CMS Releases Medicare Physician Fee Schedule Proposed Rule for CY 2024

Spotlight

Phrenic Nerve Stimulation System (3X008, 3X009, 3X010, 3X011, 3X012, 3X013, 3X014, 3X015, 9X045, 9X046, 9X047, and 9X048)

CMS proposes to accept RUC recommended work RVUs without refinement for twelve new Category I CPT codes to describe insertion, repositioning, removal, and removal and replacement (3X008-3X015), activation, interrogation, and programming (9X045-9X048) of a phrenic nerve stimulation system. 

The new CPT codes will replace thirteen existing Category III codes (0424T-0436T).  CMS further proposes to increase the direct practice expense (PE) inputs for 3X014  from 36 minutes to 53 minutes to reflect a Level 4 Evaluation and Management (E/M) Office Visit included in the global period, and refine the equipment time for the exam table.  For all other codes, CMS proposes to accept the RUC recommended direct PE inputs as advocated for by the Society.

Remote Interrogation Device Evaluation (G2066, 93297 and 93298)

CMS proposes to delete the technical component HCPCS code G2066 (Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, implantable loop recorder system, or subcutaneous cardiac rhythm monitor system, remote data acquisition(s), receipt of transmissions and technician review, technical support and distribution of results), and accept RUC recommended direct PE inputs for remote monitoring CPT codes 93297 (Interrogation device evaluation(s), (remote) up to 30 days; implantable cardiovascular physiologic monitor system, including analysis of 1 or more recorded physiologic cardiovascular data elements from all internal and external sensors, analysis, review(s) and report(s) by a physician or other qualified health care professional) and 93298 (Interrogation device evaluation(s), (remote) up to 30 days; subcutaneous cardiac rhythm monitor system, including analysis of heart rhythm derived data, analysis review(s) and report(s) by a physician or other qualified health care professional). 

G2066 was created in January 2020 as a Medicare carrier-priced service to report the technical component of remote interrogation and monitoring of implantable cardiac rhythm devices.  HRS has long advocated for CMS to adopt direct PE inputs for 93297 and 93298 to stabilize payment for this life-saving service and supports CMS' proposal.

Payment & Other Policy Proposals

CY 2024 Conversion Factor

CMS estimates the Conversion Factor (CF) for CY 2024 will be $32.7476, which reflects an across-the-board $1.14 (or almost -3.4%) reduction fromthe current CF of $33.8872. If Congress fails to intervene, and the CF is finalized as proposed, this will be the 4th year in a row that the MPFS CF has decreased.

The CF cut is primarily driven by 2 factors:

• In 2023, Congress provided a one-year boost to the CF formula of 2.5%, but that boost lapses to 1.25% in 2024; and
• Statute requires that changes made by CMS that increase Medicare spending by more than $20 million be "budget neutral." CMS is planning to implement a "complexity add on code," HCPCS code G2211, which Congress had previously prohibited. That prohibition ends January 1st, and CMS estimates that the increased spending across the fee schedule, primarily from the introduction of G2211, requires a budget neutrality cut to the CF of 2.17%.

The estimated impact of the CF on payment rates represents a flawed Medicare payment system in serious need of reform. While CMS projects the overall combined impact of payment and policy changes to cardiology services will be 0.0% (1.0% increase in the non-facility setting and 1.0% decrease in the facility setting), the actual impact of Medicare revenues will differ based on geographic location, patient volume, and mix of services. Electrophysiologists cannot afford to absorb another year of Medicare payment cut; particularly, following drastic reductions to ablation services this year and in CY 2022.

HRS will continue its advocacy efforts to reform the Medicare physician payment system through support of H.R. 2474, the Strengthening Medicare for Patients and Providers Act, which would provide a permanent, annual update equal to the increase in the Medicare Economic Index (MEI), and working with the medical community to urge Congress to prevent the across-the-board CF cuts from taking effect on January 1, 2024.

Nomination of Potentially Misvalued Services (Ablation Add-on Codes 93655 and 93657)

In February, HRS nominated the two add-on ablation codes (CPT 93655 and CPT 93657) as potentially misvalued, reiterating the request for CMS to accept the RUC recommended work RVU of 7.00 for these services. In the proposed rule, CMS disagreed that the add-on codes are misvalued, and will maintain the current work RVU of 5.50 for the CY 2024 fee schedule.

Split (or Shared) E/M) Visits

CMS proposes another delay of its split and shared E/M visit policy "through at least December 31, 2024." A split or shared visit refers to an E/M visit performed by both a physician and a non-physician practitioner (NPP) in the same group practice in the facility setting where "incident to" billing is not available. CMS previously finalized a provision that designates the billing practitioner as the practitioner who performs the "substantive portion" of the service, defined as "more than half of the total time." During the CY 2023 rulemaking cycle, HRS urged the Agency to rescind the policy and will support CMS' proposal to further delay implementation in CY 2024. This will maintain billing of split or shared E/M visits based on the current policy definition of substantive portion as one of the following: history, or exam, or medical decision-making, or more than half of total time through the calendar year.

