EM Coding Alert

Hint: Some providers could get a Medicare pay boost.

Due to a separate add-on code for outpatient/office E/M services, certain Medicare providers may find themselves on the right side of a payment increase despite the proposed conversion factor (CF) decrease.

Lowdown: Beginning Jan. 1, 2024, the Centers for Medicare & Medicaid Services (CMS) proposes to implement the long-delayed 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…), which is appended as an add-on code for outpatient/office E/M services.

The add-on code accounts for the “inherent costs” providers “incur when longitudinally treating a patient’s single, serious, or complex chronic condition,” oftentimes via outpatient/office E/M visits, a CMS rule fact sheet indicates. The agency insists that “establishing payment for this add-on code would have redistributive impacts for all other CY 2024 payments.”

Reminder: “CMS originally finalized this policy in 2021, but Congress suspended its use and prohibited CMS from implementing it before 2024,” explains Atlanta-based attorney Doug Comin with law firm King & Spalding LLP in the firm’s Health Headlines newsletter. “Hence, CMS is proposing to implement the policy this year, but with refinements that would reduce the redistributive impact compared to the original proposal from 2021,” Comin continues.

Here’s the CF Connection

You may be wondering how the proposed implementation of add-on code G2211 will help your practice circumvent the CF cuts. Well, it all depends on your specialty. For example, some physician specialties perform more office/outpatient E/M visits than others. Providers such as family and nurse practitioners, physician assistants, clinical psychologists, and others will likely see a boost from the code.

“The most widespread specialty impacts of the [relative value unit] RVU changes are generally related to the changes to RVUs for specific services resulting from the misvalued code initiative, including RVUs for new and revised codes,” the proposed rule says. “These increases can largely be attributed to proposed implementation of the separate payment for the O/O E/M visit inherent complexity add-on code, the Year 3 update to clinical labor pricing, and/or the proposed adjustment to certain behavioral health services,” CMS clarifies.

Plus, more than 90 percent of the budget neutrality associated with the CF update is due to the add-on code while other code valuations make up the other 10 percent, CMS says. “The services that make up these specialties rely primarily on E/M services, behavioral health care, or on clinical labor for their practice expense costs.”

Other payment increases can be attributed to service valuations changes and pricing updates for supplies and equipment made from AMA Relative Value Scale Update Committee (RUC) recommendations and CMS reviews.

Though the final rule won’t be out until the late fall, you may want to check and see what CMS estimates the impact on your payments for CY 2024 will be. Here are the top and bottom specialties most affected by the proposals:

Remember: Before you start to panic, the policies are merely proposals and haven’t been finalized yet. Plus, CMS admits that its payment estimates don’t necessarily factor in the various elements that make up a claim and what is eventually paid to a provider.

“We often receive comments regarding the changes in RVUs displayed on the specialty impact table (Table 104), including comments received in response to the valuations,” CMS notes in the proposed rule. “We remind interested parties that although the estimated impacts are displayed at the specialty level, typically the changes are driven by the valuation of a relatively small number of new and/or potentially misvalued codes.”

The agency continues, “The percentage changes in Table 104 are based upon aggregate estimated PFS allowed charges summed across all services furnished by physicians, practitioners, and suppliers within a specialty to arrive at the total allowed charges for the specialty, and compared to the same summed total from the previous calendar year. Therefore, they are averages, and may not necessarily be representative of what is happening to the particular services furnished by a single practitioner within any given specialty.”