prolonged office visit cpt code for medicare

What are the Changes to Prolonged Services Coding in 2023?

by Loralee Kapp | Published on Feb 24, 2023 | Medical Billing , Medical Coding

Physicians need to document their visits correctly and understand when their service can and cannot be reported using a prolonged services add on code.

With new codes and coding conventions for prolonged services in 2023, physicians can benefit immensely from outsourced medical coding services . Leading medical coding service providers are knowledgeable about revised codes and code selection facts, and can help physician practices report their services correctly and ensure proper payment.

Since joining our RCM Division in October 2021, Loralee, who is HIT Certified (Health Information Technology/Health Information Management), brings her extensive expertise in medical coding and Health Information Management practices to OSI.

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Find-A-Code Articles, Published 2021, June 3

Understanding non-face-to-face prolonged services (99358-99359) in 2021.

by   Wyn Staheli, Director of Content - innoviHealth and   Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT Jun 3rd, 2021

Due to the extensive changes in office or other outpatient services ( 99202 - 99215 ), there are many questions which still need to be answered, one of which is related to the prolonged services without face-to-face contact. This article explores the question regarding the appropriate use of codes 99358 / 99359 and how to report it in relation to office or other outpatient E/M services ( 99202 - 99215 ). To answer this question, we will evaluate different published statements and guidelines. Please keep in mind that it is critical to know payer-specific policies for these codes and whether or not the payer has officially adopted the CPT codebook guidelines as published by the American Medical Association. Identify payers with whom you are contracted and determine which guidelines they are following for 99202 - 99215 and whether they have any additional rules regarding the reporting of 99358 /9.

Note: The CPT Assistant and CPT Changes are considered the AMA’s opinion on the codes and descriptions. As mentioned above, payers (e.g., CMS) may publish policies which are different from information contained in those publications, and if contracted with them, the provider is obligated to abide by those payer-specific policies.

CPT Codebook Guidelines

The official 2021 CPT codebook guidelines indicate that an extensive record review related to an E/M service that has or will occur may qualify for reporting these prolonged code. It states:

As noted above, the code description identifies 99358 as a prolonged service code that correlates to an E/M service (before, on the same day [except 99202 - 99215 ], or after) direct patient care. Because 99358 is NOT an add-on code, it may be reported alone but the documentation must identify it as related to an E/M encounter. 

Code 99358 may be reported in addition to any level of E/M service in the outpatient, inpatient, or observation setting (e.g., 99231 , 99213 , 99244 ), except 99211 and must be performed by a physician or other qualified healthcare professional (QHP).

Coding Tip: Do not report 99358 , 99359 for a prolonged service related to 99202 - 99215 on the same day as the E/M service. Code 99417 / G2212 is reported exclusively for prolonged services on the same day as 99202 - 99215 and is ONLY reported with 99205 or 99215 . If the prolonged service ( 99358 ) occurs on a date other than the day the E/M service was performed, it may be correlated with any level of E/M service ( 99202 - 99215 ).

Report 99358 for the first hour of prolonged service time once a minimum of 30 minutes has been completed. For prolonged services that extend beyond one hour, add-on code 99359 may be reported for each additional 15-30 minutes beyond the first hour. Documentation in the medical record should include the time (i.e., total time or start/stop) and a summary of the E/M-related service performed. 

Prolonged service code 99358 may be reported for work that correlates with an E/M encounter from another date, including 99202 - 99215 when the original E/M service code was determined based on MDM instead of time. As a stand-alone-code, 99358 is based on time spent performing the prolonged service, unrelated to the time spent performing the related E/M encounter. For example, if on Tuesday the provider documented data that supports an MDM level 99213 (not based on time) and on Wednesday, the provider finally receives the medical records for the patient he saw the day before and spends 47 minutes reviewing and summarizing them, the codes reported would be 99213 for Tuesday and 99358 for Wednesday. 

