Federal regulators last week finalized a pay rule that will boost payment for an add-on code used by primary care doctors for complex patient care. But observers are warning that providers who care for skilled nursing patients and others will ultimately pay a steep price.
The 2024 Medicare Physician Fee Schedule issued Thursday by the Centers of Medicare & Medicaid Services includes the G2211 complexity code, which pays a doctor an extra fee for “visit complexity” associated with the ongoing evaluation or management of medical services that underlie a patient’s serious condition or a complex fees for E/M visits for new or established patients.
“The code itself is not relevant to nursing facility providers but its impact is extremely relevant,” Cynthia Morton, executive vice president of ADVION told McKnight’s. “The impact to the remainder of providers who bill the Fee Schedule is highly relevant because the dollar value that CMS is devoting to this complexity code is ‘budget neutral,’ meaning values of all the other CPT codes are reduced to reflect the increased value of the complexity code.”
In other words, therapists and others who deliver care under the Fee Schedule, not under the skilled nursing prospective pay rule, will experience cuts that zero out spending on the new complexity code.
CMS, in its rule, estimated the code will be billed with 38% of office, outpatient, evaluation and management visits. The American Academy of Family Physicians has said the code will be paid at $16.05 in 2024.
Because of Medicare’s budget neutrality, every one of those new dollars must be clawed back from somewhere else in the system.
Morton said offsetting that complexity code accounts for about 2% of the 3.4% decrease to the rule’s conversion factor, used to calculate pay for Current Procedural Terminology (CPT) codes, which are used by therapists to bill for specific treatments or services. The conversion factor went from $33.89 this year to $32.74 in 2024, a decrease of $1.15 or 3.4%.
“So this is good news for primary care but not so good news for nursing facilities and other ancillary care services that are providing services to nursing facility patients under the Part B benefit,” Morton added.
For its part, CMS said the cost of the primary care incentive is actually lower than when the agency first proposed it in 2021. At that time, Congress suspended the use of the add-on code by prohibiting CMS from making additional payment under the PFS for these inherently complex visits before 2024.
CMS said it made to reduce the estimated redistributive impacts, limiting its use for certain office visits related to specific procedures or services.
Stakeholders from a range of healthcare sectors have been working on a fix to redistributive impacts of adding new payment incentives. But like almost any solution requiring Congressional action, timing remains highly uncertain.
ADVION is working with Congress to provide additional provider relief in addition to the 1.25% Congress already passed. A draft bill being scheduled to be considered by the Senate Finance Committee Wednesday includes some relief, which Morton called a “great sign.”
“This increases our possibility of gaining additional relief for all providers, including nursing facilities, in the end of year package or whatever package Congress will consider as they get closer to the need to fund the government past the Nov. 17 deadline,” she said.