These policy shifts reflect a broader commitment to strengthening Medicare and ensuring equitable healthcare access for underserved communities. As stated by U.S. Department of Health and Human Services Secretary Xavier Becerra, these policies aim to “expand access to care and services for people who are part of underserved communities,” while also reinforcing the Biden-Harris Administration’s focus on behavioral health, caregiver support, value-based care, and the fight against cancer.
While the CY 2024 PFS final rule mandates a 1.25% overall reduction in PFS payments compared to CY 2023, it also strategically increases payments for essential services like primary and longitudinal care visits. The finalized CY 2024 PFS conversion factor is set at $32.74, a decrease from the previous year, but these targeted payment increases signal a shift in priorities within Medicare’s reimbursement structure, requiring healthcare providers to carefully navigate health care coding changes to optimize their revenue and service delivery.
CMS Administrator Chiquita Brooks-LaSure emphasized the agency’s dedication to supporting physicians and ensuring Medicare beneficiaries receive necessary care. “CMS is taking important steps toward those goals in this rule by improving payment for primary care and access to mental health care, paying for new navigation services to help people with cancer and other serious illnesses navigate their treatment, supporting family caregivers, paying for services involving community health workers to address health-related social needs that impact care, and enhancing access to dental care for people with certain cancers.” These words underscore the comprehensive nature of the policy updates and the need for healthcare professionals to stay informed about the evolving landscape of health care coding.
Dr. Meena Seshamani, CMS Deputy Administrator, highlighted the holistic approach of these changes, stating they represent “some of the largest changes ever towards a Medicare that recognizes people with Medicare as whole persons, with their own families and unique life stories.” This patient-centric approach is reflected in the new coding and payment structures designed to address a wider range of patient needs.
Expanding Access and Equity through Updated Healthcare Codes
A central theme of the CY 2024 PFS final rule is advancing health equity and caregiver support. Building upon CMS’s commitment to health equity and the Biden-Harris Administration’s focus on caregiver support, the rule introduces separate coding and payment for new services aimed at underserved populations. This includes addressing social determinants of health, which are increasingly recognized as critical factors influencing patient outcomes and healthcare utilization.
One significant update is the introduction of coding and payment for caregiver training services. This recognizes the vital role caregivers play in patient care and ensures practitioners are appropriately compensated for engaging with caregivers to support Medicare beneficiaries in adhering to their treatment plans. Accurate health care coding for these services is crucial for ensuring proper reimbursement and the sustainability of caregiver support programs.
Furthermore, CMS is finalizing separate coding and payment for community health integration services. These services encompass person-centered planning, health system coordination, patient self-advocacy promotion, and facilitating access to community-based resources to address social needs that impact health. These are groundbreaking services within the Physician Fee Schedule, specifically designed to incorporate the work of community health workers. By connecting underserved communities with essential healthcare and social services, these initiatives aim to expand equitable access to care and improve health outcomes within the Medicare population. The introduction of specific health care coding for these services highlights their importance and facilitates their integration into mainstream healthcare delivery.
Alt text: Healthcare professionals collaborating on person-centered care plan, emphasizing community health integration and patient advocacy.
The final rule also establishes coding and payment for principal illness navigation services, designed for individuals facing high-risk conditions like cancer. Navigating a serious diagnosis such as cancer can be overwhelming. These navigation services aim to guide patients and their families through the complexities of treatment, fulfilling a key objective of the Cancer Moonshot initiative. Moreover, a subset of principal illness navigation services will support individuals with behavioral health conditions, utilizing auxiliary personnel such as peer support specialists. The development of specific health care coding for principal illness navigation is a major step forward in making these crucial support services accessible and reimbursable.
Adding to these advancements, the rule finalizes coding and payment for social determinants of health risk assessments. These assessments can be administered as an add-on to annual wellness visits or in conjunction with evaluation and management or behavioral health visits. By systematically identifying and addressing social determinants of health, providers can deliver more holistic and effective care. The inclusion of specific health care codes for these assessments encourages their routine use and integration into patient care workflows.