The following coding scenario may make it easier to see the complexities associated with reporting prolonged service 99358 vs 99417 / G2212 on the same day as an E/M encounter:

Scenario: The provider requested copies of the patient’s medical records from a previous surgeon but by the appointment time they had still not arrived. The E/M service was completed and scored based on MDM and a total time of 22 minutes was documented. Later the same day, the medical records arrive and the provider spends 47 minutes reviewing and summarizing them and makes adjustments to the patient’s medications based on the record review. 

Scoring: The medical records review cannot be reported with 99358 , as it was performed on the same day as the E/M encounter reported with 99213 . As such, the provider may only report 99417 or G2212 for the additional time as long as the encounter meets qualification for code 99215 because those are the codes which are exclusively used to report same day prolonged services. 

The 47 minutes spent on records review/summary is added to the total time (22 minutes) spent on the E/M encounter, making a total time of 69 minutes, which changes the E/M code from 99213 to 99215 based on time. The time range associated with 99215 is 40-54 minutes. If the payer follows CPT codebook guidelines, the provider may report one unit of 99417 once 15 minutes beyond the lower number in the time range (40) has been reached (40+15=55 minutes). To report a second unit though, the time would have to be a total of 70 minutes. However, if the payer follows Medicare guidelines, code G2212 may be reported once 15 minutes beyond the upper end of the time range (55 minutes) has been reached (55+15=70 minutes). In this scenario, if the payer followed Medicare guidelines, they would not qualify to report G2212 and the additional time spent would only be reflected in the increase from 99213 to 99215 . 

If the service, however, had been a consultation and reported with 99243 based on MDM, the prolonged time spent performing the record review of 47 minutes technically could be reported as one unit of 99358 , allowing additional compensation. 

This is a great example of why understanding and correctly following the specific payer guidelines is important.

Other AMA Information 

The CPT Assistant is considered a secondary source of guidance to the CPT codebook guidelines, and is published by the AMA. At the time of publication of this article, the most current CPT Assistant available on these codes was published in September 2020 , so keep in mind that any other changes made to the CPT codebook guidelines in 2021 might not be reflected in the following statement (emphasis added):

At the beginning of the CPT Assistant , there is a disclaimer which states that “[u]sers should consult the CPT 2021 code set for the final code numbers, descriptors, and guidelines language. Furthermore, the calendar year (CY) 2021 physician fee schedule (PFS) proposed rule, released August 3, 2020, introduces alternative interpretations to time reporting for the new prolonged service(s) code.” Those PFS alternative interpretations are discussed in the “CMS PFS Final Rule 2021” section below.

RUC Work Valuation

The concern that some auditors have expressed has to do with the valuation of the work component as defined by the CPT/RUC Workgroup. The Chairmen of the AMA CPT Editorial Panel and the AMA/Specialty Society Relative Value Update Committee (RUC) formed the CPT/RUC Workgroup which had the task of developing both the “coding structure for office visits to foster burden reduction, while ensuring appropriate valuation.” They stated in 2019 (emphasis added):

Keep in mind that although this information was released in 2019, it gives insight into how much work was considered inclusive to the work RVU of an Office/Outpatient E/M visit. There are several important things to note in this statement about how they valued the work involved. 

• Codes are reported based on time and not MDM (and only time on the calendar day of the service)
• Total work is calculated to include 3 days before and 7 days after the intraservice time of the related E/M encounter
• Only telephone and inter-professional consultations include the description excluding work related to an E/M encounter that is within 3 days prior or 7 days after it
• Services have been undervalued

So just how much extra time did they include as part of pre-service and post-service time in that 3 days before and 7 days after the related E/M visit window? Their recommendations were included in the 2021 Medicare Physician Fee Schedule Proposed Rule as follows:

Looking at the pre-service and post-service times, it is clear that time spent far beyond these times could justify the reporting of prolonged service codes, as applicable. 

CMS PFS Final Rule 2021

Now that we know what the AMA has officially stated about these services, we need to look at what CMS stated in the 2021 Final Rule about these codes (emphasis added). 

