Weekly Roundup – July 17-21, 2023
Physician payment, coding, coverage, and quality reporting news highlights.
PAYMENT
Key Insights from the CY 2024 Medicare Physician Fee Schedule (PFS) Proposed Rule. On July 13, 2023, the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2024 Medicare Physician Fee Schedule (PFS) Proposed Rule. CMS proposes a 2024 Physician Conversion Factor (CF) of $32.7476. This is a reduction of 3.34% from the 2023 Physician CF of $33.8872. The change in value is driven by a 0% annual update, a negative 2.17% impact from budget neutrality adjustments, the expiration of the 2.5% statutory payment increase for CY 2023, and a 1.25% statutory payment increase for 2024. The agency notes that this reduction results from a formula they must abide by.
As a reminder, the Medicare CF is a dollar conversion factor used to calculate payment rates for Medicare PFS services. To calculate rates, geographically adjusted relative value units (RVUs) representing work, practice expense (PE), and malpractice costs are multiplied by the CF. By law, the Medicare PFS is budget neutral, so any increases greater than $20 million must be balanced by cuts elsewhere.
Addressing this payment reduction will require Congressional action. Providers were anticipating this cut and have been heavily lobbying Congress for a short-term solution to avoid a payment cut in 2024 and a more long-term solution for the physician payment system to bring greater stability to the fee schedule and annual updates that reflect the rising practice costs to the physician payment system. In general, there does seem to be bipartisan support for at least a short-term fix for 2024. A more long-term solution that addresses issues such as an annual inflationary update, updating the $20 million threshold for budget neutrality, and concerns related to the Quality Payment Program (QPP) remains more uncertain.
Beyond the conversion factor, some significant policy themes that impact clinician payment and beneficiary access to services of note include:
Specific policy proposals create specialty winners and losers.
Prioritization of health equity moves from quality measurement to payment for particular services.
The agency moves cautiously on addressing data needs, which provides some stability to the fee schedule.
Telehealth flexibilities are maintained throughout CY 2024.
CMS proposes updates to the QPP for 2024 but also seeks comments on its future.
Continue reading HERE.
CODING
CMS Delays Changes to Split Billing; Why it Matters. In the CY 2024 Medicare PFS Proposed Rule CMS has once again delayed revising the definition of “substantive” as it relates to split billing. Since the billing provider must demonstrate that they have performed the substantive portion of the service, this seemingly technical change could potentially have significant financial implications for practices.
The current definition of substantive: In the calendar year 2022 final rule, CMS finalized that for 2022, the billing provider’s portion of a split/shared E/M visit can be determined based on one of two methods: more than 50% of the total time spent, or one of the three key components (history, exam, or medical decision-making.
Proposed revision of substantive: A substantive portion of the E/M visit will be defined only as more than 50% of the total time spent.
Through split billing, services can be jointly provided by physicians and Advanced Practice Providers (APPs) (e.g., Advanced Practice Nurses and Physician Assistants), who are paid at 85%. APPs are often used to help streamline practices, and if they have spent more than 50% of the time on the visit, under the revised definition, the visit would be billed by the APP at 85% of the physician rate. Physician medical specialty societies have been urging the agency to reconsider this proposal. They feel that beyond the financial implications of this proposal, this proposed change could harm collaborative care models, is administratively burdensome, and could “pit physicians and APPs against each other.”
This was initially proposed in the CY 2023 PFS Proposed Rule, and its implementation was delayed for a year. With the decision delayed yet again, the agency will likely hear once from stakeholders through the public comment process.
COVERAGE
CMS Proposes to Expand Coverage of PET Scans for Alzheimer Patients. This week the Centers for Medicare and Medicaid Services (CMS) proposed to eliminate the current limit of one amyloid positron emission tomography (PET) scan per lifetime and permit coverage to be made at the discretion of local Medicare Administrative Contractors (MACs). PET scans are used to diagnose and monitor the treatment of Alzheimer’s disease. This proposed change follows the agency’s recent announcement to expand coverage for Lequembi after it had received approval from the Food and Drug Administration. Lequembi has been shown to slow the progression of Alzheimer’s Disease.
While stakeholders are generally pleased with the proposed expansion, there is concern that inconsistent coverage decisions could be made since the agency has deferred coverage decisions to local MACs.
CMS issued the proposed decision memo on July 17, 2023, with a 30-day comment period.
E&C Directs Frustration on NCD Process in a Letter to Agency Requesting Greater Transparency. On July 14, 2023, Chairs of the House Energy and Commerce Committee issued a letter with members of their committee to CMS requesting greater transparency on the agency’s process to vet and select public National Coverage Decision (NCD) requests. Specifically, they request to provide them by July 28, 2023, a list of items awaiting NCD decision and a plan for updating the NCD website. The letter indicates that the NCD dashboard has not been updated since September 16, 2020.
The letter raises concerns regarding the need for more information on the current requests, the timeline for reviewing them, and how the agency prioritizes them. The letter also noted that the Transitional Coverage of Emerging Technologies rule was posted two months after the agency had indicated it would be released.
A timeline is posted on the Medicare Coverage website, which indicates that the NCD process takes 9-12 months. But this timeline starts once CMS formally accepts the NCD request. Information on NCD requests received by the agency is not posted on the website. CMS notes on the website that “NCD requests are accepted on a rolling basis. If CMS has a large volume of NCD requests for simultaneous review, requests are prioritized based on the magnitude of the potential impact on the Medicare program and its beneficiaries and staffing resources.”
For more information and questions, please contact:
Sheila Madhani, MA, MPH
Madhani Healthcare Consulting, LLC
Email: smadhani@madhani-health.com
www.madhani-health.com
Tel: (202) 679-2977