Primary Care Coding Alert

Also: Gain insight into the split/shared policy update.

On Nov. 16, the Centers for Medicare & Medicaid Services (CMS) published the calendar year (CY) 2024 Medicare Physician Fee Schedule (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 public health emergency- (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 Medicare telehealth services 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, POS code 10 (Telehealth provided in patient’s home), will pay at the higher, non-facility MPFS rate in alignment with Consolidated Appropriations Act (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 and be present when the resident furnishes Medicare telehealth services at all residency training locations through Dec. 31, 2024.

2. Understand These Equity-Inspired Changes

CMS acknowledged longstanding, social 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 primary care practices is yet to be seen, but at the very least, there is potential for continued incentive for reporting 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 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^®.