RCM eNews – December 2023

As the new year approaches, here are some reminders to support a healthy revenue cycle:

• Verify patient eligibility and benefits – Many patients will have new insurance at the start of the year. Keep claim denials at bay by verifying eligibility and benefits ahead of time.
• Verify patient deductibles – Best practice is to communicate with patients to remind them of their deductible and that payment may be due at the time of service.
• Confirm prior authorization/precertification requirements – Many insurances update their prior authorization requirements at the start of a new year, be sure to utilize insurance websites to access this information and have a solid process in place for obtaining authorizations. Most insurances will not provide back-dated authorizations, don’t let this be a source of revenue loss for your practice.
• CPT code changes – Be aware of any CPT code additions, deletions, and/or revisions.

The final rule addresses split-shared billing rules, telemedicine flexibilities extensions, the G2211 outpatient/office E/M visit complexity add-on code, new and revised CPT code valuations as well as updates to the Medicare Shared Savings Program (MSSP), Merit Based Incentive Payment System (MIPS) and Quality Payment Program (QPP). To read the final rule in its entirety, click here.

CY 2024 PFS Ratesetting and Conversion Factor
The final CY 2024 PFS conversion factor is $32.74, a decrease of $1.15 (or 3.4%) from the current CY 2023 conversion factor of $33.89.

Evaluation and Management (E/M) Visits
Beginning January 1, 2024, CMS is finalizing implementation of a separate add-on payment for healthcare common procedure coding system (HCPCS) code G2211. This add-on code will better recognize the resource costs associated with evaluation and management visits for primary care and longitudinal care. Generally, it will be applicable for outpatient and office visits as an additional payment, recognizing the inherent costs involved 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.

Reimbursement for G2211 will be approximately $16.50 depending on geographic location.

Here are some guidelines for reporting G2211:

• Do not report G2211 on dates of service for which modifier -25 should be appended to the E/M code.
• Do not report G2211 unless an E/M code is reported for the same date of service.
• Do not report G2211 for an encounter for a patient who is not under your ongoing care for a separate single, serious condition or a complex condition for a problem that is transient.
• Report code G2211 if an E/M visit is reported for a patient for a visit in which you are managing total patient care for a single, serious/complex condition.
• Report code G2211 if an E/M visit is provided to a patient with a transient or temporary problem (eg, UTI) or if you have an established relationship with the patient for whom you are providing ongoing longitudinal care, even if it is unrelated or potentially related to the transient problem being treated.

Split (or Shared) Evaluation and Management (E/M) visits
CMS has revised the definition of “substantive portion” of a split or shared service. The “substantive portion” shall mean more than half of the total time spent by the physician or nonphysician practitioner, OR a substantive portion of the medical decision making.

Caregiver Training Services
For CY 2024, CMS is finalizing its proposal to make payment when practitioners train caregivers to support patients with certain diseases or illnesses (e.g., dementia) in carrying out a treatment plan. Medicare will pay for these services when furnished by a physician or a non-physician practitioner (nurse practitioners, clinical nurse specialists, certified nurse-midwives, physician assistants, and clinical psychologists) or therapist (physical therapist, occupational therapist, or speech language pathologist) as part of the patient’s individualized treatment plan or therapy plan of care.

CPT codes 96202 and 96203 are defined as services provided by a physician or other qualified health care professional.

CPT codes 97550, 97551 and 97552 are caregiver training services under a therapy plan of care established by a PT, OT, SLP.

Telehealth Services under the PFS
For CY 2024, CMS is finalizing their proposal to add health and well-being coaching services to the Medicare Telehealth Services List on a temporary basis for CY 2024, and Social Determinants of Health Risk Assessments on a permanent basis.

