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What gastroenterologists need to know about the 2024 Medicare payment rules
Medicare Physician Fee Schedule (MPFS) Final Rule
Cuts to physician payments continue: The final calendar year (CY) 2024 MPFS conversion factor will be $32.7442, a cut of approximately 3.4% from CY 2023, unless Congress acts. The reduction is the result of several factors, including the statutory base payment update of 0 percent, the reduction in assistance provided by the Consolidated Appropriations Act, 2023 (from 2.5% for 2023 to 1.25% for 2024), and budget neutrality adjustments of –2.18 percent resulting from CMS’ finalized policies.
New add-on code for complex care: CMS is finalizing complexity add-on 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), that it originally proposed in 2018 rulemaking. CMS noted that G2211 cannot be used with an office and outpatient E/M procedure reported with modifier –25. CMS further clarified that the add-on code “is not intended for use by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature ...” CMS further stated, “The inherent complexity that this code (G2211) captures is not in the clinical condition itself ... but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” For gastroenterologists, it is reasonable to assume G2211 could be reported for care of patients with complex, chronic conditions such as inflammatory bowel disease (IBD), celiac disease, and/or chronic liver disease.
CMS to align split (or shared) visit policy with CPT rules: Originally, CMS proposed to again delay “through at least December 31, 2024” its planned implementation of defining the “substantive portion” of a split/shared visit as more than half of the total time. However, after the American Medical Association’s CPT Editorial Panel, the body responsible for maintaining the CPT code set, issued new guidelines for split (or shared) services CMS decided to finalize the following policy to align with those guidelines: “Substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making except as otherwise provided in this paragraph. For critical care visits, substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit.”
While the CPT guidance states, “If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service,” this direction does not appear in the finalized CMS language.
CMS has extended Telehealth flexibility provisions through Dec. 31, 2024:
- Reporting of Home Address — CMS will continue to permit distant site practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home through CY 2024.
- Place of Service (POS) for Medicare Telehealth Services — Beginning in CY 2024, claims billed with POS 10 (Telehealth Provided in Patient’s Home) will be paid at the non-facility rate, and claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will be paid at the facility rate. CMS also clarified that modifier –95 should be used when the clinician is in the hospital and the patient is at home.
- Direct Supervision with Virtual Presence — CMS will continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through CY 2024.
- Supervision of Residents in Teaching Settings — CMS will allow teaching physicians to have a virtual presence (to continue to include real-time audio and video observation by the teaching physician) in all teaching settings, but only in clinical instances when the service is furnished virtually, through CY 2024.
- Telephone E/M Services — CMS will continue to pay for CPT codes for telephone assessment and management services (99441-99443) through CY 2024.
Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Final Rule
Hospital and ASC payments will increase: Conversion factors will increase 3.1% to $87.38 for hospitals and $53.51 for ASCs that meet applicable quality reporting requirements.
Hospital payments for Peroral Endoscopic Myotomy (POEM) increase: The GI societies successfully advocated for a 67% increase to the facility payment for POEM. To better align with the procedure’s cost, CMS will place CPT code 43497 for POEM into a higher-level Ambulatory Payment Classification (APC) (5331 — Complex GI procedures) with a facility payment of $5,435.83.
Cuts to hospital payments for some Level 3 upper GI procedures: CMS has finalized moving the following GI CPT codes that had previously been assigned to APC 5303 (Level 3 Upper GI Procedures — $3,260.69) to APC 5302 (Level 2 Upper GI Procedures — $1,814.88) without explanation and against advice from AGA and the GI societies. This will result in payment cuts of 44% to hospitals.
- 43252 (EGD, flexible transoral with optical microscopy)
- 43263 (ERCP with pressure measurement, sphincter of Oddi)
- 43275 (ERCP, remove foreign body/stent biliary/pancreatic duct)
GI Comprehensive APC complexity adjustments: Based on a cost and volume threshold, CMS sometimes makes payment adjustments for Comprehensive APCs when two procedures are performed together. In response to comments received, CMS is adding the following procedures to the list of code combinations eligible for an increased payment via the Complexity Adjustment.
- CPT 43270 (EGD, ablate tumor polyp/lesion with dilation and wire)
- CPT 43252 (EGD, flexible transoral with optical microscopy)
For more information, see 2024 the payment rules summary and payment tables at https://gastro.org/practice-resources/reimbursement.
The Coverage and Reimbursement Subcommittee members have no conflicts of interest.
