Breaking Down the 2024 CMS Physician Final Regulations - PowerPoint PPT Presentation

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Breaking Down the 2024 CMS Physician Final Regulations


The CMS final rule, expected on November 1, 2023, will outline the confirmed guidelines for 2024. Being present at the update ensures that providers and staff are among the first to know about any changes that may impact their practices. With significant changes anticipated in areas such as EM services, splits/shared care, RPM, and CCM, attending the update is essential to understanding how these alterations will affect coding practices. Being well-informed is key to accurate documentation and coding, preventing potential reimbursement issues. – PowerPoint PPT presentation

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Title: Breaking Down the 2024 CMS Physician Final Regulations

CMS 2024 Final Rule Find out What CMS has
Finalized from the Proposed Rules
Jan Rasmussen PCS, CPC, ACS-OB, ACS-GI
Professional Coding Solutions 715.595.4278
2024 PFS Rate Setting
  • CMS states overall physician payments must be
    budget neutral
  • CMS cant improve payment in any area of the fee
    schedule without cutting it somewhere else.
  • The conversion factor may be reduced to offset
    CPT codes with increases and newly introduced
  • CMS is proposing significant increases in payment
    for primary care and other kinds of direct
    patient care.

2024 Conversion Factor
  • CY 2024 PFS conversion factor is 32.74
  • Decrease of 1.15 to the CY 2023 PFS conversion
    factor of 33.89.
  • Final rule includes implementation of policies
    mandated by Congress in the Consolidated
    Appropriations Act, 2023.

  • Originally introduced in CY 2021 and delayed
    until this years final rule.
  • Encourage holistic, patient-centered care that
    involves collaboration and coordination across
    specialties and provides continuity and
    consistency in patient care. 
  • Establish meaningful relationships with patients
    and address their health care needs with
    consistency and continuity.
  • Stronger clinician-patient relationships can lead
    to improved functional health for patients
  • Not limited to any specific specialty but must
    have ongoing medical relationship with patients

Split Shared Care
  • Services billed using the physicians NPI are
    paid at a 100 of the PFS rate
  • 15 reduction of PFS rate for services billed by
  • CMS requirements for split shared care in 2024
    were supposed to be based on total time to
    determine the substantive portion.
  • Significant change under the 2024 final rule.
  • Substantive portion now either 50 of the
    total practitioner time or substantive portion of
    medical decision making.

Maternity Services
  • Increased RVUs for global maternity codes 59400,
    59410, 59510, 59515, 59610, 59614, 59618, 59622)
    to allow for previous increases in values of
    office/outpatient E/M services
  • Global codes that provide a single payment for
    almost 12 months of services include a relatively
    large number of E/M visits performed along with
    delivery services and imaging

Caregiver Training (CTS)
  • Caregiver adult person who helps care for
    someone who is ill, disabled, or aged.
  • Recognize and pay for two existing CPT codes
    which are currently considered bundled.
  • 96202 Multiple-family group behavior
    management/modification training for caregiver(s)
    of patients with a mental or physical health
    diagnosis, administered by physician or other
    qualified health care professional (without the
    patient present), face-to-face with multiple sets
    of parent(s)/guardian(s)/caregiver(s) initial 60
  • Requires full 60 minutes before billing add on
  • 96203each additional 15 minutes

New Auxiliary Services
  • Three new types services that may be provided by
    auxiliary personnel incident to the billing
    physician or practitioners professional
    services, and under the billing practitioners
    supervision, when reasonable and necessary to
    diagnose and treat the patient
  • Social Determinants of Health Risk Assessment
  • Community Health Integration Services
  • Principal Illness Navigation

SDOH Risk Assessment
  • Implemented a new code to separately identify and
    value a SDOH risk assessment furnished in
    conjunction with an E/M visit.
  • G0136, Administration of a standardized,
    evidence-based Social Determinants of Health Risk
    Assessment, 5-15 minutes, not more often than
    every 6 months
  • Review of the individuals SDOH or identified
    social risk factors that influence the diagnosis
    and treatment of medical conditions
  • Work RVU of 0.18
  • Permanently added to telehealth list including
    audio only

