Oncology & Hematology Coding Alert

A 3 percent CF reduction is just the tip of the iceberg.

The Centers for Medicare & Medicaid Services’ (CMS’) have made public their annual proposals for payment policies under the Physician Fee Schedule (PFS) and Part B payment and coverage policies, and as usual, it’s a gigantic mixed bag of positives and negatives for oncology and related specialties.

On the plus side, CMS is proposing to cover dental care for certain cancer patients taking high-dose bisphosphonate agents, and to provide an opportunity for some providers to capture additional payments for longitudinally treating patients with a single serious condition or with complex conditions. On the minus side, a reduction in the conversion factor (CF) could spell reduced payments for some, but not all, oncology practices.

Want to know how you might be impacted next year? You’ve come to the right place.

Know What Could Be in Your Wallet in 2024

As usual, all eyes are on what Medicare is proposing to do with the CF, the final multiplier in the complex formula by which CMS calculates its payments for services and procedures.

As a reminder, the formula, known as the resource-based relative value scale (RBRVS), is comprised of three relative value unit (RVU) components: work (w), practice expense (pe) and malpractice insurance (mp). Each component is then multiplied by geographic practice cost indices (GPCI), added together, then multiplied again by the CF to produce a dollar value for all services and procedures: [(wRVU x wGPCI) + (peRVU x peGPCI) + (mpRVU x mpGPCI)] x CF.

For 2024, CMS is proposing a CF of 32.7476, a reduction of 1.1396, or -3.3629 percent compared to 2023. The reduction continues a distressing trend. “Medicare physician payment already has effectively declined 26 percent from 2001 to 2023 before additional inflation and these cuts are factored in,” explains AMA President Jesse M. Ehrenfeld, MD, MPH, in a release. This latest reduction is the culmination of “seven lean years that include a pandemic and rampaging inflation. Physicians need relief from this unsustainable journey,” Ehrenfeld remarks.

Interestingly, CMS estimates the proposed CF decrease will not significantly negatively impact practices in the oncology specialty across the board. While radiation oncology could possibly see a -2 percent reduction in both nonfacility and facility payments, according to estimates in the proposed rule, hematology/ oncology might actually see an overall 2 percent increase, with facilities potentially seeing the full amount of that increase and nonfacility practices likely being the beneficiaries of a 1 percent revenue bump for 2024. But with heavyweight professional organizations such as the AMA expected to lobby strongly against any possible reduction in healthcare revenues, such predictions still remain up in the air.

Know How the Additional Complex Patient Payment Will Work

HCPCS Level II 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. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established) “is expected to be available in CY2024 to enhance payments … [for] longitudinal care of complex patients,” according to Kelly Loya of Pinnacle Enterprise Risk Consulting Services, Charlotte, North Carolina.

CMS originally created G2211 in 2021 to “recognize the resources inherent in holistic, patient-centered care that integrates the treatment of illness or injury, management of acute and chronic health conditions, and coordination of specialty care in a collaborative relationship with the clinical care team.” The code was intended to serve as “a focal point for the patient’s care … by furnishing care for some or all of the patient’s conditions across a spectrum of diagnoses and organ systems with consistency and continuity over time,” according to CMS.

However, Medicare delayed implementation of the code at the time “due to public comment and the expected great impact on other service reimbursement and specialty providers to remain budget neutral, meaning if a provider type gets more money, it results in less 1:1 for other provider types,” according to Amy Crenshaw of Pinnacle Enterprise Risk Consulting Services, Charlotte, North Carolina.