Orthopedic Coding Alert

Conversion factor cut again; experts disappointed again.

On Nov. 16, the Centers for Medicare & Medicaid Services (CMS) released the 2024 Medicare Physician Fee Schedule (MPFS). Since the final rule is now published, we can now see what the new year has in store for coders.

Hint: If you’re expecting a bump in the MPFS conversion factor (CF), you’re going to be disappointed.

Read on if you want to know how your 2024 is going to shape up.

Don’t Expect Change in CF

The bad news is CMS has finalized the conversion factor (CF) to be 32.7442, a reduction of 1.1396, or minus-3.37 percent compared to the 2023 CF of 33.8872.

Although the 2024 MPFS CF has been set, there is hope that the CF change won’t stand.

Note: For CYs’ 2021, 2022, and 2023, Congress stepped in with last-minute legislation to circumvent the cuts, but even its intervention was miniscule.

AMA weighs in: Physician payments have been on a downward spiral for years — and that’s a problem, warns the AMA. “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. Physicians are one of the only providers without an automatic inflationary increase,” explained AMA President Jesse M. Ehrenfeld, MD, MPH, in a release.

“This is almost biblical in its impact,” he argued. “Seven lean years that include a pandemic and rampaging inflation. Physicians need relief from this unsustainable journey.”

CMS Makes Split/Shared Official in 2024

The CY 2024 PFS final rule also contains one of CMS’ 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 that 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, however, 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, G0136 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. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established) active beginning Jan. 1, 2024. However, while you’ll be able to report G2211, CMS will bundle the service and you won’t be reimbursed for it.

For 2024, CMS also created a new code, G0136 (Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes, not more often than every 6 months), for social determinants of health (SDOH) risk assessment.