Pediatric Coding Alert

Find detailed information about the split/shared policy update.

In Pediatric Coding Alert volume 26, issue 10, we reported on four of the big 2024 Medicare Physician Fee Schedule (MPFS) proposals. On Nov. 16, the Centers for Medicare & Medicaid Services (CMS) published the calendar year (CY) 2024 MPFS final rule in the Federal Register, and not without a few surprises.

See how the proposed and final rules compare, so you can start 2024 year in the know.

1. Prepare for Telehealth to be Front and Center

In the proposed rule, CMS communicated the plan to continue PHE-style flexibilities for telehealth services.

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 These Equity-Inspired Changes

CMS acknowledged longstanding, systemic problems in the proposed rule, as they described the plan to roll out programs aimed at ensuring that all people receive the same level of healthcare, regardless of where they live.

Right in line with their proposal, “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.

How profoundly these programs will impact pediatric practices is yet to be seen, but at the very least there is potential for continued incentive for reporting social determinants of health (SDoH).

3. Implement Split/Shared in 2024

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 final rule says, “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 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.

4. See More of a CF Cut In 2024

Last July, CMS proposed a 3.34-percent cut to the conversion factor (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. A combination of federal laws, budgetary constraints, and expiring legislation all factored into the CF decrease for CY 2024.

“CMS is taking important steps toward those goals in this rule by improving payment for primary care and access to mental health care, paying for new navigation services to help people with cancer and other serious illnesses navigate their treatment, supporting family caregivers, paying for services involving community health workers to address health-related social needs that impact care, and enhancing access to dental care for people with certain cancers,” says CMS Administrator Chiquita Brooks-LaSure in a release on the rule.

Note: CMS estimates the following impact the RVU changes will have for pediatrics: -1 percent for pediatric practices in the facilities setting, 2 percent in the outpatient setting, and a 1percent increase overall for 2024.

Learn more: 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.