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Breaking: CMS escalates rate cuts in 2024, debuts services, firms up telehealth pay parity

The conversion factor cuts that CMS floated earlier in the year are now confirmed – and heightened. Part B providers will have to prepare for a net 3.4% payment decrease across services in 2024,  according to the final 2024 Medicare physician fee schedule released today.
Also, you will find new services moving to active status, such as caregiver training and principal illness navigation, a one-year telehealth parity patch, key value-based care updates and the launch of the much anticipated add-on complexity code G2211.
The sprawling, 2,709-page policy-setting rule covers numerous operational areas for medical groups, from new coverage opportunities and billing revisions to coding and compliance updates. The rule, and most of the provisions within it, take effect Jan. 1, 2024.
Check out 2024 rates
Despite opposition from multiple trade groups, CMS is going forward with a single-digit percentage cut to the conversion factor. The reduction is even higher than the proposed rate ($32.7476) that CMS issued in July. Instead of losing $1.1396 as proposed, the final conversion factor for 2024 settles in at $32.7375, a $1.1497 dip, or a 3.39% loss. (The proposed rate came in at a 3.36% drop.)
Calculating the CY 2024 PFS conversion factors (CF)
CY 2023 CF
CY 2024 CF
YTY% change
CY 2023 anesthesia CF
CY 2024 anesthesia CF
YTY% change
*Note: All rates are effective Jan. 1, 2024, according to the final 2024 Medicare physician fee schedule
The final anesthesia conversion factor also takes a higher cut than in the proposed rule, settling in at $20.4349, a few notches below the proposed rate of $20.4370, still a 3.3% net decrease.
While the conversion factor decrease will suppress the universe of Part B allowed charges in 2024, not all individual services will be affected the same. Final payment rates will vary depending on other inputs, such as relative value units (RVU).
CMS sticks with the add-on visit-complexity code
You can now fully prepare for the launch of the long-anticipated and much-disputed add-on 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).
CMS finalized its decision to move the code to “active” status as of Jan. 1, while also clarifying several definitions related to the service. After a robust comment period, the agency lowered its initial estimate of billing frequency for the add-on code, projecting that it will be reported on 38% of all office visit codes at the immediate outset. That number could rise to 54% of office visits once the provider community grows more comfortable with its use, the agency says.
Key to the code’s correct usage is the manner of the relationship between the provider and patient. “We clarify that it is the relationship between the patient and the practitioner that is the determining factor of when the add-on code should be billed,” the agency states in the final rule.
CMS says that, under the current fee structure, cognitive work associated with providing longitudinal care to patients is underpaid, and that G2211 is intended to make up for part of the shortage. The agency offers an example of when – and why – the code should be used.
“For example, a patient has a primary care practitioner that is the continuing focal point for all health care services, and the patient sees this practitioner to be evaluated for sinus congestion," the final rule states. “The inherent complexity that this code (G2211) captures is not in the clinical condition itself— sinus congestion — but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.”
CMS accepted a work relative value unit (RVU) figure of 0.33 for the code. As proposed, the add-on code will not be accepted with an E/M service reported with modifier 25 (Significant, separately identifiable E/M service).
CMS finalizes decision to potentially revalue 19 therapy codes
CMS states in the final 2024 Medicare physician fee schedule that it will add 19 therapy codes to its potentially misvalued codes list to determine whether they were misvalued during their last review in 2018. 
The agency notes that it received numerous comments in favor of its proposal to revalue the codes (and none against it).  A requestor had submitted the 19 codes for revaluation stating that the AMA Relative Value Scale Update Committee (RUC) had miscalculated their values. During that 2018 review, the RUC and the Healthcare Professional Advisory Committee review board (HCPAC) may have inappropriately applied a multiple-procedure payment reduction (MPPR) to the codes’ PE clinical labor times, the agency stated in the proposed rule.
In the proposed 2024 physician fee schedule, CMS noted that it would not be appropriate to apply an MPPR reduction to the value of the codes themselves. That reduction is applied during the claims process. The 19 codes include:  
Mechanical traction therapy 
Electric stimulation therapy 
Vasopneumatic device therapy 
Paraffin bath therapy 
Whirlpool therapy 
Electrical stimulation 
Electric current therapy 
Contrast bath therapy 
Ultrasound therapy 
Therapeutic exercises 
Neuromuscular reeducation 
Aquatic therapy/exercises 
Gait training therapy 
Manual therapy 1/> regions 
Therapeutic activities 
Sensory integration 
Self care mngment training 
Community/work reintegration 
Wheelchair mngment training 
Elec stim other than wound 
Source: Proposed 2024 Medicare physician fee schedule 
As part of its potentially misvalued code initiative, CMS entertains nominations from providers and other requestors about codes they believe should be reviewed. As well as the 19 therapy codes, CMS received requests to review the following: 
Therapeutic apheresis values to be evaluated. CMS states will add therapeutic apheresis codes 36514 and 36516 and extracorporeal photopheresis (36522) to its list of potentially misvalued codes in response to a request the agency received to increase the codes’ practice expense (PE) RVUs. The requestor argued that the direct PE of clinical labor for an RN/LPN, at $0.525 per minute, is about half of what it should be, and that some of the supplies involved are undervalued according to Medicare’s direct PE allowances. CMS states in the final rule that “after considering the public comments, we believe there may be a possible disparity with the clinical labor type for this service and that these codes would benefit from additional review in future rulemaking.”
