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Newly billable services can boost revenue in 2024

Medical Economics JournalMedical Economics April 2024
Volume 101
Issue 4

New billable services for 2024: ©Gamjai - stock.adobe.com

New billable services for 2024: ©Gamjai - stock.adobe.com

Although the calendar year 2024 Medicare Physician Fee Schedule effective January 1 brought with it significant payment cuts for physicians nationwide, one positive aspect is this: Several new Current Procedural Terminology (CPT) codes can increase revenue. The best part? Experts say it may only take a few small operational changes to start billing them.

Caregiver training

One of these codes is caregiver training services (CPT code 97550). The code, which pays approximately $52 for the first 30 minutes, is billable when physicians and certain nonphysician practitioners provide caregivers with strategies and techniques to facilitate a patient’s functional performance in the home or community. This includes activities of daily living, transfers, mobility, communication, swallowing, feeding, problem solving, and safety practices. For each additional 15 minutes of training, they can bill CPT code 97551 that pays approximately $26. If physicians provide 30 minutes of group caregiver training, they can bill CPT code 97552 that pays approximately $22.

Many physicians already provide this type of training, but until January 1, 2024, there was no way to bill separately for it, says Toni Elhoms, CCS, CPC, CPMA, CRC, chief executive officer at Alpha Coding Experts, LLC, in Orlando, Florida.

“Physicians should think about how they can structure their documentation differently so they can bill for this service in addition to other services provided at the same encounter,” she adds. “Documentation must include the activities and techniques discussed, and there must be clear lines of demarcation if other services are being separately reported on the same date of service.”

With that said, if physicians plan to bill 97550, they must ensure the service is medically necessary. According to the Centers for Medicare & Medicaid Services (CMS), caregiver training services are reasonable and necessary when the treating practitioner determines the patient could not carry out a treatment plan without the help of a caregiver.

Notably, CMS adopted a new definition of caregiver to include “an adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other health condition, disability or functional limitation” and “a family member, friend or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.”

Elhoms says caregiver training applies to all physicians, but it could be particularly beneficial for internists integrating other therapies into their medical practice. When furnished by physical therapists, occupational therapists and speech-language pathologists, these services are always furnished under therapy plans of care and must be accompanied by the appropriate therapy modifier (-GP, -GO or -GN) to reflect that they are provided under a physical therapy, occupational therapy, or speech-language pathology plan of care, respectively.

In addition, the patient requiring assistance does not need to be present for the service. This is a historic change from previous stringent requirements because it means physicians can extend their reach and help patients achieve a better quality of life even when those patients are bedridden or unable to travel into the office, Elhoms says.

SDOH risk assessments

This is another service that can boost revenue, Elhoms says. More specifically, when physicians administer a standardized, evidence-based social determinants of health (SDOH) assessment tool, they can bill Healthcare Common Procedure Coding System (HCPCS) code G0136 that pays approximately $19.

Elhoms advises physicians to incorporate the SDOH assessment into all annual wellness visits while keeping in mind that they can perform it during office visits, behavioral health visits, hospital discharge visits and visits in other outpatient settings. She also reminds physicians that a minimum of five minutes is required to report this time-based code.

The good news? Medicare permanently added this service to its telehealth list starting January 1, 2024. Physicians can report this service twice per year.

To bill it, first decide what SDOH risk assessment tool the medical practice will use. Medicare does not require a specific tool, but it does give these examples of evidence-based tools for consideration: CMS Accountable Health Communities Health-Related Social Needs screening tool, the Protocol for Responding to and Assessing Patients’ Assets, Risks and Experiences tool, and instruments identified for Medicare Advantage Special Needs Population Health Risk Assessment.

To ensure compliance, create an electronic health record documentation template specific to the requirements of G0136, Elhoms says. Then decide who will administer the assessment. Providers can assign medical assistants, or patients could even complete the assessment prior to the visit through the patient portal. Either way, physicians must document that they reviewed it and created an action plan to address any findings.

E/M add-on code

Evaluation and management (E/M), a newly billable service, is designed to compensate physicians when they serve as the focal point for all needed health care services related to a patient’s single, serious condition or a complex condition. To report it, use HCPCS code G2211 that pays approximately $16.

“This code is for anybody who performs longitudinal care,” says Steven P. Furr, M.D., FAAFP, a family physician in Jackson, Alabama, and president of the American Academy of Family Physicians. “We think it’s very positive for those who provide continuous care to their patients. There have been no inflationary updates for more than 20 years. We’ve had to absorb rising costs, and primary care is struggling. This code helps signify all the complexity of what we do.”

Although the code is most appropriate for primary care physicians, Furr says specialists also may be able to report it depending on the scenario. He provides the example of an endocrinologist caring for a patient with diabetes or a rheumatologist caring for someone with rheumatoid arthritis. G2211 is not prescriptive in terms of what it requires; however, Furr says it could include tasks such as discussing preventive care needs, addressing SDOH, coordinating care with specialists, and more.

Physicians can report G2211 with new and established patient office/outpatient E/M services; however, they cannot report it when the associated office visit E/M includes a modifier -25. For example, a physician sees a patient in the office for diabetes, counsels them on how to connect with community resources, and injects the knee to relieve osteoarthritis pain, all during the same encounter. In this scenario, they cannot report G2211, Furr explains.

There are also no frequency limitations for this code, meaning physicians can report it as often as medically necessary. In addition, G2211 is on Medicare’s approved list of telehealth services, meaning physicians can bill it with telehealth office visits (i.e., CPT codes 99202-99215).

According to the proposed rule, CMS expects G2211 will be billed initially with 38% of all outpatient/office visit E/M codes. Once the proposed rule is fully adopted, the agency anticipates it will be billed with 54% of outpatient/office visit E/M codes.

Will private payers and Medicare Advantage cover G2211? “At this point, we can only say with certainty that G2211 is paid in traditional Medicare,” Furr says. “We are seeing, however, that some insurance companies are paying G2211 for their Medicare Advantage line of business, so it is likely getting paid here and there. It’s too soon to have a grasp of how it’s playing out at the national level.”

If a provider plans to bill it, Elhoms says they should keep the following in mind:

  • G2211 is not appropriate for acute or minor problems.
  • Physicians should be as specific as possible with any diagnosis codes they assign on a claim billed with G2211, including any relevant codes to denote SDOH.
  • The care plan should include current treatment goals and an explanation of why the E/M visit is inherently complex.
  • When renegotiating managed care contracts, ask commercial payers to cover G2211 especially when reimbursement is tied to current Medicare Physician Fee Schedule rates.

On January 18, 2024, Medicare published an MLN Matters article regarding G2211, but Elhoms says it only adds confusion and does not provide realistic clinical examples. In the absence of additional guidance from Medicare, she urges physicians to proceed with caution when billing G2211. She adds: “We don’t have much published guidance at this point to know what Medicare expects in terms of clinical documentation. It’s a question of how much invited risk you want to assume.”

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