Medicare Physician Fee Schedule (MPFS) Final Rule
Cuts to physician payments continue: The final calendar year (CY) 2024 MPFS conversion factor will be $32.7442, a cut of approximately 3.4% from CY 2023, unless Congress acts. The reduction is the result of several factors, including the statutory base payment update of 0 percent, the reduction in assistance provided by the Consolidated Appropriations Act, 2023 (from 2.5% for 2023 to 1.25% for 2024), and budget neutrality adjustments of –2.18 percent resulting from CMS’ finalized policies.
New add-on code for complex care: CMS is finalizing complexity add-on 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), that it originally proposed in 2018 rulemaking. CMS noted that G2211 cannot be used with an office and outpatient E/M procedure reported with modifier –25. CMS further clarified that the add-on code “is not intended for use by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature ...” CMS further stated, “The inherent complexity that this code (G2211) captures is not in the clinical condition itself ... but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” For gastroenterologists, it is reasonable to assume G2211 could be reported for care of patients with complex, chronic conditions such as inflammatory bowel disease (IBD), celiac disease, and/or chronic liver disease.
CMS to align split (or shared) visit policy with CPT rules: Originally, CMS proposed to again delay “through at least December 31, 2024” its planned implementation of defining the “substantive portion” of a split/shared visit as more than half of the total time. However, after the American Medical Association’s CPT Editorial Panel, the body responsible for maintaining the CPT code set, issued new guidelines for split (or shared) services CMS decided to finalize the following policy to align with those guidelines: “Substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making except as otherwise provided in this paragraph. For critical care visits, substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit.”
While the CPT guidance states, “If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service,” this direction does not appear in the finalized CMS language.
CMS has extended Telehealth flexibility provisions through Dec. 31, 2024:
- Reporting of Home Address — CMS will continue to permit distant site practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home through CY 2024.
- Place of Service (POS) for Medicare Telehealth Services — Beginning in CY 2024, claims billed with POS 10 (Telehealth Provided in Patient’s Home) will be paid at the non-facility rate, and claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will be paid at the facility rate. CMS also clarified that modifier –95 should be used when the clinician is in the hospital and the patient is at home.
- Direct Supervision with Virtual Presence — CMS will continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through CY 2024.
- Supervision of Residents in Teaching Settings — CMS will allow teaching physicians to have a virtual presence (to continue to include real-time audio and video observation by the teaching physician) in all teaching settings, but only in clinical instances when the service is furnished virtually, through CY 2024.
- Telephone E/M Services — CMS will continue to pay for CPT codes for telephone assessment and management services (99441-99443) through CY 2024.
Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Final Rule
Hospital and ASC payments will increase: Conversion factors will increase 3.1% to $87.38 for hospitals and $53.51 for ASCs that meet applicable quality reporting requirements.
Hospital payments for Peroral Endoscopic Myotomy (POEM) increase: The GI societies successfully advocated for a 67% increase to the facility payment for POEM. To better align with the procedure’s cost, CMS will place CPT code 43497 for POEM into a higher-level Ambulatory Payment Classification (APC) (5331 — Complex GI procedures) with a facility payment of $5,435.83.
Cuts to hospital payments for some Level 3 upper GI procedures: CMS has finalized moving the following GI CPT codes that had previously been assigned to APC 5303 (Level 3 Upper GI Procedures — $3,260.69) to APC 5302 (Level 2 Upper GI Procedures — $1,814.88) without explanation and against advice from AGA and the GI societies. This will result in payment cuts of 44% to hospitals.
- 43252 (EGD, flexible transoral with optical microscopy)
- 43263 (ERCP with pressure measurement, sphincter of Oddi)
- 43275 (ERCP, remove foreign body/stent biliary/pancreatic duct)
GI Comprehensive APC complexity adjustments: Based on a cost and volume threshold, CMS sometimes makes payment adjustments for Comprehensive APCs when two procedures are performed together. In response to comments received, CMS is adding the following procedures to the list of code combinations eligible for an increased payment via the Complexity Adjustment.
- CPT 43270 (EGD, ablate tumor polyp/lesion with dilation and wire)
- CPT 43252 (EGD, flexible transoral with optical microscopy)
For more information, see 2024 the payment rules summary and payment tables at https://gastro.org/practice-resources/reimbursement.
The Coverage and Reimbursement Subcommittee members have no conflicts of interest.
