Pulmonology Coding Alert

Study how to correctly report split/shared visits.

On Nov. 16, 2023, the Centers for Medicare & Medicaid Services (CMS) published its calendar year (CY) 2024 Medicare Physician Fee Schedule (MPFS) final rule to the Federal Register. We reported on several of proposals for payment policies in Pulmonology Coding Alert, Volume 24, Issue 10, and now that CMS has finalized its proposals, the published final rule clarifies what your pulmonology practice can expect in the new year.

Read on to see how CMS’ final rule will affect your 2024 reimbursement.

Move Forward With the Proposed CF

CMS finalized its proposed conversion factor (CF) of $32.7442 for 2024, which marks a fourth straight year of decreased CFs. Upon finalization, the 2024 CF is a 3.37 percent decrease, or a $1.1396 reduction, when compared to the 2023 MPFS CF of $33.8872.

The good news on the surface is that the finalized CF reduction’s effect on the pulmonary disease specialty will be the same as estimated in the proposed rule. CMS estimates a 3 percent increase for non-facility payments and a 2 percent decrease for facility payments. However, the total allowed charges, which includes impact of the work, practice expense (PE), and malpractice relative value units (RVUs), is estimated to be $1,295 (mil) — or $1.295 billion — for the pulmonary disease specialty in CY 2024. CMS finalized each of these RVU change factors and estimated the combined impact to be zero percent for the upcoming year.

While the neutral combined impact appears to be a positive in the light of the decreased CF, pulmonary practices may end up experiencing reimbursement losses due to the costs of operating the practice and inflation. Healthcare industry experts recognize that those factors can contribute to further losses.

“This is a recipe for financial instability,” says Jesse M. Ehrenfeld, MD, MPH, president of the AMA. He continues, “The declining revenues in the face of steep cost increases disproportionately affect small, independent, and rural physician practices, as well as those treating low-income or other historically minoritized or marginalized patient communities” (www.ama-assn.org/press-center/press-releases/medicare-payment-cuts-thin-gruel-seniors-physicians).

Learn How to Report Split/Shared Visits in 2024

The CY 2024 PFS final rule also contains one of CMS’s 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, then CPT^® requires 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.

Remember to Add G2211 to Your E/M Coding Knowledge

CMS also finalized its proposal to activate 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)). CMS bundled G2211 with office/outpatient E/M services in previous years, but you’re able to report G2211 as of Jan. 1, 2024. According to the 2024 MPFS final rule, CMS is “finalizing changing the status of HCPCS code G2211 to make it separately payable by assigning it an ‘active’ status indicator, effective January 1, 2024.”

CMS emphasizes repeatedly in the CY 2024 MPFS final rule that primary care is a focal point of recent policymaking, and the implementation of add-on code G2211 “will better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care.”

Resource: Download the CY 2024 PFS final rule by going to www.federalregister.gov/public-inspection/2023-24184/medicare-and-medicaid-programs-calendar-year-2024-payment-policies-under-the-physician-fee-schedule.