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Will the 2024 fee schedule rule see the debut of G2211?

Opinion
Article

Proposed rule includes incorporation of controversial E/M code.

Jonathan Rubenstein, MD

Jonathan Rubenstein, MD

The Centers for Medicare & Medicaid Services (CMS) unveiled the proposed rule for the Medicare Physician Fee Schedule of calendar year 2024 on July 13, 2023.1 The rule encompasses the suggested changes for payment and policy adjustments set to take effect January 1, 2024. As customary, a comment period is in place, during which CMS will review and address each received comment in their response and subsequent actions. Comments can be posted online by going here: https://tinyurl.com/yrzzn6yt. Below are several significant areas of relevance for urologists and urology practices.

Conversion factor (CF). The CF is slated to undergo a reduction of approximately 3.3% for 2024, decreasing from $33.89 in 2023 to $32.75. This reduction is attributed to several factors: a 0% statutory update, a 2.17% decrease for budget neutrality reasons, and an additional 1.25% decline due to the absence of an increase in the Consolidated Appropriations Act of 2023. The decrease in the CF is partially influenced by the reintroduction of the add-on code G2211, which will be further explored in this article.

Mark Painter

Mark Painter

Evaluation and management (E/M) services proposed revisions. Effective January 1, 2024.

CMS again has proposed the incorporation of the add-on Healthcare Common Procedure Coding System (HCPCS) G 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”). This code characterizes the inherent complexity of visits related to the evaluation and management of medical care services that serve as a continuous focal point for comprehensive health care needs. It also applies to medical care services tied to ongoing care for either a patient’s singular serious condition or a complex condition. According to coding instructions, G2211 functions as an add-on code that is reported alongside an office visit or other outpatient E/M visit, whether it’s a new or established visit. The primary purpose of this code is to capture the extra time, complexity, and resources required when treating patients with chronic health conditions longitudinally. (Although the final rule will likely stipulate what defines longitudinal care more clearly, it is expected this will follow along the definition of a chronic problem and/or a problem that requires coordination of care with others.) Although primarily aimed at primary care providers and those delivering prolonged care to patients, urologists will also utilize this code for patients meeting the criteria. Medicare’s proposal stipulates that the code may not be utilized if the E/M code is submitted with a modifier –25 for the service date. The implications of this code are substantial and need to be accommodated within the Medicare budget.

It should be noted that the budget impact, as noted above, of the implementation of this code is significant and skewed toward primary care. The American College of Surgeons and other organizations have expressed significant concern that the impact of the code warrants further study and that they will likely oppose the implementation as proposed.2 In addition to the impact to the CF, the implementation of the code will require significant training and workflow changes for each office. In the urology office, the implementation of the code will require changes for both the billing staff and the clinical staff.

A list of systems and areas we project will need to be addressed if the code is implemented as proposed is as follows:

• clinical staff training to document and then communicate the visit, including the treatment of a disease state that is being cared for or will be cared for by the urology office that is expected to require ongoing care;

• electronic health record template refinement to allow appropriate documentation;

• billing team education with support from billing staff for payer-specific billing changes in addition to situational modification;

• practice management scrubber updates that may include ICD-10 requirements, modifier flags, and payer-specific rules; and

• compliance review updates to ensure proper billing compliance.

Split/shared services. CMS has proposed to delay the change requiring split/shared services policy to be determined solely by the qualified health professional (QHP) spending the most time with the patient on the date of service for 1 more year, until 2025. Current CMS rules allow that the QHP documenting the most substantive portion of a visit for the history, physical exam, or medical decision-making or by documenting the most time spent with the patient for the visit. Under the current rules, which will continue through next year, it is recommended the QHP documenting the most substantive portion of medical decision-making or documented as having spent the most time dedicated to the visit should be the billing QHP.

Delayed implementation of the updated Medicare Economic Index (MEI) weights. CMS is proposing to delay the implementation of the weights based on MEI relative to the Medicare Physician Fee Schedule. These numbers were finalized in the 2023 final rule; however, CMS is proposing to delay this implementation to collect and further analyze data related to physician practice expense.

Relative value unit (RVU) changes. Medicare projects that RVU changes for urology will result in a 1% increase in overall RVU production on a similar volume of services, including the addition of code G2211. Although there will be several small adjustments to RVUs in urology, only postvoid residual in the office setting is changing more than 5% up or down, going from a 0.32 nonfacility total in 2023 to a nonfacility total of 0.34 in 2024.

Telehealth. Although the COVID-19 Public Health Emergency (PHE) has expired, the Consolidated Appropriations Act of 2023 required Medicare to extend coverage of telehealth under PHE rules until December 30, 2024. CMS has acknowledged this extension in the proposed rule and will continue to cover telehealth next year as they are currently. In the proposed rule, CMS took the additional step of proposing to pay telehealth services provided to the patient in the home at the nonfacility rate. This means that in 2024, if Place of Service Code 10 (Telehealth Provided in Patient’s Home) is used to report services provided, telehealth services provided while the patient is in their home will be paid the same amount as what would have been paid to the physician if the patient were in the office. CMS is proposing this to accommodate the final rule of 2023 and the expansion proposed in 2024 for services for certain mental health, substance abuse, and behavioral health services.

CMS is proposing as well to continue all coverage of services provided in the office setting by support staff “incident to” the physician if the physician is available via audio and visual remote connection while the service is provided. CMS is also proposing that telephone-only services 99441 through 99443 will continue to be covered in 2024.

Merit-based Incentive Payment System (MIPS)/Medicare Access and CHIP Reauthorization Act of 2015. CMS is proposing to raise the threshold for MIPS from 75 points to 82 points. The penalty for not meeting the threshold is –9% of Medicare payments for MIPS-eligible physicians. As we will not learn of the final adoption of this policy until late October 2023, we would encourage all urology offices to pay attention to their MIPS performance immediately.

New and updated category 1 Current Procedural Terminology (CPT) codes of interest to urology

Cystourethroscopy with dilation and drug delivery: This as-yet-unreleased CPT code describing “Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when performed,”will be available to report starting January 1, 2024. CMS is proposing to accept theSpecialty Society Relative Value Scale Update Committee (RUC)-recommended work RVU (wRVU) valuation of 3.10.

Neurostimulator services: CPT codes 64590 and 64595. The descriptor for CPT code 64590 will be updated to read “Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver”and is proposed to be valued at a RUC-recommended wRVU of 5.10. Similarly, CPT code 64595 (Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array and pulse generator or receiver)and will be valuated with a wRVU of 3.79.

We will review and update a wider range of new and updated category 1 and category 3 CPT codes in an article later this year.

We will update you again once the final rule is released, typically late October or early November 2023. We encourage each of you to comment on this proposed rule as you deem appropriate and to coordinate where possible with LUGPA, the American Urological Association, and the American Association of Clinical Urologists.

References

1. Medicare and Medicaid programs; CY 2024 payment policies under the Physician Fee Schedule and other changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program. Fed Regist. 2023;88(150):52262-53197

2. College joins fight against implementation of G2211 code. American College of Surgeons. August 1, 2023. Accessed August 21, 2023. https://tinyurl.com/32jh6ub8

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