The 2024 Medicare Final Payment Rules Have Been Released: Part 2

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In the November Business Briefs column, we reviewed how hospital owned outpatient wound/ulcer management provider-based departments (PBDs) and physicians and other qualified healthcare professionals (QHPs) will be paid for the application of cellular and/or tissue-based products (CTPs) for skin wounds in 2024. We also reviewed a brief overview of the 2024 Medicare allowable rates for other common wound/ulcer management procedures and services.

This Part 2 article will review a few other new 2024 payment regulations that pertain to wound/ulcer management professionals.

2024 Outpatient Prospective Payment System (OPPS) Final Rule

Various types of diagnostic imaging for wound assessment have become invaluable tools for wound ulcer management physicians and QHPs. The 2024 OPPS Final Rule included important coding and payment changes (See Table 1 for a comparison of the 2023 vs 2024 coding and payment) that should continue to make these technologies attractive to PBDs and to the physicians and QHPs who work in PBDs. After reviewing the changes in Table 1, PBDs should make the appropriate changes to their electronic health records, Charge Description Masters, and coding and billing systems. They should also inform their entire revenue cycle team about these changes. In addition, physicians and QHPs should continue to educate the payers about the clinical and economic benefits of these innovative technologies.

OPPS Status Indicators:

E1       Not paid by Medicare when submitted on outpatient claims (any outpatient bill type)
M         Items and services not billable to the MAC; not paid under OPPS
N         Items and services packaged into APC rates; paid under OPPS; payment is packaged into payment for other services, including outliers. Therefore, there is not separate APC payment
T          Significant procedure, multiple reduction applies; paid under OPPS; separate APC payment

2024 Medicare Physician Fee Schedule (MPFS) Final Rule

As discussed in November Business Briefs, existing legislation forced CMS to reduce the 2024 allowable MPFS rates. Therefore, all MPFS allowable rates for services and procedures performed by wound/ulcer management physicians/QHPs were reduced. However, the Congress might release legislation that adjusts that reduction before the January 1, 2024, implementation. Stay tuned—if Congress allows CMS to increase the allowable MPFS rates, Business Briefs will keep readers informed.

G2211 Add-On Code Implementation

Wound/ulcer management professionals are interested in the new add-on code G2211 to office and other outpatient services 99202–99215. However, the code description and coding guidelines for G2211 may not be applicable to all wound/ulcer management professionals. First, let us consider the code description:

Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code; list separately in addition to office/outpatient evaluation and management visit, new or established)

Now let us consider the G2211 coding guidelines that are in the 2024 MPFS Final Rule:

• The code is for physicians/QHPs who report most of their work with evaluation and management (E/M) codes.
• The code is not restricted to particular medical specialties.
• Because the E/M codes do not reflect the resource costs associated with primary care and other longitudinal care of complex patients, the goal of G2211 is to pay physicians/QHPs consistently and continually for visits associated with longitudinal, non-procedural care where the physician has an ongoing relationship with the patient. The CMS emphasizes the longitudinal relationship between the physician/QHP and the patient.
• The relationship between the physician/QHP and the patient is the determining factor for when the G2211 add-on code should be used.
• G2211 may not be used with an E/M code service if modifier -25 is appended to the E/M code.

This author can think of a few instances where a wound/ulcer management professional may be managing the longitudinal care of complex chronic ulcer patients and may not be performing a procedure at the same encounter. However, this author does not expect to see widespread reporting of G2211 by wound/ulcer management professionals.

Remote Physiologic Monitoring (RPM) and Remote Therapeutic Monitoring (RTM)

Wound/ulcer management professionals have been showing great interest in using RPM and RTM to assist in care coordination. The 2024 MPFS Final Rule clarified several important issues:

• RPM should only be offered to established patients. RTM should only be furnished to a patient after an initial interaction between the patient and the billing professional and the RTM services should be furnished consistent with the treatment plan established during that initial interaction.
• Physical therapy assistants (PTAs) and occupational therapy assistants (OTAs) working in private practice may furnish RTM under general supervision of a physical therapists (PT) or occupational therapists (OT) who are enrolled in Medicare. This means that the PTs or OTs are not required to be present in the office suite when RTM is provided by their assistants. NOTE: If the PT or OT is not enrolled in Medicare, then PTAs and OTAs may only furnish RTM under direct supervision.
• To bill for the following RPM and RTM services, data must be collected for at least 16 days in a 30-day period for the following services:

