On July 13, 2023, the Centers for Medicare & Medicaid Services (CMS) published the annual Medicare Physician Fee Schedule (MPFS) proposed rule. The rule describes proposed payment, policy and quality program changes for 2024, including several proposals which impact physiatry. CMS estimates a combined impact of -1% on PM&R resulting from the proposals in the rule. Key elements of this proposed rule are described below, including numerous areas in which AAPM&R advocacy has had a positive impact. AAPM&R is currently reviewing the rule in detail and will provide specifics, including proposed changes to relative value unit (RVU) values and payment for physiatric services, in the coming weeks.
Updates to Physician Payment
Of immediate concern, the rule includes a proposed 3.4% reduction to the Conversion Factor, which is used to calculate payment for all services paid under the MPFS. This decrease is in part resulting from a reduction to the temporary payment increase Congress approved in late 2022. Additionally, the decrease reflects statutorily required budget neutrality cuts associated with payment for new services including a new add-on code for certain evaluation and management (E/M) services, described in more detail below. AAPM&R continues to express concerns to Congress and CMS about the annual threat of cuts to physician payment and the lack of increases to payment commensurate with inflation and increased costs of running a medical practice. Earlier this year, AAPM&R joined a broad group of medical specialties urging Congress to advance legislation including a permanent inflation-based update to the MPFS. Physician payment reform continues to be one of the Academy’s primary advocacy priorities.
Split (or Shared) E/M Visits
Your Academy is pleased to share that CMS has proposed to again delay changes to the split (or shared) visits policy through the end of 2024. CMS proposes to maintain the current policy, which allows the substantive portion of a visit to be met by either history, physical exam, medical decision-making, or time. This delay is consistent with AAPM&R advocacy over the last year. CMS notes an interest in engaging with stakeholders, including the AMA CPT Editorial Panel, on this issue. AAPM&R will continue to actively advocate to CMS for an appropriate split (or shared) E/M policy, which should take into consideration the importance of team-based care while appropriately recognizing the significant value of physician medical decision-making.
Implementation of an Add-on Code for E/M Services
CMS proposes to implement separate payment for an add-on code, G2211, for E/M services. G2211, billed as an add-on to outpatient and office visit E/M services, describes the extra work associated with longitudinally treating a single, serious or complex condition. This add-on code was initially created in the 2021 MPFS, however Congress prohibited CMS from paying for G2211 due to the significant impact its implementation would have on the conversion factor. In this proposed rule, CMS has revised its estimates of how frequently G2211 is expected to be billed, thereby decreasing the conversion factor impact. However, its implementation is still a contributing factor to the 3.4% reduction proposed for this year. AAPM&R previously commented on the implementation of G2211, urging CMS to reduce its utilization estimates. We are pleased that CMS is working to minimize the impact this code will have on the larger fee schedule.
Appropriate Use Criteria
We are pleased to share that CMS has proposed to indefinitely pause implementation of the Appropriate Use Criteria (AUC) program. The AUC program was designed to require use of a qualified clinical decision support mechanism when ordering advanced diagnostic imaging. Since it was originally conceived in 2014, AAPM&R has consistently advocated for CMS to reconsider the AUC initiative due to the excessive burden of the program on physicians, including the high cost associated with qualified clinical decision support mechanisms. Reducing administrative burden for practicing physiatrists remains a critical advocacy priority for your Academy.
CMS is proposing to implement provisions of the Consolidated Appropriations Act of 2023 which extend certain telehealth flexibilities through the end of 2024. AAPM&R has supported the extension of telehealth flexibilities in communications to both CMS and Congress. Highlights include proposals to:
- Expand the definition of qualified originating site for telehealth services to include any site in the United States where the beneficiary is located, including the beneficiary’s home.
- Expand the definition of qualified providers of telehealth services to include occupational therapists, physical therapists, speech-language pathologists and audiologists.
- Extend the current definition of direct supervision which allows that the supervising practitioner may be immediately available via real-time audio and video interactive telecommunications.
- Allow teaching physicians to use audio/video real-time communications technology to qualify as being present for a service provided by a resident, if the service being provided by the resident is a telehealth service.
CMS also notes it will consider making some of these flexibilities permanent after 2024.
Quality Payment Program
CMS included several changes and additions to the Quality Payment Program in the proposed rule.
Highlights include proposals to:
- Implement a proposed new Merit-based Incentive Payment System (MIPS) Value Pathway (MVP) for Rehabilitative Support for Musculoskeletal Care. AAPM&R submitted comments voicing concerns about the implementation of this MVP earlier this year.
- Increase the 2024 MIPS performance threshold from 75 points to 82 points for 2024.
- Increase participation thresholds for Advanced Alternative Payment Model participants.
Comments regarding the rule are due to CMS by September 11, 2023 and can be submitted via the Federal Register website once the rule has been officially posted. Your Academy will submit comments on the above-described issues and other elements of the rule on behalf of physiatry. #PMRAdvocates are also encouraged to submit their own comments to CMS.
A fact sheet about the rule is available on the CMS website. Additionally, CMS has released a fact sheet specific to the Quality Payment Program. If you have specific questions about the proposed rule, please email email@example.com.