Ophthalmology and Optometry Coding Alert

Steady reimbursement decline is a recipe for financial instability, AMA warns.

Practices may have hoped that the continued rise in inflation and the growing costs of running a medical practice would nudge the feds to keep Medicare payments stable for 2024, but that doesn’t appear to be the case. Despite industry outcry and widespread discontent surrounding another decrease in the conversion factor (CF) for 2024, Medicare went ahead and cut it anyway — and for more than originally promised.

Context: On Nov. 16, the Centers for Medicare & Medicaid Services (CMS) unveiled the calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) final rule, and per usual, there’s a lot to unpack in the 1,230 pages published in the Federal Register.

Keep reading to learn about the policy changes on the horizon and how they may affect your bottom line.

Beware, Conversion Factor Reduction Confirmed

Last July, CMS proposed a 3.34 percent cut to the CF. But in the final rule, the agency opted to reduce the CF further by 3.37 percent, which equates to $32.7442 or $1.15 less than the 2023 CF of $33.89. On top of that, CMS anticipates overall payment rates under the CY 2024 MPFS will fall by 1.25 percent, according to the final rule.

Analysis: “Several factors impact the formula for determining the fee schedule each year. At the end of 2022, Congress granted a 2.5 percent increase in 2023 and another in 2024 (1.25 percent). Another major issue is the mandatory budget neutrality adjustment for +G2211 (-2.18 percent). Significantly, the -2 percent sequestration adjustment applies for 2024, too,” explains Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

Size Up Specialty Impacts

The final rule includes comparative data showing the estimated overall change to Medicare reimbursement, per specialty, expected for next year. Interestingly, despite the lower CF, some specialties, such as internal medicine and family practice, have a projected positive change in their Medicare payment percentage due to changes in relative value units (RVUs) for many services. Conversely, specialties such as ophthalmology and optometry are slated to realize a reduction of -1 and -2 percent, respectively.

A range of policy changes related to physician work, practice expense, and malpractice RVUs will impact actual payment rates. You’ll find CMS’ estimates of the payment impacts of the policies in the final rule on MPFS services in Table 118.

Understand the Split/Shared Definition Update

The CY 2024 MPFS final rule also contains one of CMS’s most awaited rulings — its definition of split/shared visits and the additional decision to implement that definition beginning Jan. 1, 2024. Much to the relief of all who bill services to both Medicare and private payers, CMS has at last decided to finalize its definition to make the “substantive portion” of a split/shared visit “align … with the CPT^® [evaluation and management] E/M guidelines for this service.” The final rule adds, “These guidelines should be applied to determine whether the physician or [nonphysician practitioner] NPP may bill for the service.”

Per CPT^®, this means “if code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service.”

Applying the substantive portion guidelines to code selection based on medical decision making (MDM) is a little trickier. Again, per CPT®, “performance of a substantive part of the MDM requires that the physician or other [qualified healthcare professional] QHP ... has performed two of the three elements used in the selection of the code level based on MDM.” This is usually satisfied when the physician or QHP has “made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management.”

If the physician or other QHP uses the amount and/or complexity of data element as one of the elements to determine the MDM level for the reported code level, CPT^® requires that “an independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP.” Even so, “assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP, because the relevant items would be considered in formulating the management plan,” per CPT^®.

So, it appears at this time, “if the physician is able to meet the level for the code selected with two of the three columns of MDM, the physician will bill the service under their provider number even if the QHP/NPP is also able to meet the MDM level for the code selected with two of the three columns of MDM. There will be

scenarios where documentation may be unclear who performed which component of the MDM. So, documentation clarity will be of utmost importance when two providers are rendering and documenting the visit,” according to Lori Carlin, CPC, COC, CPCO, CRC, CCS, Principal at Pinnacle Enterprise Risk Consulting Services.

Add +G2211 to Your Coding Arsenal in 2024

CMS has also made good on its promise to make 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 ...) active beginning Jan. 1, 2024.

“It is noteworthy that the CMS website includes a listing of pertinent ‘practitioner primary care specialties,’ and it does not include ophthalmology or optometry. At this time, it does not appear that the new code will be helpful to ophthalmology in recovering any of the MPFS decrease,” Johnson notes.

Know Telehealth Flexibilities Can Continue

CMS plans to implement several telehealth-related provisions of the 2023 Consolidated Appropriations Act (CAA) through the end of next year. For example, CMS will:

• Extend coverage and payment of certain telehealth services via an audio-only communications system;
• Continue to temporarily expand the scope of telehealth originating sites to include any site in the United States where the patient is located at the time of service; and
• Continue to define direct supervision to permit the immediate availability of the supervising practitioner through real-time audio and visual interactive telecommunications through Dec. 31, 2024.

The agency will pay for telehealth services furnished in a patient’s home — POS 10 (Telehealth provided in patient’s home) — at the higher, non-facility PFS rate beginning in CY 2024. “For telehealth provided when the patient is at an originating site other than the patient’s home, report POS 02,” Johnson adds. Note that you will no longer use the POS that the physician normally provides the service in once CMS implements this POS 10 reimbursement rule on Jan. 1, 2024.

For further study: Download the CY 2024 MPFS final rule by going to www.federalregister.gov/public-inspection/2023-24184/medicare-and-medicaid-programs-calendar-year-2024-payment-policies-under-the-physician-fee-schedule.

Find more information about using +G2211 by going to www.cms.gov/files/document/physician-fee-schedule-pfs-payment-officeoutpatient-evaluation-and-management-em-visits-fact-sheet.pdf.