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Calendar Year (CY) 2024 Medicare Physician Fee Schedule
Proposed Rule - NEW "Patient-Centered" Care Broad/Expanded
Reimbursement Proposal
  Jul 13, 2023
On July 13, 2023, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that announces and solicits public comments on proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, effective on or after January 1, 2024.
The calendar year (CY) 2024 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a more equitable health care system that results in better access to care, quality, affordability, and innovation.
Background on the Physician Fee Schedule
Since 1992, Medicare payment has been made under the PFS for the services of physicians and other billing professionals. Physicians' services paid under the PFS are furnished in a variety of settings, including physician offices, hospitals, ambulatory surgical centers (ASCs), skilled nursing facilities and other post-acute care settings, hospices, outpatient dialysis facilities, clinical laboratories, and beneficiaries' homes. Payment is also made to several types of suppliers for technical services, most often in settings for which no institutional payment is made.
For most services furnished in a physician's office, Medicare makes payment to physicians and other professionals at a single rate based on the full range of resources involved in furnishing the service. In contrast, PFS rates paid to physicians and other billing practitioners in facility settings, such as a hospital outpatient department (HOPD) or an ASC, reflect only the portion of the resources typically incurred by the practitioner in the course of furnishing the service.
For many diagnostic tests and a limited number of other services under the PFS, separate payment may be made for the professional and technical components of services. The technical component is frequently billed by suppliers, like independent diagnostic testing facilities and radiation treatment centers, while the professional component is billed by the physician or practitioner.
Payments are based on the relative resources typically used to furnish the service. Relative value units (RVUs) are applied to each service for work, practice expense, and malpractice expense. These RVUs become payment rates through the application of a conversion factor. Geographic adjusters (geographic practice cost indexes) are also applied to the total RVUs to account for variation in costs by geographic area. Payment rates are calculated to include an overall payment update specified by statute.
we are proposing to pay separately for Community Health Integration, Social Determinants of Health (SDOH) Risk Assessment, and Principal Illness Navigation services to account for resources when clinicians involve community health workers, care navigators, and peer support specialists in furnishing medically necessary care.
Community Health Integration (CHI) and Principal Illness Navigation (PIN) services involve a person-centered assessment to better understand the patient's life story, care coordination, contextualizing health education, building patient self-advocacy skills, health system navigation, facilitating behavioral change, providing social and emotional support, and facilitating access to community-based social services to address unmet social determinations of health (SDOH) needs. Community Health Integration services are to address unmet SDOH needs that affect the diagnosis and treatment of the patient's medical problems. Principal Illness Navigation services are to help people with Medicare who are diagnosed with high-risk conditions (for example, mental health conditions, substance use disorder, and cancer) identify and connect with appropriate clinical and support resources. CMS is further clarifying that the community health workers, care navigators, peer support specialists, and other such auxiliary personnel may be employed by Community-Based Organizations (CBOs) as long as there is the requisite supervision by the billing practitioner for these services, similar to other care management services.
In addition to better recognizing costs associated with patient-centered care, access to these services could contribute to equity, inclusion, and access to care for the Medicare population and improve the outcomes for the patient (particularly in RHCs, FQHCs, underserved, and low-income populations, where there is a disparity in access to quality care). We are also proposing coding and payment for SDOH risk assessments to recognize when practitioners spend time and resources assessing SDOH that may be impacting their ability to treat the patient. Additionally, we are proposing to add the SDOH risk assessment to the annual wellness visit as an optional, additional element with an additional payment. Separately, we are also proposing codes and payment for SDOH risk

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