This statement brings up the fact that the RUC table of recommended times for the components of pre-, intra-, and post-service doesn’t necessarily add up. 

CMS also questioned the RUCs use of the 3 days before (pre-service) and 7 days after (post-service) to be included in the valuation of the codes, which seems to contradict the CPT codebook guidelines indicating 99358 / 99359 should be reported for an extended medical record review the day prior to or following a related E/M encounter. According to the above CMS statement, they do not recognize reporting 99358 / 99359 for prolonged services related to office or other outpatient (O/O) E/M visits ( 99202 - 99215 ), but they also do not specify what they consider to be pre- and post-service work nor mention how to handle it when prolonged services are on a different day and related to the E/M visit. At this time, we haven’t been able to find any statements about what CMS considers pre-service and post-service other than the table published in the 2021 Proposed Rule.

In summary, it comes down to what the payer considers bundled into the E/M service and if they adhere to the RUC workgroup’s stated 3-day pre-service and 7-day post-service inclusion period in which certain E/M-related services (e.g., call with test results, order medications, order new tests, confer with another provider, review medical records) are performed. Therefore, based on all the presented information, unless a payer states otherwise, according to CPT codebook guidelines, codes 99358 / 99359 may be reported as long as the following are met:

• Time requirements have been met meaning that there has been at least 30 minutes of non-face-to-face services (e.g., extensive record review and summary)
• The service is related to another E/M visit that has happened or will happen
• Time also exceeds the RUC time recommendations as shown in the table above for an O/O E/M

As always, the documentation  must support the time spent performing non-face-to-face services.

About Wyn Staheli, Director of Content - innoviHealth

Wyn Staheli is the Director of Content Research for innovHealth. She has over 30 years of experience in the healthcare industry. With her degree in Management Information Systems (MIS), she has been a programmer for a large insurance carrier as well as a California hospital system. She is also the author and editor of many medical resource books and the founder of InstaCode Institute.

About Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Understanding Non-face-to-face Prolonged Services (99358-99359) in 2021. (2021, June 3). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/understanding-non-face-to-face-prolonged-services-99358-99359-36851.html

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August 24, 2024

Prolonged Services Codes for Medicare Preventive Medicine Services: G0513, G0514

There are HCPCS prolonged services codes to be used with Medicare preventive services reported based on time.  CMS allows these prolonged care codes to be used with wellness visits.

Someone asked where to find the CMS chart with the intraservice guidelines. It is hidden deep on the CMS site! It is in the files that go with the 2018 Final Rule . Scroll down to about the 20th on the list and download 2018 List of Preventive Services Billed with Prolonged Preventive Codes.

Did you (or your clinician) ever have a wellness visit that took a really, truly, madly long time? And wondered what—if anything—you could bill with it? Wonder no more.

CMS has developed codes to be used with preventive medicine services that are time based.  These codes can be used in addition to the Welcome to Medicare visit, and initial and subsequent wellness visits.  These prolonged codes may also be used with other preventive services.  You can download a complete chart of codes using the link at the top of this page. I’ll discuss the other services later in the article.

Prolonged services and wellness visits

There are two new HCPCS codes that can be billed for wellness visits that are especially time consuming.

The provider must meet the threshold time for the visit, and half of the prolonged services time.

• Reference Sheet_Wellness visits and prolonged care G0513 G0514

At an Open Door Forum , I asked if CMS was following the CPT ® time rule for prolonged codes, and was told that they were.  The full time of the wellness visit must be met, however, before adding the time for the prolonged code.

HCPCS codes

G0513 Prolonged preventive service(s) (beyond the typical service of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (listed separately in addition to code for preventive service) G0514 Prolonged preventive service(s) (beyond the typical service of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (listed separately in addition to code for preventive service)

CPT ® time rule

A unit of time is attained when the mid-point is passed. For example, an hour is attained when 31 minutes have elapsed (more than midway between zero and sixty minutes). A second hour is attained when a total of 91 minutes have elapsed. https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/medicare-preventive-services/MPS-QuickReferenceChart-1.html#PROLONGED

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There are a host of changes that will affect family physicians, including new vaccine codes and bundled Medicare payments for chronic pain management.