Whole-Person Care and the Role of Behavioral and Mental Health Coding
The CMS Behavioral Health Strategy emphasizes the importance of emotional and mental well-being within overall healthcare. The CY 2024 PFS final rule implements transformative changes to improve access to behavioral health care within Medicare, necessitating updates to health care coding practices in this domain.
A landmark change is the enrollment of marriage and family therapists and mental health counselors, including eligible addiction, alcohol, or drug counselors, into Medicare for the first time. Starting January 1, 2024, these professionals can bill Medicare for their services, significantly expanding the network of behavioral health providers available to beneficiaries. This expansion requires these new provider types to understand and correctly apply relevant health care coding for their services within the Medicare system.
Furthermore, the rule increases payment for critical behavioral health services, including crisis care, substance use disorder treatment, and psychotherapy. Based on public feedback, CMS is also increasing payment for psychotherapy performed alongside office visits and for Health Behavior Assessment and Intervention services. These payment increases acknowledge the value and complexity of behavioral health care and incentivize providers to offer these essential services. Accurate and up-to-date health care coding knowledge is essential for behavioral health providers to take advantage of these payment adjustments.
Primary care remains a cornerstone of whole-person care. CMS recognizes the inherent value and complexity of primary and longitudinal care by refining payment and coding mechanisms to more accurately reflect the services provided. These changes align with the HHS Initiative to Strengthen Primary Care and aim to ensure that primary care physicians are appropriately compensated for their comprehensive and ongoing patient care. The nuances of health care coding in primary care, especially for longitudinal care management, are becoming increasingly important for accurate billing and revenue cycle management.
The Medicare Shared Savings Program, the largest ACO program in the nation, also sees advancements in promoting whole-person care. Changes to the assignment methodology will improve access to accountable care for individuals who receive primary care from nurse practitioners, physician assistants, and clinical nurse specialists. Additionally, modifications to the financial benchmarking methodology aim to encourage participation from ACOs serving complex populations. These changes are projected to increase participation in the Shared Savings Program by 10% to 20%, expanding access to coordinated care for Medicare beneficiaries. Understanding the coding and billing implications within ACO models is crucial for participating providers and organizations.
Dental Services and Diabetes Prevention: New Coding and Coverage Areas
Expanding Medicare coverage to include certain dental services related to cancer treatments is another significant advancement in the CY 2024 PFS final rule, directly supporting the Biden-Harris Administration’s Cancer Moonshot initiative. Medicare will now make payments for specific dental services linked to various cancer treatments, such as chemotherapy. This new coverage area necessitates the adoption of appropriate dental health care coding within the Medicare system. Dentists interested in enrolling in Medicare to provide these services should seek information on enrollment procedures and relevant coding guidelines.
The Medicare Diabetes Prevention Program (MDPP) Expanded Model is further enhanced to improve care for individuals with diabetes and increase participation in underserved communities. The rule extends Public Health Emergency Flexibilities for the MDPP Expanded Model for four years, allowing MDPP suppliers to continue offering virtual services through December 31, 2027. This extension ensures continued access to diabetes prevention programs, particularly in underserved areas, and highlights the importance of understanding program-specific health care coding for MDPP services.
Conclusion: Navigating the Future of Healthcare Coding and Medicare
The CY 2024 Medicare Physician Fee Schedule final rule introduces a wide array of policy changes that significantly impact health care coding, billing, and service delivery within the Medicare system. From expanding access to behavioral and oral health to introducing new services like principal illness navigation and community health integration, these updates reflect a commitment to whole-person care, health equity, and patient-centered healthcare.
For healthcare providers, understanding and effectively navigating these changes in health care coding is paramount. Staying informed about new codes, payment adjustments, and program requirements is essential for optimizing revenue, ensuring compliance, and most importantly, providing high-quality, accessible care to Medicare beneficiaries. The finalized policies in the CY 2024 PFS rule represent a significant step forward in evolving Medicare to meet the changing needs of patients and the healthcare landscape.