         99453       Set-up and patient education on use of the RPM device(s)
         99454       Supply of the RPM device for daily recording or programmed alert transmissions
         98975       Set-up and patient education on use of the RTM device(s)
         98976       Supply of the RTM device for daily recording and/or programmed alert transmissions to monitor respiratory system
         98977       Supply of the RTM device for daily recording and/or programmed alert transmissions to monitor musculoskeletal system
         98978       Supply of the RTM device for daily recording and/or programmed alert transmissions to monitor cognitive behavioral therapy
NOTE:     Regardless of the number of RPM and RTM devices that a patient may be using, only one professional can report the above services.

• The following RPM and RTM treatment management services do not require 16 days of data collection:

         99457       RPM management by clinical staff/physician/other qualified health care professional with a live interactive communication with the patient or caregiver; first 20 minutes in calendar month
         99458       RPM management by clinical staff/physician/other qualified health care professional with a live interactive communication with the patient or caregiver; each additional 20 minutes in calendar month
         98980       RTM management by a physician or other qualified health care professional with at least one interactive communication with the patient or caregiver; first 20 minutes in calendar month
         98981       RTM management by a physician or other qualified health care professional with at least one interactive communication with the patient or caregiver; each additional 20 minutes in calendar month

• If a patient is in a global surgical period, the surgeon may not bill for RPM or RTM. However, the patient may receive RPM or RTM billed by a different covered professional.

Telehealth

For physicians and other QHPs who provide wound/ulcer management assessments via telehealth, the MPFS Final Rule allows the following services through 2024:

• Patients may receive telehealth in their homes and professionals will be paid at the non-facility rate
• Physicians/QHPs may provide telehealth from their homes, but bill under their practice location address
• Qualified therapists (physical, occupations), speech-language pathologists, and audiologist may offer services via telehealth

Wound/ulcer management professionals should check the list of services that Medicare will cover when provided via telehealth: List of Telehealth Services | CMS or click here (Table 2). NOTE: The list identifies which interactions may be performed via audio only, and identifies if the service may be provided via telehealth permanently or provisionally.

2024 Home Health Prospective Payment System Final Rule

The home health agency (HHA) final rule continues to allow separate Medicare payment for medically necessary disposable negative pressure wound therapy (dNPWT) devices provided by HHAs. To make coding and billing of dNPWT easier for the agencies, the 2024 HHA final rule implements the following changes effective January 1, 2024:

• Ceases paying the HHA separately for 97607 and 97608, which were for the visit and the dNPWT device.
• Begins paying the HHA separately for A9272 Wound suction, disposable, includes dressing, all accessories and components, any type, each, which does not include payment for the visit.
• Ceases requiring the HHA to report provision of dNPWT on type of bill (TOB) 034x, which is different than the TOB 032x that they use to report their nursing and therapy visits.
• Begins allowing the HHA to report provision of dNPWT on TOB 032x, with revenue code 027x (exception—not 0274).

These changes should make the provision of dNPWT devices acceptable to HHAs because they want to report 1) their nursing and therapy visits separately from the dNPWT device, and 2) all services on TOB 032x.

Because the separately paid dNPWT code A9272 only represents the device, dressings, and accessories, the 2024 Medicare allowable rate of $270.09 is less than the 2023 Medicare allowable rate for 97607 ($373.07), which also represented the nursing or therapy visit, the HHAs should not mind the rate reduction. The $270.09 should be adequate for the HHA to purchase the dNPWT device, plus they can still report the nursing or therapy visit.

CAUTION: Just like 97607 and 97608, A9272 is included on the home health consolidated billing list for 2024. The HHAs should purchase and receive Medicare reimbursement for dNPWT devices ordered for their patients who are under a home health plan of care. Therefore, PBDs should not provide dNPWT devices to patients who are under a home health plan of care.

Watch for Part 3 of "2024 Medicare Final Payment Rules Have Been Released" in the January Business Briefs column!

Kathleen D. Schaum oversees her own consulting business and is a founding member of the Today’s Wound Clinic editorial advisory board. She can be reached for consultation and questions at kathleendschaum@gmail.com.