KENT MOORE, EMILY HILL, PA, AND ERIN SOLIS

Fam Pract Manag. 2023;30(1):22-27

Author disclosures: no relevant financial relationships.

As the new year begins, it's time to get familiar with the 2023 changes to CPT coding, Medicare payment policies, and Medicare's Quality Payment Program (QPP). There are a host of coding changes, including substantial revisions to evaluation and management (E/M) services that occur in hospitals or nursing homes, and changes to how prolonged services can be reported. The most concerning Medicare payment policy is a reduction in the overall payment rate under the physician fee schedule, but it's not as large as it originally was slated to be. Medicare is also rolling out new bundled coding and payment options for chronic pain management and expanding the list of services that can be provided via telehealth. The changes to QPP are small this year, but noteworthy nonetheless. Now, let's get into the details.

In addition to significant changes to hospital and nursing home evaluation and management coding, 2023 brings several changes to vaccine administration and remote monitoring coding.

Medicare is cutting the amount it pays per relative value unit by 2%, revising certain telehealth policies, and creating bundled payments for chronic pain management.

Changes to the Quality Payment Program in 2023 are minimal.

There are changes to E/M coding on several fronts, as CPT follows up on the office and outpatient E/M visit reforms of 2021. 1

Hospital and nursing home visits . The most consequential changes to E/M coding this year come in hospital and nursing home settings, which have moved to the same code level selection criteria as office/outpatient E/M services. Physicians will now select codes for these services based on either their total time spent caring for the patient or their level of medical decision making (MDM). The same MDM table CPT used for office-based E/M codes will now be used for hospital and nursing home E/M services, with a few revisions from CPT: 2

Added “1 stable acute illness” and “1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care” to the low-level MDM elements in the problems category,

Added decisions regarding the “escalation of hospital-level of care” and “parenteral controlled substances” to the high-level MDM elements in the risk category,

Added “multiple morbidities requiring intensive management” to the risk category, but this applies only to initial nursing facility visits.

Other CPT changes also impact how you will report these services. For 2023, CPT has done the following:

Consolidated hospital inpatient and observation codes into a single family of codes: 99221-99223 and 99231-99233,

Redefined the lowest level of emergency department codes (99281) to describe visits that do not require a physician or other qualified health care professional (much like office-visit code 99211),

Deleted the separate code for nursing home annual exams, which will now be coded as subsequent nursing home visits (99307-99310),

Consolidated the category “Domiciliary, Rest Home (e.g., Boarding Home), or Custodial Care Services” into a new category called “Home or Residence Services.”

For more on these changes, and how physicians can use them to code hospital and nursing home visits more quickly, see “ The 2023 Hospital and Nursing Home E/M Visit Coding Changes ."

Multiple E/M services on the same day . CPT has also revised its guidelines for hospital E/M to allow the reporting of multiple services when a patient is admitted to inpatient or observation status during a visit at another site of service (e.g., office or emergency department). The CPT guidelines advise clinicians to append modifier 25 to the initial service and then also report the hospital-based service (no modifier required on that). However, the Centers for Medicare & Medicaid Services (CMS) is retaining its policy that clinicians should only report one service (the hospital visit) per calendar date in these situations. It remains to be seen whether non-Medicare payers will follow CPT's guidance or Medicare's.

Prolonged services . CPT has deleted the codes for prolonged E/M services with direct patient contact in the office (99354-99355) and inpatient (99356-99357) settings. Physicians have been able to use code 99417 (in conjunction with 99205 or 99215) to report prolonged services in the office setting since the 2021 changes, and that will now be the only option there. Meanwhile, a new code, 99418, will be used for prolonged services in hospitals and nursing homes.