Medicare Physician Fee Schedule (MPFS) Final Rule
Cuts to physician payments continue: The final calendar year (CY) 2024 MPFS conversion factor will be $32.7442, a cut of approximately 3.4% from CY 2023, unless Congress acts. The reduction is the result of several factors, including the statutory base payment update of 0 percent, the reduction in assistance provided by the Consolidated Appropriations Act, 2023 (from 2.5% for 2023 to 1.25% for 2024), and budget neutrality adjustments of –2.18 percent resulting from CMS’ finalized policies.
New add-on code for complex care: CMS is finalizing complexity add-on 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), that it originally proposed in 2018 rulemaking. CMS noted that G2211 cannot be used with an office and outpatient E/M procedure reported with modifier –25. CMS further clarified that the add-on code “is not intended for use by a professional whose relationship with the patient is of a discrete, routine, or time-limited nature ...” CMS further stated, “The inherent complexity that this code (G2211) captures is not in the clinical condition itself ... but rather the cognitive load of the continued responsibility of being the focal point for all needed services for this patient.” For gastroenterologists, it is reasonable to assume G2211 could be reported for care of patients with complex, chronic conditions such as inflammatory bowel disease (IBD), celiac disease, and/or chronic liver disease.
CMS to align split (or shared) visit policy with CPT rules: Originally, CMS proposed to again delay “through at least December 31, 2024” its planned implementation of defining the “substantive portion” of a split/shared visit as more than half of the total time. However, after the American Medical Association’s CPT Editorial Panel, the body responsible for maintaining the CPT code set, issued new guidelines for split (or shared) services CMS decided to finalize the following policy to align with those guidelines: “Substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit, or a substantive part of the medical decision making except as otherwise provided in this paragraph. For critical care visits, substantive portion means more than half of the total time spent by the physician and nonphysician practitioner performing the split (or shared) visit.”
While the CPT guidance states, “If code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service,” this direction does not appear in the finalized CMS language.
CMS has extended Telehealth flexibility provisions through Dec. 31, 2024:
- Reporting of Home Address — CMS will continue to permit distant site practitioners to use their currently enrolled practice location instead of their home address when providing telehealth services from their home through CY 2024.
- Place of Service (POS) for Medicare Telehealth Services — Beginning in CY 2024, claims billed with POS 10 (Telehealth Provided in Patient’s Home) will be paid at the non-facility rate, and claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will be paid at the facility rate. CMS also clarified that modifier –95 should be used when the clinician is in the hospital and the patient is at home.
- Direct Supervision with Virtual Presence — CMS will continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through CY 2024.
- Supervision of Residents in Teaching Settings — CMS will allow teaching physicians to have a virtual presence (to continue to include real-time audio and video observation by the teaching physician) in all teaching settings, but only in clinical instances when the service is furnished virtually, through CY 2024.
- Telephone E/M Services — CMS will continue to pay for CPT codes for telephone assessment and management services (99441-99443) through CY 2024.
Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgery Center (ASC) Final Rule
Hospital and ASC payments will increase: Conversion factors will increase 3.1% to $87.38 for hospitals and $53.51 for ASCs that meet applicable quality reporting requirements.
Hospital payments for Peroral Endoscopic Myotomy (POEM) increase: The GI societies successfully advocated for a 67% increase to the facility payment for POEM. To better align with the procedure’s cost, CMS will place CPT code 43497 for POEM into a higher-level Ambulatory Payment Classification (APC) (5331 — Complex GI procedures) with a facility payment of $5,435.83.
Cuts to hospital payments for some Level 3 upper GI procedures: CMS has finalized moving the following GI CPT codes that had previously been assigned to APC 5303 (Level 3 Upper GI Procedures — $3,260.69) to APC 5302 (Level 2 Upper GI Procedures — $1,814.88) without explanation and against advice from AGA and the GI societies. This will result in payment cuts of 44% to hospitals.
- 43252 (EGD, flexible transoral with optical microscopy)
- 43263 (ERCP with pressure measurement, sphincter of Oddi)
- 43275 (ERCP, remove foreign body/stent biliary/pancreatic duct)
GI Comprehensive APC complexity adjustments: Based on a cost and volume threshold, CMS sometimes makes payment adjustments for Comprehensive APCs when two procedures are performed together. In response to comments received, CMS is adding the following procedures to the list of code combinations eligible for an increased payment via the Complexity Adjustment.
- CPT 43270 (EGD, ablate tumor polyp/lesion with dilation and wire)
- CPT 43252 (EGD, flexible transoral with optical microscopy)
For more information, see 2024 the payment rules summary and payment tables at https://gastro.org/practice-resources/reimbursement.
The Coverage and Reimbursement Subcommittee members have no conflicts of interest.