Pulmonology Coding Alert

Medicare Physician Fee Schedule:

Prepare for Possible E/M and SDoH Reporting Changes in 2024

Published on Fri Sep 08, 2023

Plus: Is a zero percent change a positive? Find out.

The Centers for Medicare & Medicaid Services (CMS) published its calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) proposed rule to the Federal Register on Aug. 7, 2023. As a pulmonology coder, you’ll want to be aware of proposed changes to reporting complex patient visits as well as incentives for reporting social determinants of health (SDoH).

Read on to find out what Medicare changes could be arriving in the new year.

Learn if a Neutral Combined Impact Is Good or Bad for Your Practice

CMS is proposing a conversion factor (CF) of $32.75 for 2024. The proposed CF is a $1.14 reduction when compared to the 2023 CF of $33.89, which is a 3.34 percent decrease. As many providers are still battling inflation and financially recovering from the COVID-19 public health emergency (PHE), they were hoping CMS wouldn’t adjust the CF further for 2024.

The total allowed charges, which includes impact of the work, practice expense (PE), and malpractice relative value units (RVUs), is estimated to be $1,290 (mil) — or $1.29 billion — for the pulmonary disease specialty in CY 2024. CMS proposes each of these RVU change factors and the combined impact to be zero percent for the upcoming year.

While the proposed rule may feature a proposed zero percent change in charges, pulmonology practices may end up experiencing losses on Medicare patients if the rule is finalized. “Although the proposed impact appears revenue neutral, the true impact cannot be appreciated if the other costs to running a practice increase,” says Carol Pohlig, BSN, RN, CPC, manager of coding and education in the department of medicine at the Hospital of the University of Pennsylvania in Philadelphia.

Understand G2211’s Proposed Reimbursement Rules

Starting in 2021, physicians could report 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)) with office and outpatient evaluation and management (E/M) codes when the visit involved a complex patient.

“Code G2211 represents care addressing the patient’s overall, ongoing care. These are visits in which the chronic condition is being managed, monitored, or observed by a specialist who has taken responsibility for subsequent, ongoing medical care for that patient to provide consistency and continuity over time for a particular disease or condition,” Pohlig explains. For example, pulmonologists who care for chronic obstructive pulmonary disease (COPD), cystic fibrosis (CF), and lung transplant patients, could possibly report G2211, but not for every visit.

“[G2211’s use] was delayed due to public comment and the expected great impact on other service reimbursement and specialty providers to remain budget neutral, meaning if a provider type gets more money, it results in less 1:1 for other provider types,” writes Kelly Loya, CPhT, CPC-I, CHC, CRMA, associate partner, Lori Carlin, CPC, COC, CPCO, CCS, director, and Amy Crenshaw-Pritchett, CCS, CPC-I, CPMA, CDEO, CASCC, CANPC, CRC, CDEC, CMPM, C-AHI, manager, HCC coding/audit & education services, of Pinnacle Healthcare Consulting in their online analysis (https://askphc.com/proposed-rule-summary-of-topics-and-interesting-points-physician-fee-schedule-2024/).

In 2021, CMS estimated that providers would report this add-on code with approximately 90 percent of office/outpatient E/M visits. As a result, the code affected the budget neutrality significantly for the 2021 MPFS, which led to Congress suspending G2211’s use until CY 2024.

When the calendar flips to 2024, CMS is proposing that G2211 takes effect as expected, but the agency has also proposed policy refinements to help reduce the impact on the PFS payments.

CMS explains in the proposed rule that one of the changes involves the provider’s relationship to the patient. You won’t be able to report G2211 with an office/outpatient E/M code when the visit is furnished by “a professional whose relationship with the patient is of a discrete, routine, or time-limited nature; such as, but not limited to, treatment of a simple virus; for counseling related to seasonal allergies, … and where comorbidities are either not present or not addressed,” according to the agency’s proposal.

Other refinements CMS is proposing for G2211 include:

Not allowing G2211 to be billed when the corresponding E/M code is appended with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) in which an E/M visit is unbundled from a procedure to address the patient’s existing complexity; and
Regulating the frequency with which G2211 can be billed alongside an office/ outpatient E/M code.

If the proposed refinements are finalized, CMS estimates the add-on code would be billed with 38 percent of associated E/M visits at first, and 54 percent of E/M claims after several years of use.

Receive Reimbursement for Risk Assessments

The MPFS proposed rule also examines supporting and expanding care integration and patient access to care initiatives. Among the proposals are changes to coding and payment for reporting Community Health Integration (CHI), Principal Illness Navigation (PIN) services, and SDoH risk assessments.

Regarding the SDoH risk assessment, CMS proposes adding the service to annual wellness visits as an optional element. The bonus is that the risk assessment would include additional reimbursement. “The recognition of SDoH assists providers in delivering equitable care. Incentivizing physicians will help practices develop and initiate a process to assess and address SDoH which can benefit all patients,” Pohlig says.

CMS also proposes codes and payments for SDoH risk assessments performed on the same day as an E/M visit. For example, the agency proposed HCPCS code GXXX5 (Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes, not more often than every 6 months.), which you could report for risk assessments furnished during an E/M visit on the same day if the risk assessment is necessary to determine the diagnosis and establish a treatment plan during the visit.

“If the SDoH risk assessment can be reported by any provider or specialist caring for a patient, it will increase awareness and attentiveness to patient-specific issues. Providers can identify the best care plan possible knowing the needs and barriers for a particular individual,” Pohlig explains.

Important: The proposed SDoH risk assessment reimbursement wouldn’t happen without restrictions. “The downfall is that the proposed rule limits reporting to once every six months. This is likely to be a limitation across providers, meaning only one claim will be accepted for a patient every six months, regardless of who is submitting the claim,” Pohlig adds.

This is important to remember if providers are seeing a patient who requires several follow-up visits throughout the year. The provider can perform the SDoH risk assessments during the visits, but they will only be eligible for reimbursement every six months.

Deadline: CMS was seeking public comments on the proposed rule through September 11.

Resource: Review the CY 2024 MPFS proposed rule at www.federalregister.gov/documents/2023/08/07/2023-14624/ medicare-and-medicaid-programs-cy-2024-payment-policies-under-the-physician-fee-schedule-and-other.