Every July, CMS releases the draft version of the Physician Fee Schedule, the listing of codes and requirements that Medicare uses to pay doctors and other providers. The document is over 2,000 pages long, but we’ve taken a run at summarizing the highlights from a primary care and population health vantage point.
You may have already heard reactions from groups in the popular press about the 3.34% decrease in the conversion factor (the number of dollars assigned to a Relative Value Unit or RVU) from 2023. However, there are several new elements in the proposed draft that offer good news for primary care and population health that you may not have heard about. Key among them:
- An add-on code (G2211) and payment designed to capture “resource costs associated with E/M visits for primary care and longitudinal care of complex patients”.
- A new caregiver training code (9X015-17) to provide payment when practitioners train and involve caregivers to support patients with illnesses such as dementia, etc.
- Payment for SDoH Assessment (including assessment via telehealth). SDOH needs identified through the risk assessment must be documented in the medical record. The code could also be used for assessments conducted during an annual wellness visit or other E&M visit.
- GXXX5 — Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months.
- Community Health Integration (CHI) Services via community health workers (CHWs), etc. to gain a deeper understanding of a patient’s circumstances and support their journey in navigating the health system and connection with community-based organizations to support unmet SDoH needs. CHI services would be initiated via a CHI Initiating Visit (E/M code). CHI services could be billed monthly and the design of the code also seems similar to that of the CCM. Cost-sharing would be applicable and advance consent is not required.
- GXXX1 Community health integration services performed by certified or trained auxiliary personnel, including a community health worker, under the direction of a physician or other practitioner; 60 minutes per calendar month
- GXXX2 – Community health integration services, each additional 30 minutes per calendar month
- Two codes for Principal Illness Navigation services via certified navigators to help patients navigate cancer treatment and treatment for other serious illnesses. These services are also designed to include care involving other peer support specialists, such as peer recovery coaches for individuals with substance use disorder . The design seems similar to that used for the Chronic Care Management (CCM) code. Cost-sharing for patients is applicable, though as drafted, advance consent is not required.
- GXXX3 Principal Illness Navigation services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator or certified peer specialist; 60 minutes per calendar month
- GXXX4 – Principal Illness Navigation services, additional 30 minutes per calendar month
The proposed 2024 PFS language will be finalized late this year but shows a strong start at better resourcing primary care and population health to better support and partner with patients for improved outcomes.
Michigan Multipayer Initiatives 