Management Visits
As mentioned above, CMS is proposing to implement HCPCS code G2211, which would be used as an “inherent complexity add-on” to office/outpatient evaluation and management (E/M) visits. HCPCS code G2211 is described as follows:
Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).
The proposal, however, has a limitation that would significantly impact allergists’ ability to bill HCPCS code G2211. CMS would not accept the use of HCPCS code G2211 when it is reported the same day as an E/M visit that is modified with “25.” Because spirometry codes must be billed with a “25” modifier, allergists would 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. Therefore, allergists would lose money by billing HCPCS code G2211 instead of a spirometry code. However, you can bill G2211 with telehealth or with an E/M when no other service (no modifier 25) is provided.
| PROPOSED National Reimbursement Amounts* |
|
|---|---|
| G2211 | $16.05 |
| 94010 | $26.85 |
| 94060 | $38.31 |
| *These amounts do not account for geographic adjustments. | |
Direct Supervision
In general, Medicare pays for “incident to” services that are performed under the direct supervision of a physician. The direct supervision requirement is also embedded in the reimbursement for allergen and venom immunotherapy codes. Prior to the COVID-19 public health emergency (PHE), “direct supervision” required the physician to be present in the office suite and immediately available to provide direction and assistance throughout the performance of the service.
In response to the COVID-19 PHE, CMS temporarily relaxed this direct supervision requirement, allowing the supervising physician (or other supervising practitioner) to be immediately available through virtual presence via real-time audio and video technology.
The PHE concluded on May 11, 2023. Under the Proposed Rule, CMS would continue to permit the use of real-time, interactive audio and video telecommunications to satisfy the direct supervision requirement through Dec. 31, 2024. If adopted, the direct supervision requirement would be met if a practitioner is “immediately available” through real-time audio and video interactive communication. CMS is soliciting comments on whether this extension of the definition of direct supervision to permit virtual presence should go beyond Dec. 31, 2024.
The Advocacy Council strongly supports this proposal and urges CMS to permanently adopt this policy. This would facilitate greater efficiencies in the workforce.
Remote Monitoring Services
The Proposed Rule contains proposals related to remote patient monitoring (RPM). First, the Proposed Rule makes it explicitly clear that patients who received initial RPM services during the PHE are now considered “established patients,” which meets the requirement that RPM services may only be provided to an established patient. Another proposal includes a clarification that data collection minimums apply to RPM codes. This means that practitioners, including allergists, may only report these codes after at least 16 days of data are collected within a 30-day period.
The Advocacy Council views this time requirement as problematic and considers providers to be in the best position to determine the appropriate length of time to monitor patients. For instance, in asthma use cases, a week’s worth of data is sufficient. Alternatively, a practitioner discharging a patient from the hospital may only need to monitor oxygen status for a few days.
Telehealth
CMS proposes significant policies related to telehealth services, many of which would impact physicians’ offices and allergists. Notably, in the Proposed Rule, CMS would implement all telehealth provisions that the Consolidated Appropriations Act of 2023 has extended through the end of 2024. This means CMS proposes that the following policies – among others – would 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 located in a patient’s home.
- 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, including follow-up visit codes.
Social Determinants of Health
Social Determinants of Health (SDOH) risk assessment involves a review of the patient’s SDOH or social risk factors that influence the diagnosis and treatment of medical conditions. CMS is proposing to add payment codes for administering a SDOH risk assessment as part of a comprehensive social history – when medically reasonable and necessary – in relation to an E/M visit. Specifically, the agency is proposing a new G code, GXXX5 (Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5 – 15 minutes, not more often than every six months).
Required elements would include the administration of a standardized, evidence based SDOH risk assessment tool that has been tested and validated through research. The tool should include the domains of food insecurity, housing insecurity, transportation needs, and utility difficulties.
Nothing in the Proposed Rule would preclude allergists from billing this code. The Proposed Rule provides an example where SDOH may be relevant to a practitioner upon discovery that an asthma patient’s living situation is not conducive to a power-operated nebulizer for treatment (i.e., the patient does not have access to electricity). The practitioner would use this information to prescribe an inhaler rather than a nebulizer. However, the Advocacy Council notes that CMS is requesting feedback on whether, as a condition of payment for SDOH risk assessment, the billing practitioner must have the capacity to furnish community health integration, principal illness navigation, or other care management services, or have partnerships with community-based organizations to address SDOH needs.
For more information about proposed changes to the Quality Payment Program, please refer to our recent Insider article.
Read more on the 2024 Medicare Physician Fee Schedule proposed rule.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
