Medicare Compliance & Reimbursement

As the healthcare industry moves on from the pandemic, the feds are focusing their policymaking on bolstering primary providers and ensuring equitable care.

Context: The Centers for Medicare & Medicaid Services (CMS) published the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) final rule on Nov. 16 in the Federal Register — and it’s chock full of billing revisions, policy provisions, and equity updates. Though a conversion factor (CF) cut may affect Medicare payments substantially (see story, p. 1), there are still some key policy updates that do offer Part B providers some positives, specifically in the behavioral health realm and community centers.

“The impact of these changes means that people with Medicare will be able to access Marriage and Family Therapists and Mental Health Counselors for behavioral health treatment, access culturally-sensitive care from community health workers, care navigators, and peer support workers, access primary care where the provider is invested in a long-term, trusting relationship, and that caregivers for persons with Medicare will have access to appropriate training,” cheers Meena Seshamani, MD, CMS Deputy Administrator and Director of the Center for Medicare, in a release. “Taken holistically, these are some of the largest changes ever towards a Medicare that recognizes people with Medicare as whole persons, with their own families and unique life stories. After all, people are more than the sum of their ailments and diagnoses,” Seshamani expounds.

Take a gander at four policy changes that may affect your bottom line:

1. Prepare for telehealth services to be front and center. During the COVID-19 public health emergency (PHE), the Medicare telehealth services expansion allowed many providers to continue to care for their patients virtually. For CY 2024, CMS continues to push forward with these finalizations:

• Add health and well-being CPT^® codes (0591T-0593T) to the Medicare telehealth services list temporarily.
• Add Social Determinant of Health (SDoH) HCPCS code G0136 (Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes) permanently to the list starting Jan. 1, 2024.
• Modify request and determination process for adding codes permanently or provisionally to the list.
• Implement the Consolidated Appropriations Act, 2023 (CAA, 2023) telehealth services provisions through the end of 2024.

Solidify that telehealth services furnished in a patient’s home, code POS 10 (Telehealth provided in patient’s home), will pay at the higher, non-facility PFS rate in alignment with CAA, 2023 provisions.

“Continue to define direct supervision to permit the presence and immediate availability of the supervising practitioner through real-time audio and video interactive telecommunications through December 31, 2024,” CMS says in a fact sheet.

Permit teaching physicians to use audio/video real-time communications technology when they furnish Medicare telehealth services at residency training locations through Dec. 31, 2024.

2. Understand the split/shared definition update. After proposing to put off revising the definition for “substantive portion” of split/shared E/M visits until 2025, CMS instead opted to change the definition for CY 2024 to align with AMA’s CPT^® guidelines. “The ‘substantive portion’ means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making,” CMS says. “This responds to public comments asking that we allow either time or medical decision making to serve as the substantive portion of a split (or shared) visit.”

3. Get ready for more behavioral health options. With a focus on whole-person care, CMS is implementing several provisions outlined in the CAA, 2023 as well as finalizing other mental health services proposals. Top highlights include:

• Section 4121 of the CAA, 2023 will be implemented, providing Part B coverage and payment when marriage and family therapists (MFTs) and mental health counselors (MHCs) bill for their services.
• Section 4123 of the CAA, 2023 will be implemented, establishing new HCPCS codes for psychotherapy services.
• Payment for crisis care, substance use disorder treatment, and psychotherapy will increase for CY 2024.
• CMS finalized allowing Health Behavior Assessment and Intervention (HBAI) services billing by clinical social workers, MFTs, and MHCs, and clinical psychologists.

4. Know these equity-inspired changes. “CMS finalized new codes and payment methods for Social Determinants of Health risk assessments, community health integration, principal illness navigation and caregiver training services,” explains McDermott +Consulting, an affiliate of law firm McDermott Will & Emery in a rule summary.

Resources: Find the final rule at www.federalregister.gov/documents/2023/11/16/2023-24184/medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other and read the fact sheet at www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-final-rule.