CPT guidance allows clinicians to report 99417 and 99418, along with a primary E/M code for the highest level of service in each setting, once they surpass the minimum time of the highest level of service by 15 minutes. But this is another area where CPT and Medicare differ. Medicare requires clinicians to surpass the maximum time of the highest E/M level by 15 minutes before reporting prolonged services codes. As such, CMS has developed its own HCPCS codes to report prolonged services to Medicare when those conditions are met:

G2212, prolonged services for office or other outpatient services,

G0316, prolonged services for inpatient and observation care services,

G0317, prolonged services for nursing facility services,

G0318, prolonged services for home/residence services.

CPT is maintaining two of its previous prolonged services codes — 99358 and 99359 — for reporting non-face-to-face services that occur on a different date than the face-to-face visit. But those codes are revised, with their headings changing from “Prolonged evaluation and management service before and/or after direct patient care” to “Prolonged service on date other than the face-to-face evaluation and management service without direct patient contact.”

OTHER CPT CHANGES

In addition to the E/M changes, there are a number of other CPT revisions family physicians may want to take note of.

Remote therapeutic monitoring (98975-98978) . CPT has revised the description for remote therapeutic monitoring code 98975 to accommodate the addition of a new CPT code, 98978, specifically for monitoring for cognitive behavioral therapy. (The description's parenthetical section now includes only “therapy adherence” and “therapy response.” References to respiratory and musculoskeletal systems have been removed.) As with remote monitoring codes 98976 and 98977, clinicians will use code 98978 once per 30-day monitoring period to report supplying the monitoring device to the patient for scheduled recordings and/or programmed alert transmissions.

CPT has also revised the introductory guidelines to the remote therapeutic monitoring section to recognize the new code and made changes to the introductory guidelines for remote therapeutic monitoring treatment management services to clarify the appropriate reporting of these services. There are no changes to the existing CPT codes 98980 and 98981 for remote therapeutic monitoring treatment/interactive communication.

Vaccine product and administration codes . CPT 2023 includes multiple new codes for COVID-19 vaccines and their administration. CPT also revised several codes to accommodate changes in patient ages as vaccine guidelines were updated. The codes are unique for each of the COVID-19 vaccines approved in the U.S., and administration codes are unique to each vaccine and dose. All COVID-19 vaccine codes and administration codes are listed in the vaccine section of CPT and in Appendix Q. 3

Other new vaccine codes this year include the following:

90584, “Dengue vaccine, quadrivalent, live, 2 dose schedule, for subcutaneous use,”

90678, “Respiratory syncytial virus vaccine, preF, subunit, bivalent, for intramuscular use.”

CPT has also revised code 90739 to read, “Hepatitis B vaccine (HepB), CpG-adjuvanted, adult dosage, 2 dose or 4 dose schedule, for intramuscular use.” The American Medical Association maintains current information on all CPT vaccine codes on its website. 4

Suture and staple removal . CPT created two new codes for reporting removal of sutures and/or staples not requiring anesthesia. Code +15853 is for removing either sutures or staples without anesthesia, and code +15854 is for removing both sutures and staples without anesthesia. Both are add-on codes reported in addition to an E/M service (modifier 25 is not required on the E/M code when you report add-on codes).

Prior to 2023, CPT made a distinction between suture removal by the same physician who performed the primary procedure and suture removal by a different physician. However, CPT 2023 removed that language, and the suture-removal codes now can be reported by the physician who performed the primary procedure or another clinician.

MEDICARE PAYMENT POLICY CHANGES

CMS was slated to set the 2023 conversion factor (i.e., the amount Medicare pays per relative value unit [RVU] under its physician fee schedule) at $33.06 — about 4.5% lower than 2022. Most of that reduction was because a 3% increase in the 2022 conversion factor that Congress applied via legislation was due to expire. The remaining 1.5% reduction was due to budget neutrality adjustments that CMS must make to offset spending increases from regulatory changes that increase RVUs for some services, such as the hospital, nursing facility, and home E/M services. But Congress acted to reduce the cut, and just before the new year President Biden signed into law a budget bill with a 2% reduction instead. 

