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Issue Brief: Physician Fee Schedule (PFS) Proposed Rule CY 2024

Centers for Medicare & Medicaid Services (CMS)

July 25, 2023

This proposed rule makes changes to the Physician Fee Schedule (PFS), which governs payment policy in Medicare Part B for ambulatory care practice.  The proposed rule also encompasses changes to related programs, including the Quality Payment Program and the Medicare Shared Savings Program, among others. Overall, the Centers for Medicare & Medicaid Services (CMS) is proposing a net decrease to overall PFS payment for CY 2024, but notes that it is increasing payment for primary care and direct patient care services. The agency is also proposing changes in other areas, including telehealth, billing for evaluation and management (E/M) services, opioid treatment programs, preventive vaccine services, and more.  CMS updates these rules annually, so many of the policy changes outlined for 2024 build on existing policies.

Major Proposed Changes for CY 2024
  • Telehealth Services
    • Covered Services: CMS is proposing to add health and well-being coaching services to the telehealth services list for 2024. CMS is also continuing to implement elements of the Consolidated Appropriations Act of 2022, and “allowing telehealth services to be furnished in any geographic area and in any originating site setting, including the beneficiary’s home, and allowing certain services to be furnished via audio-only telecommunications.” CMS is also proposing to extend the flexibility allowing institutional providers to bill for diabetes self-management training, outpatient therapy, and medical nutrition therapy when provided remotely through 2024. Additionally, CMS is proposing to allow Diabetes Prevention Programs to continue to provide services remotely through 2027 if providers maintain an in-person CDC organization code.
    • Telehealth Practitioner Additions: CMS is also proposing to add new telehealth practitioners, including qualified occupational therapists, qualified physical therapists, and qualified speech-language pathologists. These new categories of telehealth practitioners are Medicare-eligible. ASHP continues to push CMS to ensure that pharmacists can fully and effectively engage in the provision of telehealth services.
    • Virtual Supervision: CMS is also proposing to extend the virtual supervision flexibility through 2024. While ASHP welcomes this extension, we will continue to advocate aggressively for making this flexibility permanent.

  • To provide meaningful feedback to CMS on telehealth, we are seeking member input regarding telehealth utilization and reimbursement, including on the use of virtual supervision. Specifically, we are looking for feedback on whether pharmacists have been able to utilize telehealth codes, if telehealth reimbursement is sufficient to support service provision, what (if any) additional codes should be added, and what other changes are necessary to make telehealth provision sustainable over the long term.

  • Vaccine Provision and Reimbursement: Building on last year’s PFS, CMS is proposing to extend the additional add-on payment for in-home vaccination for COVID-19 to the pneumococcal, influenza, and hepatitis B vaccines when they are provided in a beneficiary’s home. The add-on payment can only be used once for an in-home visit, even if multiple vaccines are provided. However, providers will still receive a vaccine administration payment for each vaccine given.

  • Opioid Treatment Programs: CMS is proposing to extend flexibilities for use of audio-only telecommunications to provide periodic assessments “when video is not available to the beneficiary, to the extent that use of audio-only communications technology is permitted under the applicable SAMHSA and DEA requirements at the time the service is furnished and all other applicable requirements are met.”

  • E/M Coding: CMS is proposing to add a new separate add-on code for G2211 to “recognize the costs associated with E/M visits for primary and longitudinal care with complex patients.” CMS is also proposing that the add-on code will not be billed with a modifier that denotes an office or outpatient visit unbundled from another service. CMS also clarified that for split/shared services, clinicians can continue current split/shared billing practices, meaning that they continue to have a choice of using history, physical exam, medical decision-making, or time to determine who bills for the visit.

  • Complex Drug Administration Coding: CMS is requesting input from stakeholders regarding CMS “policies on the exclusion of coverage for certain drugs under Part B that are usually self-administered by the patient.” In particular, CMS is seeking feedback on coding and payment policies for complex non-chemotherapeutic drugs in order to “promote coding and payment consistency and patient access to infusion services.”

  • Manufacturer Refunds for Medication Waste: CMS is continuing the process of implementing a provision of the Infrastructure and Investment Jobs Act of 2021 that requires “manufacturers to provide a refund to CMS for certain discarded amounts from a refundable single-dose container or single-use package drug” once the amount of waste reaches a certain threshold of a product’s total allowed charges (at least 10%) in a quarter. CMS is proposing additional policies around this issue, 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.

  • ASHP is seeking member input regarding implementation of the waste provisions, particularly those related to calculation of discarded amounts and associated reporting requirements associated with this provision.
Applicability and Timing

In general, policy proposals adopted in a PFS proposed rule become effective on January of the next calendar year (so January 1, 2024 for this proposed rule).

We strongly encourage members to submit feedback, questions, or concerns to ASHP to assist in the development of our written comments on the proposed rule. Please send any input to Jillanne Schulte Wall at [email protected] by Aug. 15.  We will update members when CMS releases a final rule in late fall.