Navigating the CMS Physician Final Rule 2023 and Beyond - Tips for Physicians

1. CMS 2023 Final Rule Jan Rasmussen PCS, CPC, ACS- OB, ACS-GI Professional Coding Solutions 715.595.4278 janrpcs@aol.com 1

2. 2023 Conversion Factor • CY 2023 PFS conversion factor is $33.06 –Decrease of $1.55 to the CY 2022 PFS conversion factor of $34.61. –Many E/M services had RVU reductions from 2022 to 2023 due to category deletions and combining of categories 2

3. 2023 CPT E/M Changes • Extended 2021 documentation guidelines to determine a level of E/M service to all additional EM services i.e., hospital inpatient, hospital observation, emergency department, nursing facility, consults, home services/ residence services and cognitive assessment – CMS accepted new documentation guidelines and E/M code changes except for prolonged services. • Deleted several code categories in conjunction with new combined EM categories. • Eliminated codes with same decision making levels. 3

4. Deleted Codes and Categories • Deleted Hospital Observation Services E/M codes 99217-99220 • Deleted Domiciliary, Rest Home (e.g., Boarding Home/Assisted Living), or Custodial Care Services E/M codes 99324-99238, 99334- 99337, 99339, 99340 • Deleted Consultations E/M codes 99241 and 99251 4

5. Combined Categories • Hospital Inpatient/Observation Care Category – Codes 99221-99223 and 99231-99233 now include both inpatient and observation care – Same day codes 99234-99236 also now apply to both inpatient or observation care • New CMS add on code G0316 for inpatient/observation prolonged service to be reported in conjunction with 99223, 99233 or 99236 – Do not report G0316 for any time unit less than 15 minutes – Do not report G0316 on the same date of service as other prolonged services for evaluation and management codes 99358, 99359, 99418, 99415, 99416) 5

6. Home/Residence Services Changes • New CMS prolonged attendance add on code G0318 code for home/residence prolonged service to be reported in conjunction with 99345 or 99350. – Do not report G0318 for any time unit less than 15 minutes – Do not report G0318 on the same date of service as other prolonged services for evaluation and management codes 99358, 99359, 99417 6

7. Prolonged Services Changes… • New CMS add on code G0317 code for prolonged nursing facility service to be reported in conjunction with 99306 or 99310. – Do not report G0317 for any time unit less than 15 minutes – Do not report G0317 on the same date of service as other prolonged services for 99358, 99359, 9941 7

8. Split Shared Care • Split shared care may be billed by the provider that furnishes the substantive portion of a hospital or nursing facility visit. • CMS requirements for split shared care in 2023 remain the same as 2022. – Clinicians who furnish split (or shared) visits will continue to have a choice of history, physical exam, or medical decision making, or more than half of the total practitioner time spent to define the substantive portion – Initially intended to require time as the determining factor of “substantive portion” in 2023 9

9. Telehealth • Made several services temporarily available as telehealth services for the PHE available through CY 2023 on a Category III basis –Allow more time for collection of data that could support their eventual inclusion as permanent additions to the Medicare telehealth services list. 10

10. Telephone Only (99441-9943) • Continues to be available for mental health patients in their homes after the end of PHE and the 151day post-PHE extension period. – When a mental health practitioner furnishes a service using audio- only technology, they would bill for the same service they would bill if the service had been furnished in person. • Telephone E/M services would not be the same as in- person care; nor would they be a substitute for a face-to- face encounter. – Will not be paid after the end of the PHE and the 151- day post-PHE extension period. – Will be assigned “bundled” status. 11

11. Chronic Pain Management • No existing CPT code that specifically describes the work and potential resources of a clinician who performs comprehensive, holistic CPM. – Chronic pain generally defined as persistent or recurring pain lasting longer than three months – Often require longer office visit times, longer follow-up coordinating care with social workers and case managers, mental and behavioral health support, communications with emergency department physicians and nurses, and numerous medication adjustments • Prompt more practitioners to welcome Medicare beneficiaries with chronic pain • Expect most services to be billed by primary care providers 12 12

12. Behavioral Health Services • CMS’s goal to reduce existing barriers to mental health issues and make greater use of services of behavioral health professionals, such as licensed professional counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs). • Currently no separate benefit category under Medicare statutes that recognizes the professional services of licensed professional counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs). – Payment for the services of LPCs and LMFTs can only be made indirectly when an LPC or LMFT performs services as auxiliary personnel incident to, the services, and under the direct supervision, of the billing physician or other practitioner. 13

13. Opioid Treatment Programs… • Increased overall payments non-drug component G2074 for medication-assisted treatment and other treatments for OUD, recognizing the longer therapy sessions that are usually required. – Code description does not state 45 minutes – Increase the current crosswalk to describing a 45 minute session rather than a 30 minute session • Allow OTP intake add-on code, G2076 to be furnished via two-way audio video communications technology when billed for the initiation of treatment with buprenorphine and for periodic assessments • Increase of $24.39 codes G2067-G2075 14

14. Audiology Services • Allow direct access for certain diagnostic audiology services, when appropriate, to an audiologist without a physician referral by creating a new HCPCS code (GAUDX). – New Code GAUDX not in final rule due to comments received. – Instead initiated new modifier –AB to be used with codes already used by audiologists to identify audiology services furnished without the order of a physician or NPP. – Establish system edits through usual change management process to ensure that HCPCS codes billed with modifier – AB is only paid once every 12 months per each beneficiary. 15

15. Dental & Oral Health Services • Dental services are generally not covered by Medicare. • Exception: Inpatient hospital services with treatment, filling, removal or replacement of teeth or structures supporting the teeth when the patient has an underlying medical condition or the severity the procedures • Dental services may be paid as necessary treatment, performed as part of a comprehensive workup prior to organ transplant surgery, or prior to cardiac valve replacement or valvuloplasty procedures, that are inextricably linked to, and substantially related and integral to the clinical success of certain other covered medical services – Eliminate oral or dental infection prior to the above procedures 16

16. Skin Substitutes… • Ten products are as follows: – NovoSorb® SynPath™ – Restrata® – Wound Matrix – Symphony™ – InnovaMatrix™ AC – Mirragen® Advanced Wound Matrix – bio-ConneKt® Wound Matrix – TheraGenesis® – XCelliStem® – Microlyte® Matrix – Apis® (86 17

17. Discarded Drugs • Requiring Manufacturers of Certain Single-dose Container or Single-use Package Drugs to Provide Refunds with Respect to Discarded Amounts – Many drugs and biologicals (hereafter referred to as a drugs) payable under Medicare Part B are dosed in a variable manner such that the entire amount identified on the vial or package is not administered to the patient • Often times, these drugs are available only in single-dose containers designed for use with a single patient as a single injection or infusion 18

18. RHC & FQHC • Now covered in RHC and FQHC chronic pain management (G3002) and behavioral health integration services (G0323) under G0511. – When CPs and CSWs furnish the services described in HCPCS code G0323 in an RHC or FQHC, they can bill HCPCS code G0511. – May be billed alone or with other payable RHC or FQHC services 19 19

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