Rebasing and Revising the Medicare Economic Index (MEI)

Last year, CMS finalized a proposal to update the MEI weights using 2017 data from the United States Census Bureau's Service Annual Survey (SAS) but delayed its implementation. HRS expressed concern about the potential disruption to the MPFS from this change and urged CMS to delay implementation in order to await results from the American Medical Association (AMA) efforts to collect new data regarding practice costs. HRS is pleased that CMS is proposing yet again to delay implementation of this data given the AMA data collection efforts.

Medicare Telehealth Policies

CMS continues to refine its telehealth policies in the wake of the COVID-19 pandemic based on provisions authorized for the Public Health Emergency (PHE) and included in the Consolidated Appropriations Act, 2023 (CAA, 2023).

• Place of Service (POS) for Medicare Telehealth Services. The CAA, 2023 waives the geographic and originating site requirements for Medicare telehealth services through the end of CY 2024. By doing so, patients will continue to be able to access telehealth services regardless of their location, including their home. CMS further proposes to continue paying for telehealth services provided to patients in their homes at the non-facility payment rate. Specifically, claims billed with POS 10 (Telehealth Provided in Patient's Home) would be paid at the non-facility rate (i.e., the higher, office-based reimbursement rate) and that claims billed with POS 02 (Telehealth Provided Other than in Patient's Home) would continue to be paid at the facility rate (i.e., the lower rate assigned to payment for physician services provided in a facility setting where the facility carries more of the overhead costs). If finalized, practitioners furnishing services via telehealth would no longer bill claims with Modifier ~95 and would instead submit claims with one of the two POS codes.
• Audio-only Telephone Visits. Per the CAA, CMS is extending payment for audio-only telephone visits as well as all other services that were on the 2022 Medicare Telehealth Services List through 2024, and is delaying in-person visit requirements for telemental health services.
• Medicare Telehealth Services List. For CY 2024, several stakeholders requested that certain services temporarily approved for telehealth during the PHE be permanently added to the Medicare Telehealth Services List. While CMS is not proposing to add any previously approved services to the list on a permanent basis, the Agency is proposing to include health and well-being coaching services on a temporary basis, and permanently adopt HCPCS code GXXX5 (Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes) for CY 2024.
• Revisions to the Process for Considering Changes to the Medicare Telehealth Services List and Consolidation of Categories. CMS proposes to modify the process for making changes to the Medicare Telehealth Services List and has put forth two new indicators for the list: "permanent" or "provisional."
• Direct supervision. CMS proposes to continue to define "direct supervision" to allow the supervising clinician to be present and available through real-time audio and video interactive telecommunications through December 31, 2024, and is soliciting comment on whether to extend the policy beyond this date.

Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM) Services

CMS provides modification of certain policies that apply to remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services. These updates include:

• Clarification that RPM services may be furnished only to an established patient,
• An increase to 30 days of data collection (over the 16 days of data collection previously required); and
• Reminder that RPM and RTM services may not be billed together (although one or the other can be billed in conjunction with other specified care management services or other global services under specified circumstances).

In a separate portion of the proposed rule, Advancing Access to Behavioral Health, CMS included a request for information (RFI) on digital therapies (largely, but not solely, focused on digital cognitive behavioral therapy) to improve CMS' understanding related to its coverage and payment policies.

Cardiac and Intensive Cardiac Rehab

CMS proposes regulatory changes to align with provisions in the Bipartisan Budget Act of 2018 (not effective until January 1, 2024) that allow nurse practitioners (NPs), physician assistants (PAs), and certified nurse specialists (CNSs) to bill for and supervise cardiac and intensive cardiac rehab services.

Dental Services Related to Cardiac Interventions

In its ongoing effort to improve health outcomes via increased access to dental services, CMS proposed identification of additional scenarios where dental services are clearly linked to other covered services such that they do not fall within the statutory payment exclusions. As part of this policy development, CMS seeks specific input on additional cardiac interventions where the risk of infection posed to beneficiaries is similar to that associated with cardiac valve replacement or valvuloplasty and should be considered in coverage policy for dental services.

Appropriate Use Criteria (AUC) Program

CMS proposes to pause implementation of the Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging program for reevaluation and to rescind the current AUC program regulations. This program, authorized through legislation in 2014, would have required clinicians ordering advanced diagnostic imaging services to consult AUC via a clinical decision support tool and communicate results to the furnishing clinician for payment purposes. It was also supposed to eventually result in prior authorization for clinicians found to be outliers in terms of inappropriate ordering. Due to ongoing operational challenges, this program was delayed multiple times and not formally implemented.

Quality Reporting Program Proposals

The CY 2024 proposed rule includes numerous quality-focused provisions related to the Quality Payment Program (QPP) that could impact electrophysiologists, beginning with the 2024 performance period and affecting Medicare payments in 2026.

