Anesthesia Coding Alert

Blame anesthesia payment cuts on budget neutrality.

Physicians may be facing more payment cuts in the coming year. But on the bright side, advancements in health equity and expanded access to critical medical services are on the horizon.

Context: On July 13, the Centers for Medicare & Medicaid Services (CMS) unveiled the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) proposed rule. Per usual, there’s a lot to unpack in the 2000-plus pages, but one hot topic is the agency floating reductions to both the MPFS and anesthesia conversion factors (CFs) in the coming year.

Here’s a glimpse of four MPFS proposals you should keep an eye on, as they’ll likely impact your Medicare policies and reimbursement.

Ready Yourself for Conversion Factor Reductions

Medicare providers might need to tighten their belts next year, as another year of payment cuts is around the bend. The rule proposes a CY 2024 anesthesia CF of $20.4370, representing a 3.26 percent reduction from the CY 2023 anesthesia CF of $21.1249. The 2024 proposed Resource-Based Relative Value Scale (RBRVS) CF is $32.7476, a decrease of $1.14 (3.36 percent) from the 2023 RBRVS CF of $33.8872. These cuts are the result of a statutorily mandated, budget-neutrality adjustment for changes in work relative value units (RVUs) and practice expense updates.

In the latest fee schedule, the agency also opts to reduce the overall payment rate by 1.25 percent and the CF by 3.34 percent or $1.14, decreasing the amount from $33.89 (CY 2023) to $32.75 (CY 2024). This reflects the expiration of the 2.5 percent statutory payment increase for CY 2023; a 1.25 percent statutory payment increase for 2024; a 0.00 percent CF update under the Medicare Access and CHIP Reauthorization Act (MACRA); and a -2.17 percent budget-neutrality adjustment.

Size Up Specialty Impact — Anesthesia, Pain Medicine

According to CMS, the 2024 proposed payment increases for primary care and other direct patient care providers meant that payment cuts must occur in other specialties to achieve budget neutrality. While specialties like internal medicine and family practice would see reimbursement increases, 1 and 3 percent respectively, others are facing cuts, including anesthesiology (-2 percent) and nurse anesthetists (-2 percent). For some, like interventional pain management (0 percent), it’s a wash.

Actual payment rates are impacted by a range of proposed policy changes related to physician work, practice expense, and malpractice RVUs. You’ll find CMS’ estimates of these changes in Table 104 in the proposed rule.

New Pain Medicine Code, Valuation Purported

Pain medicine physicians will soon be able to get paid by Medicare for providing percutaneous sacroiliac (SI) joint arthrodesis using intra-articular implants such as bone allograft material or synthetic devices. CPT^® created new category I code 2X000 (Arthrodesis, sacroiliac joint, percutaneous, with image guidance, including placement of intra-articular implant(s) (eg, bone allograft[s], synthetic device[s]), without placement of transfixation device) to replace the current Category III code 0775T (Arthrodesis, sacroiliac joint, percutaneous, with image guidance, includes placement of intra-articular implant(s) (eg, bone allograft[s], synthetic device[s])). For CY 2024, CMS proposes a work RVU of 7.86 for 2X000.

Controversy Surrounds Complex E/M Add-On Code

CMS has finally decided to make 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 … ongoing care related to a patient’s single, serious condition or a complex condition) effective in 2024. The code is intended to account for visit complexity associated with certain office/outpatient (O/O) evaluation and management (E/M) services. The additional payment for G2211 aims to better recognize and account for the inherent costs clinicians may incur when longitudinally treating a patient’s single, serious, or complex chronic condition.

History: HCPCS Level II code G2211 was originally proposed three years ago, but due to pushback related to the potential payment reduction certain specialties would face, Congress delayed the implementation of the code. However, since this policy was finalized in 2021 and was simply delayed until CY 2024, the policy will go into effect without any further action on Jan. 1, 2024.

Refinements to the G2211 policy include:

1) An adjustment of the utilization estimate for G2211 from 90 percent of O/O E/M visits billed by certain physician specialties (roughly 58 percent of all office visits) to instead being billed with 38 percent of all O/O E/M visit claims initially, But in several years, when G2211 is fully adopted, CMS predicts the HCPCS Level II code will be billed with 54 percent of all office visits.

2) A proposal not to pay for G2211 when simultaneously billed with an O/O E/M visit that has payment modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure …) appended, as that denotes the O/O E/M visit is itself unbundled from another service.

Despite these revised utilization assumptions CMS is proposing, G2211 continues to drive a significant payment reduction to the MPFS overall for CY 2024. Specifically, the agency notes that approximately 90 percent of the -2.17 percent budget-neutrality adjustment to the CF for CY 2024 is attributable to G2211, with all other proposed valuation changes making up the other 10 percent.

Hear What Industry Leaders Are Saying

Provider organizations have decried the proposed payment cuts.

“Yet another year of Medicare payment cuts shows that the Medicare physician payment system is completely broken and unsustainable. A comprehensive overhaul of the Medicare payment system for physicians is long overdue,” said American Society of Anesthesiologists (ASA) president Michael W. Champeau, MD, FAAP, FASA. “The Medicare payment rates are grossly inadequate due to egregious flaws in the government formula used to calculate physician payment rates. These inadequate payment rates, rising practice costs, and COVID-19 pandemic-related financial pressures seriously threaten physicians’ practice survival and patient access to care. Congress must act.”

This echoed the sentiments of Anders Gilberg, MGA, senior vice president for government affairs at the Medical Group Management Association: “Congress must reexamine existing law to provide an annual physician payment update commensurate with inflation and do away with Medicare’s ‘robbing Peter to pay Paul’ budget neutrality requirements to provide much-needed financial stability for medical practices.”

The AMA also panned the cut. “This is almost biblical in its impact. Seven lean years that include a pandemic and rampaging inflation. Physicians need relief from this unsustainable journey.” AMA President Jesse Ehrenfeld, MD, MPH, said in a statement.

Comments: If you want to offer your two cents on these or other policies, you have until Sept. 11 to weigh in.

Resource: Check out the MPFS proposals, which include instructions on commenting, at https://public-inspection.federalregister.gov/2023-14624.pdf.