The agency also finalized its decision not to classify as misvalued a range of other codes, including initial hospital visits (99221-99223), percutaneous sacroiliac joint fusion (27279) and code 59200 (Insertion cervical dilator [e.g., laminaria, prostaglandin]), which describes dilation of the cervix to induce labor.
Sizing up a split or shared policy
CMS will adopt the AMA’s definition of the substantive portion for a split or shared visit. “Specifically, for CY 2024, for purposes of Medicare billing for split (or shared) services, the definition of “substantive portion” means 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 [MDM] as defined by CPT,” the agency announced in the final rule. Split or shared critical care services will continue to follow Medicare’s time-based rules. (Take a closer look at the AMA's revamped definition of substantive portion [subscription required].)
Set your sights on Shared Savings 
CMS has finalized its proposed new “Medicare CQMs” (clinical quality measures) for which Shared Savings ACOs can do electronic reporting on all Medicare beneficiaries – and which will be one of three CQM methods (including electronic clinical quality measures aka eCQM and MIPS CQMs) that will be mandatory for MSSP ACOs in 2025, while 2024 will be a “transitional” phase.  
Also finalized: a “health equity adjustment” to MSSP scores (upside-only in 2024). As previously announced, MSSP participants can report via Web interface in 2024 – but that will be the last year for it.  
CMS has also reconfigured its risk adjustment calculus, finding that the current model “negatively impacts ACOs with the highest average risk scores.” 
A new “faster” track will be added to the various tracks MSSP participant can choose, with “a higher level of risk and potential reward than currently available under the ENHANCED track.”  
CMS finalized updates to the definition of primary care services used for purposes of beneficiary assignment, to include telehealth codes for virtual check-ins, e-visits and telephonic communication, as well as some services performed by non-physician providers such as nurse practitioners and physician assistants. 
The proposal to end the current Shared Savings Program CEHRT threshold requirements and harmonize them with those of QPP/MIPS – and require all QPP participants to meet them – is delayed one year. 
Clif Gaus, President and CEO of the National Association of ACOs (NAACOS), applauds several attributes of the changes, including “improvements in quality reporting, more fair benchmarking policies, [and] a smooth transition to a new risk adjustment model,” according to a Nov. 2 statement.  
Quality Payment Program threshold updates
Big break for Merit-based Incentive Payment System (MIPS) reporters: Recognizing that the COVID PHE-era basis years of 2017-2019 “may not be truly reflective of clinicians’ performance,” CMS is retaining the MIPS performance threshold for 2024 at 75 points. A new floor of 82 points had been proposed.  
Medical groups, including the AMA, had complained that the proposed change would lead to reimbursement penalties for providers as high as 9%. In a statement, Medical Group Management Association (MGMA) Senior Vice President for Government Affairs Anders Gilberg applauded the delay, saying the 82 point threshold would have left “a majority of eligible clinicians receiving a negative payment adjustment.” 
All other performance thresholds are stable. 
Other than that, all the significant proposed changes are finalized, including several new measures and a longer 180-day minimum performance period for the Promoting Interoperability reporting. The new “streamlined” CEHRT standards that QPP participants will share with MSSP participants, however, is delayed one year. 
For Advanced APM reporters, the 2023 performance year bonus is still cut from 5% to 3.5%, and starting with performance year 2024 they’ll be paid an update against the physician fee schedule – the “qualifying APM conversion factor” – of 0.75% for qualifying participants (QP), and 0.25% for non-QPs. 
The MIPS Value Pathways model remains an optional method of reporting, with changes that include new MVPs such as Women’s Health, Infectious Disease Including Hepatitis C and HIV, and Mental Health and Substance Use Disorder. 
Other notes
Relaxed supervision requirements for remote therapeutic monitoring (RTM) performed by therapy assistants. CMS finalized its proposal 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.
Team-based care takes center stage. CMS finalized its proposals to debut a raft of services aimed at team-based care. "Specifically, we are finalizing to pay separately for Community Health Integration, Social Determinants of Health (SDOH) Risk Assessment, and Principal Illness Navigation services to account for resources when clinicians involve certain types of health care support staff such as community health workers, care navigators, and peer support specialists in furnishing medically necessary care," the agency states.
Telehealth pay parity, and code additions. CMS also announced that it would lock in payments at the non-facility rate when providers perform telehealth to patients who are located in their homes. The rate lock is good for one year, through the end of 2024.
CMS also finalized several proposed telehealth changes, including temporary and permanent additions to the list of telehealth services and extensions of waivers that were not covered by the Consolidated Appropriations Act of 2023.
Medicare will add health and well-being coaching codes (0591T-0593T) to its list of telehealth services on a temporary basis. It will add new social determinant of health (SDOH) assessment code G0136 (Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes) to the permanent list of codes.
CMS confirmed that it has put its home enrollment requirement on hold. “Through CY 2024, we will continue to permit the distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home,” CMS explained.
In addition, CMS extended the virtual presence waivers to Dec. 31, 2024. The waivers allow a supervising physician to provide direct supervision and a teaching physician to be present via a two-way audio and video connection,

Editor's note: This is a breaking news story. Check back for updates.
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