Merit Based Incentive Payment Program (MIPS)

CMS proposed multiple updates to the Merit-Based Incentive Payment System (MIPS), including to:

• Increase the overall MIPS performance threshold from 75 points to 82 points for 2024/2026, which would make it more difficult for clinicians to avoid a MIPS penalty. (As a reminder, the maximum penalty under MIPS is a 9% negative adjustment to all Medicare B fee-for-service claims in 2026 based on 2024 performance.)
• Increase the Quality category data completeness criteria from 70% to 75% for performance years 2024, 2025, and 2026, and 80% for 2027. (This threshold is the minimum percentage of applicable patients that a clinician must capture and report to CMS for each quality measure.)
• Adopt a new cost measure focusing on managing a chronic episode of Heart Failure.
• Add measures/activities to the Advancing Care for Heart Disease MIPS Value Pathways (MVP). As a reminder, last year, CMS began offering a new, alternative MIPS participation option known as MVPs. MVPs are a subset of measures and activities related to a specific condition or specialty. Participants opting to report through an MVP benefit from a more focused set of measures and slightly reduced reporting requirements. CMS previously finalized numerous MVPs for 2023, including the Advancing Care for Heart Disease MVP. In the rule, CMS proposes multiple additions to that MVP for CY 2024, including:
  • Quality measure #6: Coronary Artery Disease (CAD): Antiplatelet Therapy: This MIPS quality measure assesses that patients diagnosed with CAD are prescribed aspirin or clopidogrel
  • Quality measure #118: Coronary Artery Disease (CAD): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker–(ARB)–Therapy - Diabetes or Left Ventricular Systolic Dysfunction (LVEF ≤ 40%)
  • Quality measure #487: Screening for Social Drivers of Health
  • New Measure [# TBD]: Gains in Patient Activation Measure (PAM®) Scores at 12 Months. PAM® is a 10 - or 13 – item questionnaire that assesses an individual's knowledge, skills and confidence for managing their health and health care
  • Heart Failure episode-based cost measure
  • Medicare Spending Per Beneficiary (MSPB) cost measure

CMS also proposes modifications to its existing policy to publicly report utilization data, including expanding this data set to include Medicare Advantage data in addition to Fee-for-Service.

Alternative Payment Models (APMs)

The CY 2024 proposed rule also includes numerous updates related to the Alternative Payment Model (APM) track of the QPP, starting with the 2024 performance year:

• As required by statute, beginning with the 2024 performance year/2026 payment year, the APM incentive payment for Qualifying Participants (QPs) in Advanced APMs, which was recently reduced from 5% to 3.5%, goes away. Instead, QPs will receive a higher Medicare Physician Fee Schedule conversion factor update of 0.75% compared to non-QPs, who will receive a 0.25% update. QPs will continue to be excluded from MIPS and MIPS eligible clinicians will continue to be eligible for up/down performance-based payment adjustments under MIPS.
• CMS is also required by statute to increase the QP threshold percentages (i.e., the minimum amount of payments or patients seen by a clinician through an APM, which is used to determine QP eligibility). This will make it even more challenging for clinicians to qualify for this track of the QPP.
• CMS also proposes to make all QP determinations at the individual level rather than at the APM Entity-level and to change the definition of "attribution-eligible beneficiary" for purposes of QP determinations to include beneficiaries who have received a covered professional service furnished by the eligible clinician, rather than require an E/M service specifically. These changes are intended to address current policies that make it more challenging for specialists to attain QP status.

Download a fact sheet with more information on these and other 2024 QPP-related proposals, and additional information about the MVP proposals.

Hospital Outpatient and Ambulatory Surgery Center Payment System Proposed Rule

On July 13th, CMS also released the CY 2024 hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) payment system proposed rule. Of note, no electrophysiology procedures were added to the covered procedure list for ASCs.

• 2024 Payment Update. CMS proposes to increase hospital outpatient payments by 2.8%. CMS is able to provide this increase because of the formula set out in federal statute which incorporates the inflationary costs of delivering health care. This statutory inflationary component to the formula does not exist in the Medicare Physician Fee Schedule.
• Inpatient Only (IPO) List. Medicare maintains what it calls the "inpatient only list," which is a list of services that CMS restricts payment for to the hospital inpatient setting. CMS regularly revises the list, and this year plans to add several new CPT codes to the list, but makes no proposals to remove any codes from the list.
• ASC Covered Procedure List (CPL). In addition to its regular review of the IPO list, CMS annually reviews the ASC covered procedure list (CPL), a list of services for which CMS will make payment in the ASC setting only if the procedure is on the CPL. While being on the list does not restrict payment to the ASC setting, it is a requirement for payment when the service does happen to be delivered in an ASC. While CMS has received several requests over the last few years to add moreelectrophysiology procedures to the CPL, CMS made no proposals to do so this year and focuses only on the addition of dental procedures.
• Hospital Price Transparency Requirements. Over the last several years, CMS has issued regulations directed at increasing price transparency for services delivered in the hospital setting. Hospitals are required to post "standard charges" for items and services delivered in the hospital. CMS defines these "standard charges" in multiple ways and hospitals are required to post information regarding all of the following:
  • The chargemaster rate
  • The discounted cash price
  • Payer-specific negotiated charges
  • De-identified minimum and maximum negotiated charges

CMS is making several changes to the requirements, including proposals designed to increase hospital compliance with these obligations. More information on these proposals can be found in a CMS fact sheet focused solely on these provisions.