*Note: All rates are proposed, not final
Add-on visit-complexity code is back
Dormant for several years due to legislation passed in December 2020, the office visit add-on HCPCS code G2211 (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) is officially back in the plans.
CMS says it will give G2211 active status on Jan. 1, 2024, assigning the code work relative value unit (RVU) of 0.33. Previous analysis showed that the code would
return about $16 per claim. The agency says it is unsure how utilization of the code will impact budget neutrality, but that it expects the code to be reported with 54% of all office E/M visits.
CMS initially finalized the introduction of G2211 during the 2021 fee schedule rulemaking period, but subsequent legislation forbid the agency from making the code active until 2024. Medicare shifted the code’s A (active) status to B (bundled).
Note a few caveats. The code will not be payable when an office visit is reported with modifier 25 or bundled with another service, the agency states. Also, the code “would not be appropriately reported, such as when the care furnished during the [office] E/M visit is provided by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature,” the agency states, offering examples including “treatment of a simple virus; for counseling related to seasonal allergies; initial onset gastroesophageal reflux disease; treatment for a fracture; and where comorbidities are either not present or not addressed.”
Get an early look at new codes
The proposed fee schedule gives a sneak peek at CPT code additions for next year as CMS proposes valuations for them. Note that CMS refers to them with “dummy codes,” in the proposed rule, though the code descriptions are final. They include:
- Four new intraoperative ultrasound codes for the heart and aorta, including 7X000 (Ultrasound, intraoperative thoracic aorta [eg, epiaortic], diagnostic), 7X001 (Intraoperative epicardial cardiac [eg, echocardiography] ultrasound for congenital heart disease, diagnostic; including placement and manipulation of transducer), 7X002 (… ; placement, manipulation of transducer, and image acquisition only), 7X003 (… ; interpretation and report, only).
- Four new venography codes for congenital heart defects.
- A new Category I code (2X000) for percutaneous sacroiliac joint fusion without placement of a transfixion device between the ilium and the sacrum. This code will replace Category III code 0775T.
- New codes for placement and removal of vertebral body tethering, an alternative to rigid instrumentation for young patients with congenital spine deformities.
- Eight new CPT Category I codes for phrenic nerve stimulation system devices will replace 13 Category III codes. Phrenic nerve stimulation is a treatment for sleep apnea.
- Two new CPT Category I codes for endoscopic nasal nerve destruction.
- Two new codes for percutaneous insertion or replacement of peripheral nerve electrode arrays with integrated neurostimulators and imaging guidance.
Discover more critical proposals
- Temporary substantive portion definition for split/shared visits gets another year. Medicare’s unpopular time-only definition for the substantive portion of a split/shared visit will remain on hold for another year if Medicare holds to its proposal. “After much consideration, we are proposing to delay the implementation of our definition of the ‘substantive portion’ as more than half of the total time through at least December 31, 2024,” CMS announced in the proposed rule. The agency also noted that the AMA is working on a new definition of split/shared that it will review and may incorporate into the final rule.
- CMS rejects submitted requests for telehealth services. CMS received requests to add dozens of codes to the permanent list of telehealth services, it did not accept any of the codes for permanent addition, but don’t worry about the status of codes that were added during the COVID-19 public health emergency (PHE), including telephone E/M codes. Those codes will remain on the list through 2024, thanks to a provision in the CAA 2023
- A new code for collecting social determinants of health (SDOH). To boost collection of SDOH, CMS has proposed a new code GXXX5 (Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes). The listed code is a placeholder code and won’t be used to bill claims. A provider could also perform the service in conjunction with the annual wellness visit, and CMS plans to add it to the permanent telehealth list.
- Telehealth reimbursement rate will be based on place of service (POS). Medicare intends to pay telehealth services reported with place of service 10 (Telehealth provided in patient's home) at the non-facility PFS rate. It will continue to bill claims with POS 02 (Telehealth provided other than in patient's home) at the facility rate, “as we believe those services will be furnished in originating sites that were typical prior to the PHE for COVID-19.”
- Relaxed supervision requirements for remote therapeutic monitoring (RTM) by therapy assistants. CMS proposes to establish an RTM-specific general supervision policy to allow physical therapists and occupational therapists in private practice to provide general supervision for their therapy assistants. Under general supervision, the therapists are not required to be present in the office suite while their assistants provide RTM services. Therapists who are not enrolled in Medicare and working as employees of therapists in private practice would still be required to provide RTM services under direct supervision, however.
- New therapy thresholds. CMS proposes a modest increase to therapists’ KX modifier threshold to $2,330 in 2024 from this year’s $2,320. When a beneficiary’s therapy expenses for the year exceeds the KX modifier threshold, the therapy provider uses the KX modifier on subsequent claims to convey that the services are medically necessary. When a patient’s expenses reach $3,000, however, any subsequent expenses are subject to targeted medical review, CMS states.