Community Health Integration
  • Two new G codes describing CHI services performed
    by certified or trained auxiliary personnel
    incident to the professional services and under
    the general supervision of the billing
  • G0019 Community health integration services
    performed by certified or trained auxiliary
    personnel, including a CHW, under the direction
    of a physician or other practitioner 60 minutes
    per calendar month, in the following activities
    to address social determinants of health (SDOH)
    need(s) that are significantly limiting ability
    to diagnose or treat problem(s) addressed in an
    initiating E/M visit
  • RVU 1.00
  • G0022each additional 30 minutes
  • RVU 0.70

Principle Illness Navigation
  • Services to help people with Medicare who are
    diagnosed with high-risk conditions e.g.,
    cancer, mental health conditions, substance use
    disorder (SUD) etc identify and connect with
    appropriate practitioners and providers in a
    timely manner for care and support resources
  • CMS believes most important when a patient is in
    the initial stage of treatment as delay in care
    could be detrimental/deadly to the patient

  • G0140 Principal Illness Navigation Peer
    Support by certified or trained auxiliary
    personnel under the direction of a physician or
    other practitioner, including a certified peer
    specialist 60 minutes per calendar month, in the
    following activities
  • RVU 1.00, crosswalked to 99490, non complex
    chronic care management (first 20 minutes)
  • G0146additional 30 minutes per calendar month
  • RVU 0.70 crosswalked to 99439 (additional 20
    minutes) non complex CCM

  • Implemented several telehealth-related provisions
    of the Consolidated Appropriations Act, 2023
    (CAA, 2023),
  • Temporary expansion of the scope of telehealth
    originating sites for services furnished via
    telehealth to include any site in the US where
    beneficiary is located at the time of the
    telehealth service, including an individuals
  • Finalizing refinements to process to analyze
    requests received for the addition of services to
    the Medicare Telehealth Services List
  • Including determination on whether the requested
    services should be added permanently or

Behavioral Health Services
  • Implemented provisions from the Consolidated
    Appropriations Act, 2023 (CAA), 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)
  • Allow MFTs and MHCs to enroll in Medicare.
  • Allow addiction counselors that meet all the
    applicable requirements to be an MHC to enroll in
    Medicare as MHCs.
  • Taxonomy codes
  • 106H00000X Marriage and Family therapists
  • 101YM0800X Behavioral Health Social Services
  • 101YA0400X Addiction Counselors
  • Also applies to RHC and FQHC services

Behavioral Health Services
  • Health Behavior Assessment and Intervention
    (HBAI) CPT codes 96156, 96158, 96159, 96164,
    96165, 96167, and 96168, and any successor codes,
    may be billed by clinical social workers, MFTs,
    and MHCs, in addition to clinical psychologists
  • Used to identify the psychological, behavioral,
    emotional, cognitive, and social factors included
    in the treatment of physical health problems.
  • Allow for better integration of physical and
    behavioral health care,
  • Behavioral health can significantly impact
    physical health illnesses.

Preventive Vaccine Administration
  • Additional payment for the administration of a
    COVID-19 vaccine in the home.
  • Extend in-home additional payment to the
    administration of three preventive vaccines
    included in the Part B preventive vaccine benefit
    the pneumococcal, influenza, and hepatitis B
  • Payment amount for the in-home administration of
    all four vaccines will be identical
  • Limit additional payment to one payment per home
    visit, even if multiple vaccines are administered
    during the same home visit

  • Expand coverage of diabetes screening to include
    the Hemoglobin A1c (HbA1c) test.
  • Expand diabetes screening frequency limitations
  • Remove the specific clinical test criteria from
    the codified definition of diabetes for
    screening, MNT and DSMT

Dental Oral Health Services
  • Change 2023 finalized rule payment policy for
    dental services prior to, or during, head and
    neck cancer treatments, whether primary or
  • Permit payment for certain dental services
    inextricably linked to other covered services
    used to treat cancer chemotherapy services,
    Chimeric Antigen Receptor T- (CAR-T) Cell
    therapy, and the use of high-dose bone modifying
    agents (antiresorptive therapy).
  • Improve the success of cancer-related treatments
    and increase access to certain dental care.
  • Seeking comment on additional circumstances where
    evidence supports dental services being integral
    to the clinical success of covered medical

Discarded Drugs
  • Final rule 2023 implemented rules requiring
    Manufacturers of Certain Single-dose Container or
    Single-use Package Drugs to Provide Refunds with
    Respect to Discarded Amounts
  • Many drugs and biologicals 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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