From new add-on codes and extended behavioral health coverage to split/shared services revisions and continued public health emergency (PHE) flexibilities, the 2024 Physician Fee Schedule (PFS) from the Centers for Medicare and Medicaid Services (CMS) includes substantial policy changes – and challenges – for the new year. The 2024 PFS, which took effect Jan. 1, also sets policies designed to advance health equity under Medicare Part B.
While the PFS is specific to Medicare, the new policies it establishes are expected to have a far broader influence as many commercial carriers follow CMS guidance. Our webinar takes a deep dive into the 2024 PFS , and the following highlights will help health information management (HIM) teams better understand some of the most notable changes for the year.
2024 Conversion Factor
The 2024 conversion factor – the amount Medicare pays per relative value unit (RVU) – is $32.74, which is a 3.4% reduction from last year’s factor of $33.89 and includes a 3.4% payment cut due to budget neutrality rules. Each CPT code has an RVU assigned to it, which, when multiplied by the conversion factor and a geographical adjustment (GPCI), creates the compensation level for a particular service.
HCPCS Code G2211
Approximately 90% of the overall budget neutrality adjustment can be attributed to the implementation of a separate add-on payment for Healthcare Common Procedure Coding System (HCPCS) code G2211, while the remaining 10% is associated with other proposed changes in valuation of codes along with the third year of the clinical labor pricing update. G2211 is for visit complexity inherent to evaluation and management (E/M) associated with medical care services that served as the continuing focal point for all needed healthcare 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.
Listed separately from “office or other outpatient services” and used with CPT codes 99202-99215, G2211 is designed to better recognize the resources and cost associated with E/M visits for primary and longitudinal care. It is generally applicable to outpatient and office visits as an additional payment that recognizes the inherent costs involved when clinicians are continuing the focal point for all needed services, or services that are part of ongoing care related to a patient’s single serious or complex condition. The idea behind G2211 is that it will help providers assume responsibility for building effective and trustworthy relationships with their patients, which is key to providing reasonable and necessary care and improving patient compliance.
E/M Split/Shared Services
Under the 2024 PFS, split/shared services – when patients are seen during a primary E/M visit by both a physician and a nonphysician practitioner (NPP) such as a physician assistant, advanced practice registered nurse, nurse practitioner, clinical nurse specialist, or other nonphysician provider – are now billed by the individual who spent the majority, or substantive portion, of time on the patient encounter. “Substantive portion” is defined by CMS as more than half of the total time spent performing the services or a substantive part of the medical decision making. This change, which came in response to public comments asking CMS to allow either time or medical decision making to serve as the substantive portion of a split or shared visit, means documentation should clearly identify both the physician and NPP involved in the visit while the medical record is signed and dated only by the billing practitioner.
Behavioral Health
Some of the most substantive changes in 2024 relate to behavioral health services, including payment for services provided by marriage and family therapists and mental health counselors. It also allows eligible addiction or drug and alcohol counselors to enroll in Medicare as mental health counselors as of Jan. 1.
CPT codes 96156, 96158, 96159, 96164, 96165, 96167, and 96168, describe health behavior assessment and intervention (HBAI) services, can now be billed by clinical social workers, MFTs, and MHCs, in addition to clinical psychologists. HBAI codes are used to identify the psychological, behavioral, emotional, cognitive, and social factors included in the treatment of physical health problems. Valuation for behavioral health services was also increased to begin addressing years-long distortions in valuing time-based behavioral health services.
Dental and Oral Health
Payment is now permitted for certain dental and oral health services that are linked to other services related to the treatment of primary and metastatic head and neck cancers. This includes examinations performed as part of a comprehensive workup prior to medically necessary diagnostics and treatment services to eliminate an oral or dental infection prior to or contemporaneously with those treatments and to address complications from radiation, chemotherapy, surgery, or other treatment.
Telehealth Services
CMS finalized a policy in the MPFS that will allow teaching physicians in all training sessions to be present via audio, video, or real-time communication technology when a resident is providing Medicare telehealth services. This allows teaching physicians to bill if they are virtually present for key portions of the service and applies in all teaching settings through Dec. 31.
The 2024 PFS also allows practitioners furnishing telehealth services from their homes to report their office addresses on their enrollment forms, continuing a policy established under the PHE. This addresses practitioner privacy and safety concerns about including their home addresses as practice locations on their enrollment forms.
Additionally, health and wellbeing coaching services have been temporarily added to the Medicare telehealth service list for 2024, as has HCPCS G0136 (administration of a social determinants of health risk assessment tool). Further, claims billed with POS10 will be paid at the non-facility rate, protecting access to mental health and other telehealth services not aligning with telehealth-related flexibilities. Finally, frequency limitations for subsequent inpatient and nursing facility visits and critical care consults were removed for 2024, extending the flexibility that would have been lost with the PHE expiration.
Advancing Health Equity
As part of its focus on achieving health equity, CMS has added codes for several new services designed to better understand patient populations and address unmet health-related social needs that can potentially interfere with the diagnosis and treatment. This includes payment for services to assist those with cancer and other serious illnesses in navigating their treatment, support family caregivers, pay for community health workers to address health-related social needs, and enhance access to dental care for people with certain cancers.
Taken holistically, these are some of the most significant policy changes contained within the 2024 PFS and are designed to put patients at the center of care. These include the addition of HCPCS codes G0019 and G0022 for community health integration.
CMS also finalized payment for practitioners to train caregivers to support patients with dementia and similar diseases and help them carry out treatment plans. Medicare will pay for these services when furnished by a physician, NPP, or therapist as part of the patient’s individualized treatment plan.
HCPCS G1036 was also created for SDOH risk assessment, recognizing the time and resources spent by practitioners assessing for social determinants that may be impacting their ability to treat the patient. Also finalized were codes for annual wellness visits and SDOH risk assessments conducted as part of annual or behavioral health visits.
New codes – G0023, G0024, G0140, and G0146 – were also created for community health navigation or integration and principal illness navigation services to account for clinician involvement with auxiliary personnel, such as community health workers and care navigators, to support patients with unmet SDOH needs that affect the diagnosis and treatment of their medical problems and for high-risk patients who need assistance connecting with appropriate clinicians and other resources.
The payment and policy changes that took effect with the 2024 PFS are significant. To help HIM professionals gain a clear understanding of their impact, listen to our webinar, OPPS and MPFS Final Rules: A 2024 Road Map.
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