News impacting community cancer care
July 19, 2023

CMS Releases 2024 Medicare
Payment Proposed Rule

On July 13, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule for the 2024 Medicare Physician Fee Schedule (PFS) and Quality Payment Program (QPP). These policies are set to go into effect on or after January 1, 2024. Here are the highlights:

Payment Policy Changes
The proposed CY 2024 PFS conversion factor is $32.75, a decrease of $1.14 (or 3.34%) from the CY 2023 PFS conversion factor of $33.89. This conversion factor accounts for the statutorily-required update to the conversion factor for CY 2024 of 0%, the one-time 2.5% increase for 2023 and the one-time 1.25% increase for 2024 provided by the Consolidated Appropriations Act of 2023, and the statutorily-required budget neutrality adjustment to account for changes in Relative Value Units.

Changes in payment policy outlined in the proposed rule result in the overall average impact for the following specialties:
• Hematology/Oncology: 2%
• Radiation Oncology and Therapy Centers: -2%
• Urology: 1%
• Rheumatology: 2%
• Gastroenterology: 0%
• Diagnostic Testing Facility: -2%
• Independent Lab: -1%
• Ophthalmology: -1%
• General Surgery: -1%

Note, the specialty impact estimates above will be further impacted by the reduced conversion factor. 

Advancing Health Equity and Caregiver Support
In alignment with the Cancer Moonshot’s goal for everyone with cancer to have access to covered patient navigation services, CMS is proposing payment for Principal Illness Navigation services to help patients navigate cancer treatment and treatment for other serious illnesses. CMS is proposing coding and payment for social determinants of health risk assessments, which could be furnished as an add-on to an annual wellness visit or in conjunction with an evaluation and management visit. CMS is also proposing to make payment when physician or non-physician practitioners train and involve caregivers to support patients with certain diseases or illnesses in carrying out a treatment plan.

Payment for Dental Services prior to Certain Cancer Treatments
For CY 2024, CMS is proposing to codify the previously finalized payment policy for dental services prior to, or during, head and neck cancer treatments, whether primary or metastatic. Additionally, CMS is proposing to permit payment for certain dental services inextricably linked to other covered services used to treat cancer, including chemotherapy services, Chimeric Antigen Receptor T- (CAR-T) Cell therapy, and the use of high-dose bone modifying agents (antiresorptive therapy).

Evaluation and Management (E/M) Visits
Beginning January 1, 2024, CMS is proposing to implement 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 E/M visits for primary care and longitudinal care of complex patients. CMS originally finalized this policy in the CY 2021 Medicare Physician Fee Schedule final rule; however, Congress suspended the use of the add-on code by prohibiting CMS from making additional payment under the PFS for these inherently complex E/M visits before January 1, 2024.

CMS is now proposing to implement this policy with refinements. Specifically, CMS is proposing that the add-on code would not be billed with a modifier that denotes an office and outpatient E/M visit that is itself unbundled from another service (e.g., a procedure where complexity is already recognized in the valuation). Second, CMS has refined its utilization estimates for HCPCS code G2211 in response to public feedback.

Split (or Shared) E/M visits
For CY 2024, CMS is proposing to delay the implementation of the definition of the “substantive portion” as more than half of the total time through at least December 31, 2024. Instead, the agency is proposing to maintain the current definition of substantive portion for CY 2024 that allows for use of either one of the three key components (history, exam, or MDM) or more than half of the total time spent to determine who bills the visit.

Telehealth Services
For CY 2024, CMS is proposing 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.

CMS is also proposing to implement several telehealth-related provisions of the Consolidated Appropriations Act of 2023 (2023 CAA) 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, and other policies, as well as the continued coverage and payment of telehealth services included on the Medicare Telehealth Services List (as of March 15, 2020) until December 31, 2024.

CMS is proposing that, beginning in CY 2024, telehealth services furnished to people in their homes be paid at the non-facility PFS rate.

CMS is proposing to 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 to align with the time frame of the PHE-related telehealth policies that were extended under the 2023 CAA but the agency is seeking feedback on extension of this policy.

Complex Drug Administration Coding
CMS is seeking comment on coding and payment policies for complex non-chemotherapeutic drugs, in an effort to promote coding and payment consistency and patient access to infusion services.

Vial Refund Policy
CMS is proposing additional refinements to this policy, including: timelines for the initial and subsequent discarded drug refund reports to manufacturers, the method of calculating refunds for discarded amounts from lagged claims data, the method of calculating refunds when there are multiple manufacturers for a refundable drug, increased applicable percentages for certain drugs with unique circumstances, and an application process by which manufacturers may request an increased applicable percentage for a drug with unique circumstances.

Clinical Laboratory Fee Schedule
CMS is proposing to implement section 4114 of the 2023, CAA with certain conforming changes to the data reporting and payment requirements for clinical diagnostic laboratory tests (CDLTs). This includes specifying that for CY 2023, payment for an applicable CDLTs may not be reduced compared to the payment amount established for that test in CY 2022, and for CYs 2024 through 2026, payment may not be reduced by more than 15% as compared to the payment amount established for that test for the preceding year.

Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging Program
CMS is proposing to pause efforts to implement the Appropriate Use Criteria (AUC) program for reevaluation and to rescind the current AUC program regulations at 42 CFR 414.94. CMS will continue efforts to identify a workable implementation approach and will propose to adopt any such approach through subsequent rulemaking.

CY 2024 Updates to the Quality Payment Program
CMS is proposing policies that continue the development and maintenance of Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs), support the use of digital measurement and health information technology, support the integrity of program data, and increase the potential return on investment for MIPS participation.

Performance Threshold
CMS is proposing to increase the performance threshold from 75 to 82 points. This increase would be applicable to all 3 MIPS reporting options (traditional MIPS, MVPs, and the APP).

Public Reporting
CMS is proposing to modify existing policy about publicly reporting procedure utilization data on individual clinician profile pages by incorporating Medicare Advantage data for a more accurate representation of procedure volumes. CMS also notes it intends to begin publicly reporting cost measures, beginning with the CY 2024 performance period/ 2026 MIPS payment year, and provides a Request For Information seeking comment.

The US Oncology Network will submit comments on the proposed rule prior to the deadline.

To view the CMS press release on the PFS proposal, CLICK HERE.
To view the CMS fact sheet on the PFS proposal, CLICK HERE.
To view the CMS fact sheet on the QPP proposal, CLICK HERE.
To view the PFS/QPP proposed rule in its entirety, CLICK HERE