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2024 PFS Proposed Rule: Implications for Chronic Pain Providers

August 7, 2023

Summary

The 2024 PFS proposed rule contains stipulations that will affect chronic pain practitioners, if finalized. Provisions involving E/M services, telehealth and discarded drugs are specifically highlighted in today’s alert. 

Like every year, the Centers for Medicare and Medicaid Services (CMS) generates new proposals that will affect the practices of medical professionals throughout the country. The Medicare Physician Fee Schedule (PFS) Proposed Rule for 2024 is no different. We’ve already shared in a previous alert what the rule proposes as it concerns the anesthesia specialty, generally, as well as the RBRVS conversion factor (hint: it’s lower next year). Today’s article will focus specifically on those issues most likely to have implications for chronic pain practices.

New Add-On Code

The rule for 2024 proposes to implement a separate add-on payment for healthcare common procedure coding system (HCPCS) code G2211. According to CMS, “This add-on code will better recognize the resource costs associated with evaluation and management (E/M) visits for primary care and longitudinal care of complex patients.” Generally, it will be applicable for outpatient office visits as an additional payment, recognizing the inherent costs clinicians may incur when longitudinally treating a patient’s single, serious or complex chronic condition. The add-on code would not be billed with a modifier that denotes an office and outpatient evaluation and management visit that is itself unbundled from another service (e.g., a procedure where complexity is already recognized in the valuation).

The extent to which longitudinal care, for example (and, by extension, this new add-on code), will apply to the specialty of pain management is not entirely certain at this time. However, we should have greater clarification on this matter should it be addressed in the 2024 PFS final rule, which is expected to be published in November.

Split Visits

As you will recall, split (or shared) E/M visits refer to those clinical encounters provided in part by physicians and in part by other practitioners in the hospital or other facility setting. For 2024, CMS is proposing a delay in the implementation of its definition of the “substantive portion” as more than half of the total time through at least December 31, 2024. Instead, the proposed rule maintains the current definition of substantive portion for 2024 that allows for use of either one of the three key components (history, exam or MDM) or more than half of the total time spent to determine who bills the visit.

Telehealth Services

The proposed rule adds health and well-being coaching services to the Medicare Telehealth Services List on a temporary basis for 2024, and it adds Social Determinants of Health Risk Assessments on a permanent basis. In addition, the rule would implement several telehealth-related provisions of the Consolidated Appropriations Act, 2023 (CAA, 2023), including the following:

  • The temporary expansion of the scope of telehealth originating sites for services furnished via telehealth to include any site in the United States where the beneficiary is located at the time of the telehealth service, including an individual’s home; and
  • The expansion of the definition of telehealth practitioners to include qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists and qualified audiologists.

Pursuant to the rule, telehealth services furnished to people in their homes will be paid at the non-facility PFS rate to protect access to mental health and other telehealth services by aligning with telehealth-related flexibilities that were extended via the CAA, 2023.

As to supervision, the rule will continue to define direct supervision as permitting the presence and immediate availability of the supervising practitioner through real-time, HIPAA-compliant, audio and video interactive telecommunications through December 31, 2024.

Opioid Treatment Programs (OTPs)

The 2024 proposed rule would extend current flexibilities for periodic assessments that are furnished via audio-only telecommunications through the end of 2024. It allows opioid treatment programs (OTPs) to bill Medicare under the Part B OTP benefit for furnishing periodic assessments via audio-only telecommunications when video is not available to the beneficiary, to the extent that (a) use of audio-only communications technology is permitted under the applicable SAMHSA and DEA requirements at the time the service is furnished, and (b) all other applicable requirements are met.

Refunds for Discarded Amounts

In the 2023 PFS final rule, CMS had adopted many policies to implement section 90004 of the Infrastructure Act. Among them were the following: (a) the definition of “refundable single-dose container or single-use package drug,” which also specifies certain exclusions; (b) reporting requirements for use of the JW modifier to report discarded amounts of drugs from single-dose containers and the use of the JZ modifier for such drugs with no discarded amounts; (c) an increased applicable percentage of 35 percent for a category of drugs with unique circumstances; and (d) a dispute resolution process.

In the 2024 proposed rule, implements the following:

  • Timelines for the initial and subsequent discarded drug refund reports to manufacturers;
  • The method of calculating refunds for discarded amounts from lagged claims data;
  • The method of calculating refunds when there are multiple manufacturers for a refundable drug;
  • Increased applicable percentages for certain drugs with unique circumstances;
  • An application process by which manufacturers may request an increased applicable percentage for a drug with unique circumstances; and
  • Modification to the JW and JZ modifier policy for drugs payable under Part B from single-dose containers that are furnished by a supplier who does not administer the drug.

To review the full 2024 PFS proposed rule, you can click on the following link: 2023-14624.pdf (federalregister.gov).

If you have any questions on this topic, please reach out to your account executive.

With best wishes, 

Rita Astani
President—Anesthesia

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