General Surgery Coding Alert

Expect surgical procedure pay cut … again.

General surgeons should be on the lookout for how the 2024 Medicare Physician Fee Schedule (MPFS) proposed rule touches several topics surrounding the coverage landscape following the COVID-10 public health emergency (PHE) expiration, plus serves up another big conversion factor (CF) cut.

What: On August 7, CMS published the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) proposed rule in the Federal Register. These changes aren’t written in stone — the final rule won’t come out until later this year.

Look at the following four topics to get a peek at how the proposals could impact your general surgery practice.

1. Expect Continued Flexibilities for Telehealth Services

The Centers for Medicare & Medicaid Services (CMS) plans to implement the 2023 Consolidated Appropriations Act (CAA) telehealth services provisions through the end of 2024. This includes allowing the patient’s home as an originating site. Additionally, CMS proposes to pay telehealth services furnished in the patient’s home — POS 10 (Telehealth provided in patient’s home) — at the higher, non-facility PFS rate. POS 2 (Telehealth provided other than in patient’s home) would remain as-is, paid at the facility rate.

The proposal also includes lifting geographic restrictions and letting Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) provide telehealth services. Audio-only telehealth service coverage and payment may also see an extension in the coming year.

These changes would have an obvious benefit for general surgery patients. Rural and underserved areas, as well as patients experiencing various travel-related setbacks would have greater access to specialty services. This could also create more flexibility in scheduling and providing patients with chronic conditions more consistent follow-up care.

2. Look for Programs Related to Equity and SDoH

Ensuring that all people receive the same level of healthcare remains a central theme post-pandemic, which isn’t surprising as the COVID-19 PHE revealed longstanding, systemic problems.

CMS’ stated mission “is to expand access to health care and ensure that health coverage is meaningful to the people we serve,” according to CMS Administrator Chiquita Brooks-LaSure in a press release about the proposed rule.

Equity: “CMS continues to demonstrate commitment to advancing health equity and building a stronger Medicare program,” explains Meena Seshamani, MD, CMS Deputy Administrator and Director of the Center for Medicare, in a release. “If finalized, the proposals in this rule ensure the people we serve experience coordinated care focused on treating the whole person, considering each person’s unique story and individualized needs — physical health, behavioral health, oral health, social determinants of health, and are inclusive of caregivers, which are all so important to providing the care that people with Medicare deserve.”

Winners and losers: Put together, these goals help buttress payment for primary care services under the proposed rule, while necessitating payment decreases for other specialties.

3. Witness Another Split/Shared Policy Delay

CMS intends to keep the current split/shared rules for a little bit longer, with a start date for the new policy now slated for Jan. 1, 2025. CMS finalized implementing its split/shared policy that the provider who administers the substantive portion of the visit bills for the E/M services — whether it’s the physician or the nonphysician practitioner (NPP) — in the CY 2022 MPFS final rule and then delayed the implementation in the CY 2023 MPFS final rule.

Many have opposed the change since CMS first proposed the policy, so this further delay will allow CMS to gather more comments and feedback from interested stakeholders regarding he policy and how it could be altered or further refined. Stakeholders are trying to get CMS to recognize medical decision making as the substantive portion of a visit that gets the service paid at the physician fee level, rather than basing it on the physician documenting the majority of the time.

4. Swallow the CF Bitter Pill

With inflation raging and providers attempting to climb out of the financial hole created by COVID-19, many hoped CMS would not decrease the CY 2024 conversion factor (CF) — which is the multiplier for Medicare payment. But that’s not to be.

Instead, the CY 2024 MPFS overall proposed payment amounts would be reduced by 1.25 percent compared to CY 2023, in accordance with factors specified by law. “CMS is also proposing increases in payment for many visit services, such as primary care, and these proposed increases require offsetting and budget neutrality adjustments to all other services paid under the [M]PFS,” according to a CMS fact sheet. The proposed CY 2024 MPFS conversion factor is $32.75, a decrease of $1.14, or 3.34 percent, from CY 2023.

Offset not enough: “While Congress has provided temporary partial fixes to physician payment in the last several years, its latest fix in the Consolidated Appropriations Act, 2023 (CAA, 2023), enacted at the end of 2022, does not offset all the proposed cuts in this rule,” cautions McDermott + Consulting, an affiliate of law firm McDermott Will & Emery, in a rule summary. “In all, the budget neutrality constraints of the fee schedule continue to result in a negative proposed conversion factor (CF) update,” the firm says.

Refresher: In the CAA, 2023, legislators decided instead of completely overhauling the 4.5 percent CF cut for CY 2023 that they’d offer a two-part solution that also impacted CY 2024. Under that legislation, Congress provided a 2.5 percent statutory payment increase for CY 2023 and the 1.25 positive payment adjustment for CY 2024.

CMS’ proposal “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 conversion factor update under the Medicare Access and CHIP Reauthorization Act [MACRA]; and a -2.17 percent budget-neutrality adjustment,” an American Hospital Association (AHA) fact sheet on the rule clarifies.

Specifically: The proposed MPFS Table 104 indicates the overall impact to general surgery payments from 2023 to 2024 would be a decrease of 1 percent. But remember that “The percentage changes in Table 104 are based upon aggregate estimated [M]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,” according to CMS. That means the -1% value may not be representative of your practice.

Industry concerns: “When adjusted for inflation, Medicare physician payment already has effectively declined 26 percent from 2001 to 2023 before additional inflation and these cuts are factored in,” said AMA President Jesse M. Ehrenfeld, MD, MPH, in a release. “This is almost biblical in its impact,” he argues. “Seven lean years that include a pandemic and rampaging inflation. Physicians need relief from this unsustainable journey.”

The following table demonstrates continued CF decline over the past five years.

*Sources: CY 2019 MPFS final rule; CY 2020 MPFS final rule; CY 2021 MPFS final rule; CY 2022 MPFS final rule; and CY 2023 MPFS final rule; CAA, 2021; Protecting Medicare and American Farmers from Sequester Cuts Act; and CAA, 2023.

“Medical societies are lobbying hard for Congress to not only intervene once again but to change the payment system going forward to where there is an annual adjustment for inflation for physicians just as there has been for decades for hospitals, ASCs, HOPDs, SNFs etc,” says Glenn Littenberg, MD, MACP, FASGE, AGAF, a gastroenterologist and former CPT® Editorial Panel advisor for ASGE in Pasadena, California.

Resource: Review the CY 2024 MPFS proposed rule at www. govinfo.gov/content/pkg/FR-2023-08-07/pdf/2023-14624.pdf.