Pediatric Coding Alert

See how the CF cut compares to previous years.

Even though the COVID-19 public health emergency (PHE) is in the past, its impact is very much in the present proposed updates for calendar year (CY) 2024. Read on for the details.

Background: The Centers for Medicare & Medicaid Services (CMS) recently released the CY 2024 Medicare Physician Fee Schedule (MPFS). The agency addresses several post-PHE hot topics, offering policy fixes for next year.

Here are four MPFS proposals you should keep an eye on:

1. Expect Continued Flexibilities for Telehealth Services

The Centers for Medicare & Medicaid Services (CMS) plans to implement the 2023 Consolidated Appropriations Act (CAA)telehealth services provisions through the end of 2024. This includes allowing the patient’s home as an originating site. Additionally, CMS proposes to pay telehealth services furnished in the patient’s home — POS 10 (Telehealth provided in patient’s home) — at the higher, non-facility PFS rate. POS 2 (Telehealth provided other than in patient’s home) would remain as-is, paid at the facility rate.

The proposal also includes lifting geographic restrictions and letting Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) provide telehealth services. Audio-only telehealth service coverage and payment may also see an extension in the coming year.

These changes would have an obvious benefit for pediatric patients. Rural and underserved areas, as well as parents experiencing various travel-related setbacks would have greater access to specialty services. This could also create more flexibility in scheduling and provide patients with chronic conditions more consistent follow-up care.

2. Look for Programs Related to Equity and SDoH

Ensuring that all people receive the same level of healthcare remains a central theme post-pandemic, which isn’t surprising as the public health emergency (PHE) revealed longstanding, systemic problems.

“CMS continues to demonstrate commitment to advancing health equity and building a stronger Medicare program,” explains Meena Seshamani, MD, CMS Deputy Administrator and Director of the Center for Medicare, in a release. “If finalized, the proposals in this rule ensure the people we serve experience coordinated care focused on treating the whole person, considering each person’s unique story and individualized needs — physical health, behavioral health, oral health, social determinants of health, and are inclusive of caregivers, which are all so important to providing the care that people with Medicare deserve.”

“Building on CMS’ goal of increasing health equity, the agency has proposed coding and payment for several new services to help underserved communities,” summarizes Miranda Franco, senior policy advisor, with law firm Holland & Knight LLP in an H & K Health Dose blog post. “These include certain caregiver training programs, separate coding and payment for community health integration services, payment for principal illness navigation services, and coding and payment for social determinants of health risk assessments,” Franco explains.

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). To review the newest SDoH codes, effective Oct. 1, 2023, check out Volume 26, Number 9 of Pediatric Coding Alert (https://www.aapc.com/codes/ coding-newsletters/my-pediatric-coding-alert/news-you-can-use-take-a-peek-at-icd-10-2024s-newest-z-codes-175834- article).

3. Witness Another Split/Shared Policy Delay

CMS intends to keep the current split/shared rules for a little bit longer, with a start date for the new policy now slated for Jan. 1, 2025. CMS finalized implementing its split/shared policy that the provider who administers the substantive portion of the visit bills for the E/M services — whether it’s the physician or the nonphysician practitioner (NPP) — in the calendar year (CY) 2022 MPFS final rule and then delayed the implementation in the CY 2023 MPFS final rule.

Many have opposed the change since CMS first proposed the policy, so this further delay will allow CMS to gather more comments and feedback from interested stakeholders regarding he policy and how it could be altered or further refined.

4. Understand the CF Changes

In the latest proposed rule, CMS opts to reduce the overall payment rate by 1.25 percent and the CF by 3.34 percent or $1.14, decreasing the amount from the $33.89 (CY 2023) to $32.75 (CY 2024). Many hoped CMS would leave the CF, at the very least, status quo for CY 2024, but unless something drastic happens between now and the final rule, that’s not likely. However, “CMS is also proposing significant increases in payment for primary care and other kinds of direct patient care,” the agency says (source: www.cms.gov/newsroom/ fact-sheets/calendar-year-cy-2024-medicare-physician-fee-schedule-proposed-rule). The verbiage in the proposed rule does not offer an obvious indication that pediatric physicians will see a payment change that will offset the decreased conversion factor, however.

Note: CMS hasn’t proposed or finalized a CF increase in the Medicare Physician Fee Schedule (MPFS) since CY 2020. 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,” explains AMA President Jesse M. Ehrenfeld, MD, MPH, in a release.