They are also finalizing implementation of several telehealth-related provisions of the Consolidated Appropriations Act, 2023 (CAA, 2023), including 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; the expansion of the definition of telehealth practitioners to include qualified occupational therapists, qualified physical therapists, qualified speech-language pathologists, and qualified audiologists; the continued payment for telehealth services furnished by RHCs and FQHCs using the methodology established for those telehealth services during the COVID-19 PHE; delaying the requirement for an in-person visit with the physician or practitioner within six months prior to initiating mental health telehealth services, and again at subsequent intervals as the Secretary determines appropriate, as well as similar requirements for RHCs and FQHCs; and the continued coverage and payment of telehealth services included on the Medicare Telehealth Services List (as of March 15, 2020) until December 31, 2024.

Additionally, they are finalizing that they will continue to define direct supervision to permit the presence and immediate availability of the supervising practitioner through real-time audio and video interactive telecommunications through December 31, 2024.

Behavioral Health Services
For CY 2024, CMS is implementing Section 4121 of the CAA, 2023, which provides for Medicare Part B coverage and payment under the Medicare Physician Fee Schedule for the services of marriage and family therapists (MFTs) and mental health counselors (MHCs) when billed by these professionals. Additionally, they are finalizing our proposal to allow addiction counselors or drug and alcohol counselors who meet the applicable requirements to be an MHC to enroll in Medicare as MHCs. MFTs and MHCs will be able to begin submitting Medicare enrollment applications after the CY 2024 Physician Fee Schedule final rule is issued, and they will be able to bill Medicare for services starting January 1, 2024.

CMS is also implementing Section 4123 of the CAA, 2023, which requires the Secretary to establish new HCPCS codes under the PFS for psychotherapy for crisis services that are furnished in an applicable site of service (any place of service at which the non-facility rate for psychotherapy for crisis services applies, other than the office setting, including the home or a mobile unit) furnished on or after January 1, 2024.

90839 (Psychotherapy for crisis; first 60 minutes) and 90840 (Psychotherapy for crisis; each additional 30 minutes — List separately in addition to code for primary service), and any succeeding codes.

Supervision Policy for Physical and Occupational Therapists in Private Practice
Since 2005, CMS has required PTs and OTs in private practices (PTPPs and OTPPs, respectively) to provide direct supervision of their therapy assistants. CMS is finalizing a regulatory change to allow for general supervision of therapy assistants by PTPPs and OTPPs for remote therapeutic monitoring (RTM) services. This will align with the RTM general supervision policy that we finalized in our CY 2023 rulemaking.

Expanded Diabetes Screening
CMS is finalizing proposal to expand coverage of diabetes screening to include the Hemoglobin A1c (HbA1c) test. CMS is also finalizing our proposal to simplify and expand diabetes screening frequency limitations and to remove the specific clinical test criteria from the codified definition of “diabetes” for screening, MNT and DSMT regulations.

From CMS:

When you provide a screening colonoscopy in the context of a complete colorectal cancer screening (following a positive result from a non-invasive stool-based CRC screening test), the providing practitioner must apply the -KX modifier to the claim for the screening colonoscopy to confirm that the clinical requirements of the complete colorectal cancer screening policy are met. The providing practitioner is responsible for correctly applying the -KX modifier to appropriate claims for screening colonoscopy in the context of a complete colorectal cancer screening.

If you submit claim for screening colonoscopy in the context of a complete colorectal cancer screening incorrectly in that it doesn’t include the -KX modifier, your MAC will process this claim under prior established policies and claims processing instructions for regular screening colonoscopy (without the flexibilities described above for a screening colonoscopy in the context of a complete colorectal cancer screening).

Per OIG guidance, healthcare organizations are barred from hiring any individual who has been sanctioned or excluded from participating in Medicare and Medicaid. All employed individuals should be screened for sanctions against the List of Excluded Individuals/Entities (LEIE). The OIG maintains a list of all currently excluded individuals and entities. If you hire an individual/entity on the LEIE you may be subject to civil monetary penalties.

Reasons for OIG Exclusions:

• A conviction of Medicare or Medicaid fraud
• Felony convictions for healthcare-related fraud, theft, or other financial misconduct
• Felony convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances

For more information on how to check the LEIE, click here.