Here are other notable Medicare changes in 2023.

Chronic pain management and treatment bundles . CMS is implementing separate coding and payment for chronic pain management (CPM) services beginning Jan. 1, 2023. The agency will allow non-physician practitioners (e.g., nurse practitioners and physician assistants) to provide CPM and requires the initial visit to be face-to-face. CMS has created two HCPCS codes to report monthly CPM:

G3002, “Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing e.g. physical therapy and occupational therapy, complementary and integrative approaches, and community-based care, as appropriate. Required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. (When using G3002, 30 minutes must be met or exceeded.)”

G3003, “Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month (list separately in addition to code for G3002). (When using G3003, 15 minutes must be met or exceeded.)”

Telehealth . CMS greatly expanded the services that can be provided via telehealth in response to the COVID-19 public health emergency (PHE). This year we are getting a clearer picture of what Medicare telehealth services may look like after the PHE.

CMS has added some services to its official telehealth list 5 on a Category 3 (temporary) basis and some on a Category 1 (permanent) basis. Category 3 additions will be on the list through the end of 2023 or 151 days after the PHE ends, whichever is later. Several emotional/behavior assessment, psychological, and neuropsychological testing and evaluation services have been added to the list as Category 3 items. The newly finalized prolonged services codes G0316-G0318 and the chronic pain management codes G3002 and G3003 are on the list as Category 1 items.

CMS will also continue to allow audio-only (i.e., telephone) services to be billed as telehealth temporarily. But following the 151-day post-PHE extension period, CMS will once again assign the telephone E/M services (CPT codes 99441-99443) a “bundled” status, which means Medicare will no longer separately pay for them.

For allowable audio-only services, clinicians will have the option to append either Medicare modifier FQ, “Medicare telehealth service was furnished using audio-only communication technology,” or CPT modifier 93, “Synchronous telemedicine service rendered via telephone or other real-time interactive audio-only telecommunications system.” Clinicians will continue to use modifier FR on applicable claims when required to be present through an interactive real-time audio and video telecommunications link, as reflected in each service's requirements.

Until the end of 2023 or the end of the year in which the PHE ends (whichever comes later), clinicians should continue to append CPT modifier 95, “Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system” and use the place of service (POS) code reflecting where the service would have been furnished had it been in-person. CMS will continue to pay at the rate corresponding to that POS, which will typically be the higher “non-facility” rate.

Other Medicare provisions of interest . CMS has updated Medicare Part B payments for administration of the influenza, pneumococcal, hepatitis B, and COVID-19 vaccines based on the annual increases to the Medicare Economic Index (MEI) and will geographically adjust the payments. The MEI is an index that measures changes in the market price of the inputs used to furnish physician services. The MEI update for 2023 is 3.8%.

CMS has reduced the minimum age for coverage of certain colorectal cancer screening tests from 50 to 45 years of age. CMS has also finalized expanded coverage of colorectal cancer screening to include a follow-on screening colonoscopy after a non-invasive stool-based test returns a positive result, thereby removing cost sharing for most beneficiaries.

QUALITY PAYMENT PROGRAM AND MEDICARE SHARED SAVINGS PROGRAM (MSSP)

Medicare's alternative payment programs are staying much the same this year, but there are a few changes to be aware of.

QPP . For the 2023 performance year, CMS is doing the following to QPP:

Implementing Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) as a new reporting option in MIPS. There will be 12 MVPs available for clinicians to report, including two focused on primary care: promoting wellness and optimizing chronic care.

Maintaining the performance threshold at 75 points. Eligible clinicians (ECs) will receive payment increases or reductions of up to 9% on their Medicare Part B claims, depending on how their performance compares to the threshold. There is no exceptional performer threshold in 2023.

Maintaining category weights at the same levels: 30% quality, 30% cost, 25% improvement activities, and 15% promoting interoperability.

In the MIPS quality category, CMS is doing the following:

Maintaining the quality data completeness criteria threshold at 70%. Beginning in 2023, the Web Interface is only available to MSSP accountable care organizations (ACOs) reporting using the Alternative Payment Model Performance Pathway.

