Summary

The 2024 Medicare Physician Fee Schedule contains thousands of pages of new rules for the healthcare community, and a portion of them pertain to the practice of chronic pain medicine. Today’s article brings you a few of the highlights.

Last month, the Centers for Medicare and Medicaid Services (CMS) released its Medicare Physician Fee Schedule (PFS) final rule related to services beginning January 1, 2024. In a previous alert, we presented those portions of the rule that related to anesthesia. In addition, we detailed the conversion factors (both anesthesia and non-anesthesia) that will be utilized beginning next year and that will determine, in large measure, Medicare reimbursement for provider services. Reminder: it’s a disappointing downgrade.

In this article, we want to turn our attention to those provisions of the final rule that will have an impact on chronic pain practices. Much of the following is taken from a fact sheet published by CMS, which acts to summarize the 2024 PFS final rule.

Evaluation and Management

Beginning January 1, 2024, a separate payment for HCPCS code G2211 will be made available to providers. This add-on code will be applicable for outpatient and office visits as an additional payment when clinicians are “the continuing focal point for all needed services or are part of ongoing care related to a patient’s single, serious condition or a complex condition.” Here is the extended descriptor for the code:

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. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established).

The CMS fact sheet provides an example of when a provider might submit a claim for G2211:

For example, a primary care clinician, as the continuing focal point for all needed health care services for a patient, often bears the cognitive load, responsibility, and an accountability for building the most effective, trusting relationship possible amidst evaluating and managing other health care problems during a visit. Building an effective longitudinal relationship, in and of itself, is a key aspect of providing reasonable and necessary medical care and will make the patient more likely to comply with treatment recommendations after the visit and during future visits. It’s the work building this important relationship between the practitioner and patient for primary and longitudinal care that has been previously unrecognized and unaccounted for during evaluation and management visits.

A primary care physician is used as the example in the above excerpt. The question is: can a chronic pain physician bill this code? Is the service described by HCPCS G2211 one that is currently executed by a pain physician? In the commentaries we’ve reviewed involving this code, many have pointed out it is intended to be billed by those who engage in primary care and longitudinal care. We know that chronic pain is not typically thought of in terms of the former, but what about the latter? As pointed out in several related articles, the term “longitudinal care” suffers from a paucity of consistent meaning.

The U.S Department of Health and Human Services (HHS) provided the following statement in its announcement of the 2024 final rule: “CMS is also finalizing increases in payment for visits for many services, such as primary and longitudinal care.” However, HHS, in this section, failed to provide a clear-cut indication of (a) what it means by longitudinal care, and (b) whether or not such care can be provided by chronic pain practitioners, though there has been some indication by Medicare that the service can be provided by multiple specialties, in addition to primary care.

Interestingly, the final rule indicates that CMS would be providing some educational material on G2211 and its use in the future—an admission that such information is not yet extant. The rule contained lengthy discussions by commenters trying to pin CMS down on specifics, which CMS has yet to provide. However, CMS noted that it expects to see this code billed 90 percent of the time “by certain specialties” with their E/M services. The expected high usage of this code and its concomitant generation of new reimbursement is one reason given for the agency being forced to lower the overall conversion factor, as a means of budgetary offset.

Should G2211 ultimately be determined to be potentially applicable to the chronic pain space, it should be noted that the final rule goes on to state that the G2211 add-on code “cannot be billed with an office or outpatient E/M visit that is itself focused on a procedure or other service instead of being focused on longitudinal care for all needed healthcare services, or a single, serious or complex condition.” Translation: you can’t bill for G2211 where you are performing a billable procedure (e.g., ESI injection) within the same patient encounter.

Split/Shared Visits

As a reminder to our readers, a split (or shared) E/M visit refers to a service provided in part by a physician and in part by a nonphysician practitioner (NPP) in the hospital (or other institutional) setting. For 2024, CMS is revising its definition of “substantive portion” of a split (or shared) visit. Specifically, for Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician or nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making.

To provide some context, the above provision was finalized in response to public comments asking that CMS allow either time or medical decision making to serve as the substantive portion of a split (or shared) visit. In effect, then, the team has a choice of two methodologies to use in determining the billing provider.

Telehealth

The 2024 final rule finalizes the implementation of several telehealth-related provisions of the 2023 Consolidated Appropriations Act (CAA), including the following:

• The temporary expansion 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 (telehealth services furnished to patients in their homes will be paid at the non-facility PFS rate);

• The continued coverage and payment of telehealth services included on the Medicare Telehealth Services List (as of March 15, 2020) until December 31, 2024.

The final rule also addresses direct supervision in connection with telehealth. CMS will permit the presence and immediate availability of the supervising practitioner through real-time audio and video interactive telecommunications through December 31, 2024.

In terms of telehealth in the teaching setting, the final rule continues to allow teaching physicians to use audio/video real-time communications technology to be present when the resident furnishes Medicare telehealth services in all residency training locations through the end of 2024. This virtual presence will meet the requirement that the teaching physician be present for the key portion of the service.

We may provide additional alerts arising from the final rule over the next few weeks as more details emerge, so stay tuned! In the meantime, please contact your account executive if you have any questions concerning the 2024 PFS final rule.