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CMS 2024 Reimbursement Updates
The Centers for Medicare & Medicaid Services (CMS) has announced several key changes to the Medicare Physician Fee Schedule (PFS) for calendar year (CY) 2024:
1. Reduction in Payment Rates: Overall payment rates under the PFS will be reduced by 1.25% compared to CY 2023. However, there will be significant increases in payment for primary care and other direct patient care services. The final CY 2024 PFS conversion factor is set at $32.74, a decrease of $1.15 (or 3.4%) from the CY 2023 conversion factor.
2. Training for Caregivers: CMS is finalizing a proposal to make payments when practitioners train caregivers to support patients with certain diseases or illnesses (e.g., dementia) as part of the patient’s individualized treatment plan or therapy plan of care. This initiative aims to improve support for persons with Medicare by better training caregivers.
3. Services Addressing Health-Related Social Needs: CMS is finalizing coding and payment changes for services that address health-related social needs. This includes Community Health Integration Services, Social Determinants of Health (SDOH) Risk Assessments, and Principal Illness Navigation Services. These services, especially involving community health workers, care navigators, and peer support specialists, will be paid separately to better account for resources involved in providing patient-centered care.
4. Add-On Payment for HCPCS Code G2211: Beginning January 1, 2024, CMS will implement a separate add-on payment for HCPCS code G2211. This code is intended to better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care.
5. Split or Shared E/M Visits: CMS has revised the definition of “substantive portion” of split (or shared) E/M visits. Now, the substantive portion means more than half of the total time spent by the physician or non-physician practitioner performing the split visit, or a substantive part of the medical decision making.
6. Addition to Medicare Telehealth Services List: Health and well-being coaching services and Social Determinants of Health Risk Assessments will be added to the Medicare Telehealth Services List. Health and well-being coaching is added on a temporary basis for CY 2024, while Social Determinants of Health Risk Assessments are added on a permanent basis.
7. Telehealth Services in Homes: In CY 2024, telehealth services furnished to people in their homes will be paid at the non-facility PFS rate. This change aligns with telehealth-related flexibilities extended through the Consolidated Appropriations Act, 2023.
8. Preventive Vaccine Administration Services: CMS will maintain the additional payment for in-home COVID-19 vaccine administration established during the Public Health Emergency (PHE). This additional payment will also be extended to the administration of other preventive vaccines (pneumococcal, influenza, hepatitis B) when provided in the home.
9. Behavioral Health Services: For CY 2024, Medicare Part B will cover and pay for services of marriage and family therapists (MFTs) and mental health counselors (MHCs) when billed by these professionals. This includes allowing addiction counselors or drug and alcohol counselors who meet the requirements to enroll in Medicare as MHCs.
These changes reflect a broader strategy to create a more equitable healthcare system that focuses on better access to care, quality, affordability, and innovation.
The specific changes for home visits in the CMS 2024 Physician Fee Schedule include:
1. Consolidation of Home Visit Codes: Home visit codes have been consolidated. Now, all home or residence services are reported using codes 99341-99345 for new patients and 99347-99350 for established patients. This change encompasses any patient residence, including settings like assisted living facilities, which previously had a separate code category.
2. Determination of Visit Levels: Visit levels for home visits will be determined based on the time spent performing services or the level of medical decision-making required, rather than history and a physical examination.
These changes are part of CMS's efforts to streamline and simplify the coding and billing process for home visits, making it more flexible and reflective of the actual services provided.
CMS 2023 Reimbursement Updates
Reimbursement for physician home visits in 2023 under the Medicare Physician Fee Schedule has undergone some updates. Key aspects of these updates include:
1. Evaluation and Management (E/M) Visits: The CMS has continued updating E/M visit codes and related coding guidelines. These updates, effective from January 1, 2023, are intended to reduce administrative burdens. The revisions apply to various settings, including hospital inpatient, hospital observation, emergency department, nursing facility, and home or residence services.
Revised Codes for At-Home E/M Services: As of January 1, 2023, the CPT codes for at-home E/M services have been revised. Services to patients in private residences or temporary lodgings are now combined with services in facilities where only minimal health care is provided. The new patient home or residence E/M services codes are 99341, 99342, 99344, and 99345. The established patient home or residence services codes are 99347, 99348, 99349, and 99350. These codes are selected based on either the level of medical decision-making or the total time on the date of the encounter. The E/M codes specific to domiciliary, rest home, or custodial care have been deleted, and the above codes are used in these settings as well.
Prolonged Services Reporting for Medicare Patients: When the total time on the date of the encounter exceeds the threshold for code 99345 or 99350 by at least 15 minutes, code 99417 can be added to report prolonged services. However, for Medicare patients, prolonged home or residence services should be reported with code G0318 in addition to 99345 (requiring total time ≥140 minutes) or 99350 (requiring total time ≥110 minutes). Code G0318 includes any work within three days prior to the service or within seven days after.
2. New Coding and Documentation Framework: The revised framework includes changes in the definition of Other E/M code descriptors, new descriptor times, revised guidelines for levels of medical decision-making, and the option to choose between medical decision-making or time to select the code level. Importantly, the use of history and exam for determining code level has been eliminated, replaced by a requirement for a medically appropriate history and exam.
3. Consolidation of Code Sets: CMS has consolidated inpatient and observation care into a single code set and home and domiciliary care into a single home or residence-based services code set. This code set includes services provided in settings like assisted living, group homes, custodial care facilities, and residential substance abuse treatment facilities. The decision to determine visit levels will now be based on the time spent performing services or the level of medical decision-making required, rather than history and a physical examination.
Consolidation of Home or Residence E/M Codes: The E/M codes for home care services now encompass any patient residence, including assisted living facilities. Prior to 2023, there was a separate code category for such facilities. The revised coding includes codes 99341-99345 for new patients and 99347-99350 for established patients, covering all home or residence services.
4. Telehealth Services: Physicians and practitioners are allowed to continue billing with the place of service (POS) indicator that would have been used if the service had been furnished in-person, using the modifier “95” to identify these as telehealth services. This billing approach is permitted through the end of CY 2023 or the end of the year in which the Public Health Emergency (PHE) ends.
While specific reimbursement rates for home visits are not provided in these updates, they indicate a shift towards a more flexible and streamlined coding and billing process. For exact reimbursement rates in your area, it would be necessary to consult the CMS Physician Fee Schedule or use the CMS Physician Fee Schedule Lookup Tool.