Expanding the definition of a high-priority measure to include health equity-related quality measures.

Establishing a policy to score administrative claims measures against performance period benchmarks.

In the MIPS cost category, CMS is establishing a maximum cost improvement score of one percentage point. CMS began including improvement in the scoring of the cost performance category with the 2022 performance period.

In the MIPS improvement activities category, CMS made no changes except to update the inventory of activities.

In the MIPS promoting interoperability category, CMS is doing the following:

Discontinuing automatic reweighting for nurse practitioners, physician assistants, certified registered nurse anesthetists, and clinical nurse specialists. CMS will continue to apply automatic reweighting for certain clinicians, including those in small practices.

Modifying the options for active engagement for the Public Health and Clinical Data Exchange Objective measures. ECs will have two options: “pre-production and validation” and “validated data production.” ECs will attest yes or no and submit their level of active engagement. ECs can also only spend one performance period at the “pre-production and validation” level.

Requiring the Query of Prescription Drug Monitoring Program measure, which is worth 10 points, with exclusions available. In addition to including schedule II drugs, CMS is expanding the measure to include schedule III and IV drugs.

Adding a third option to satisfy the Health Information Exchange objective: “Participation in the Trusted Exchange Framework and Common Agreement (TEFCA).”

MSSP . CMS made more substantial changes to the MSSP (none of these changes apply to the ACO REACH model, which is a separate program). The changes include the following:

Providing Advance Investment Payments (AIPs) to new entrants inexperienced with performance-based risk. AIPs will be a one-time payment of $250,000 and eight quarterly payments based on the number of beneficiaries assigned to the ACO. CMS will recoup the AIP from any shared savings earned by the ACO in its current agreement period.

Allowing ACOs inexperienced with performance-based risk to remain in the Basic track level A for all five years of the agreement period.

Making the Enhanced track optional for everyone.

Reinstating a sliding scale to determine shared savings for ACOs that failed to meet the criteria under the quality performance standard to qualify for the maximum shared savings rate. CMS will use a similar policy to determine an ACO's shared loss rate in the Enhanced track for ACOs that exceed the maximum loss rate. To qualify for the sliding scale, the ACO must achieve a score in the 10th percentile or higher for at least one of the four outcome measures in the APM Performance Pathway.

Establishing a health equity adjustment of up to 10 bonus points applied to MIPS quality performance scores for ACOs that report the three electronic clinical quality measures or MIPS clinical quality measures.

Updating the benchmarking methodology to include an administrative growth factor, reinstituting an adjustment for prior savings, and reducing the cap on negative regional adjustments.

Allowing certain ACOs in the basic track that do not meet the minimum shared savings rate to qualify for shared savings if the ACO meets the quality standard (including the alternative standard).

A PLACE TO START

These are not all the updates to the Medicare physician fee schedule, QPP, or CPT codes for 2023. But this is a high-level list of the most important changes family physicians need to know about as the year begins. As always, how individual payers approach these coding and payment changes may vary, so you're advised to consult with those in your area to find out how they will handle them.

Millette KW. Countdown to the E/M coding changes. Fam Pract Manag . 2020;27(5):29-36.

CPT evaluation and management (E/M) code and guideline changes. American Medical Association. Accessed Nov. 29, 2022. https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf

Appendix Q: severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccines. American Medical Association. Accessed Dec. 2, 2022. https://www.ama-assn.org/system/files/covid-19-immunizations-appendix-q-table.pdf

Category I vaccine codes. American Medical Association. Updated Nov. 16, 2022. Accessed Dec. 2, 2022. https://www.ama-assn.org/practice-management/cpt/category-i-vaccine-codes

List of telehealth services. Centers for Medicare & Medicaid Services. Updated Nov. 2, 2022. Accessed Dec. 2, 2022. https://www.cms.gov/medicare/medicare-general-information/telehealth/telehealth-codes

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