- CMS wants to allow another diabetes screening test and ease testing limitations. The agency is calling for a third diabetes screening test – the hemoglobin A1C (HbA1c) test – to join the fasting plasma glucose (FPG) test and post-glucose challenge test as covered screening tests. The update, CMS says, follows recent coverage revisions put forth by the U.S. Preventive Services Task Force (USPSTF).
“The USPSTF and specialty societies have identified the HbA1c test as clinically appropriate for diabetes screening,” the agency states in the proposed rule.
You may find it easier to proved needed tests to patients, as well. The agency seeks to allow two screening tests in a given 12-month period, starting in 2024. Currently, only patients who have been diagnosed as pre-diabetic are eligible for as many as two tests in a 12-month window.
A proposed change to the definition of “diabetes” also applies to medical nutrition therapy (MNT) services and diabetes self-management training (DSMT) services. CMS seeks to “simplify the regulatory definition” of diabetes “to remove the codified clinical test requirements. The proposed new definition of diabetes would be “diabetes mellitus, a condition of abnormal glucose metabolism.” The agency also seeks to strike the definition of “pre-diabetes” from the regulatory language related to diabetes screening, MNT and DSMT services.
“We believe our proposals will expand access to quality care and improve health outcomes for patients through prevention, early detection, and more effective treatment,” the agency stated in the rule.
Shared Savings updates
CMS proposes changes to Shared Savings ACOs’ quality performance standards and reporting requirements under the Alternative Payment Model (APM) Performance Pathway (APP) “that would continue to move ACOs toward digital measurement of quality and align with the QPP [Quality Payment Program].”
For example, Medicare CQMs (clinical quakity measures) will be created for MSSP ACOs under APP “as a new collection type for Shared Savings Program ACOs only” that would allow these ACOs to report Medicare beneficiaries electronically.
Also, while reporting three eCQMs (electronic clinical quality measures)/MIPS CQMs/Medicare CQMs would remain an alternative to CMS web interface measures in 2024 for MSSP ACOs, in 2025 these measures would be required by all MSSP ACOs along with a CAHPS for MIPS survey.
A new, complex risk adjustment scheme is proposed that CMS says will make it easier for some lagging ACOs to retain savings. As an example, CMS offers simulation results that show ACOs that would have “negative regional adjustment applied to their benchmark” under 2023 policy would in 2024 “receive no adjustment to their benchmark.”
The agency also proposes to alter beneficiary assignment methodology in a way that would make it easier for Shared Savings ACOs to take on primary care patients. For example, CMS would adopt an “expanded window” in which they would consider assignment for patients who received a primary care service during a 12-month period “furnished from a non-physician practitioner (nurse practitioner, physician assistant, and clinical nurse specialist)” as well as a PCP or other physician at the ACO.
Equity remains a CMS priority and the agency will require MSSP ACOs to attain a “health equity adjusted quality performance score” at or over the 40th percentile across all MIPS Quality performance category scores.
CMS also seeks comments on a plan to add a new track to the MSSP program’s BASIC track, which has four sub-levels of risk/reward arrangements, and ENHANCED track; this new track “would offer a higher level of risk and potential reward than currently available under the ENHANCED track.”
QPP and MIPS changes
In its seventh year, QPP scoring metrics are stable. The scoring percentages for MIPS (Merit-Based Incentive Payment System), for example, would remain 30% for the quality performance category; 30% for the cost performance category; 15% for the improvement activities performance category; and 25% for the Promoting Interoperability performance category under the proposed rule.
But CMS proposes some tweaks as part of its “Transforming the Quality Payment Program” initiative. To the new MIPS Value Pathways (MVP) Model reporting method, for example, CMS proposes to add five new measures: Women’s Health; Infectious Disease, Including Hepatitis C and HIV; Mental Health and Substance Use Disorder; Quality Care for Ear, Nose, and Throat (ENT); and Rehabilitative Support for Musculoskeletal Care.
Also, CMS will add five new episode-based measures to the cost performance category, including two with “relevance to the CMS Behavioral Health Strategy”: Depression and Psychoses and Related conditions, as well as Emergency Medicine, Heart Failure and Low Back Pain.
The MIPS performance threshold, currently at 75 points, CMS proposes to lift to 82 points for the CY 2024 performance period, but they would base this on a pre-COVID baseline (2017-2019 performance periods).
For participants in the non-MIPS Advanced APM track, CMS proposes to “modify the CEHRT [certified EHR technology] use criterion… to tailor CEHRT use requirements to the APM and its participants,” removing the old 75% CEHRT use requirement and instead requiring all providers in the Advanced APM under a new, “modified, and more flexible, definition” of CEHRT.