What Physicians Need to Know About the CMS Final Rule for 2023

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CMS 2023 Final Rule
Jan Rasmussen PCS, CPC, ACS-OB, ACS-GI
Professional Coding
Solutions 715.595.4278
janrpcs_at_aol.com
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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

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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.

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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

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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/observatio
  n 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)

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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

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Colorectal Cancer Screening

• Expanded Medicare coverage for certain colorectal
  cancer screening tests by reducing the minimum
  age payment limitation to 45 years.
• Expanded the regulatory definition of screening
  colorectal cancer tests to include a follow-up
  after a Medicare covered non-invasive stool-based
  colorectal cancer screening test, 82270
  (Cologuard) and 82272 (hemoccult) returns a
  positive result. 

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Telehealth

• Extended duration of time services are
  temporarily included on the telehealth services
  list during the PHE, but are not included on a
  Category I, II, or III basis for a period of 151
  days following the end of the PHE
• Category 1 Services that are similar to
  professional consultations, office visits, and
  office psychiatry services that are currently on
  the Medicare Telehealth Services List.
• Category 2 Services that are not similar to
  those on the current Medicare Telehealth Services
  List.
• Category 3. Services added to the Medicare
  Telehealth Services List during the PHE for which
  there is likely to be clinical benefit when
  furnished via telehealth, but not yet sufficient
  evidence available to consider the services for
  permanent addition under the Category 1 or
  Category 2 criteria.
• Continued through the end of CY 2023

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Public Health Emergency (PHE)

• Consolidated Appropriations Act, 2023 removed the
  151 day extension and changed the following end
  of PHE criteria.
• Three things will occur at the end of PHE
• Some allowed services/flexibilities will end
  immediately
• Some services/flexibilities will continue until
  12/31/23
• Other services/flexibilities will be continued
  until the end of 2024.

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Telehealth

• Medicare Telehealth Services Current List
  https//www.cms.gov/Medicare/Medicare-General-Info
  rmation/Telehealth/index.html.
• Services that may be allowed by audio only
  indicated on telehealth list.
• Counseling or therapy services with their own
  specific code would need to be reported with
  Modifier -93 such as
• Behavioral health services, AWWs, smoking
  cessation, MNT, self care management training,
  advanced care planning, inpatient consults,
  diabetes outpatient self management, chronic
  kidney disease education, alcohol and depression
  screenings etc
• Telephone codes 99441-99443 now on telehealth
  list and would need modifier -95 reported on
  them.

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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

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Behavioral Health Services

• CMSs 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.

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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

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Opioid Treatment Programs

• Permit the use of audio-only communication
  technology to initiate treatment with
  buprenorphine in cases where audio-video
  technology is not available to the beneficiary
  and all other applicable requirements are met.
• Clarified OTPs can bill Medicare for medically
  reasonable and necessary services furnished via
  mobile units in accordance with SAMHSA and DEA
  guidance.
• Locality adjustments for services furnished via
  mobile units would be applied as if the service
  were furnished at the physical location of the
  registered OTP

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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.

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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

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Skin Substitute

• Finalized an approach for payment of each of 10
  synthetic skin substitutes in the physician
  office setting for which we had received a HCPCS
  Level II coding application,
• Finalized that those products would be payable in
  the physician office setting as contractor priced
  products that are billed separately from the
  procedure to apply them.
• Ensure all skin substitute products are assigned
  an appropriate HCPCS Level II code
• Currently carrier priced with wide variability

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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

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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

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