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Rural Health Information Hub

2024 Physician Fee Schedule Final Rule

Duration: approximately minutes

Featured Speakers

  • Sarah Heppner, Associate Director, Federal Office of Rural Health Policy
  • Lindsey Baldwin, Division of Ambulatory Services, Hospital and Ambulatory Policy Group, CMS Center for Medicare
  • Gift Tee, Division of Practitioner Services, Hospital and Ambulatory Policy Group, CMS Center for Medicare
  • Michelle Cruse, Division of Ambulatory Services, Hospital and Ambulatory Policy Group, CMS Center for Medicare
  • Michele Franklin, Division of Ambulatory Services, Hospital and Ambulatory Policy Group, CMS Center for Medicare
  • Dr. Colleen Barbero, Medicare Diabetes Prevention Program, CMS Center for Medicare and Medicaid Innovation
  • Tina Cooley, Medicare Diabetes Prevention Program, CMS Center for Medicare and Medicaid Innovation

The Centers for Medicare and Medicaid Services (CMS) recently updated the Physician Fee Schedule (PFS) for 2024 through the Calendar Year 2024 PFS Final Rule. This rule makes policy updates which may increase accessibility of behavioral health services, telehealth services, and other vital health services in rural areas. CMS subject matter experts will present on some of highlights from the final rule including these topics and the Medicare Diabetes Prevention Program.

From This Webinar


Kristine Sande: I'm Kristine Sande, and I'm the program director of the Rural Health Information Hub. I'd like to welcome you to today's webinar where we'll be discussing the 2024 Physician Fee Schedule Final Rule. We have provided a copy of the presentation on the RHI Hub website, and that's accessible through the URL on your screen. And now, it is my pleasure to introduce our speakers for today's webinar. First, we'll hear from Sarah Heppner, who is the Associate Director of the Federal Office of Rural Health Policy within the Health Resources and Services Administration. The Federal Office helped us coordinate this webinar, so we'll hear some opening remarks from Sarah.

Then, we have some speakers from the Hospital and Ambulatory Policy Group within the CMS Center for Medicare. Those include Lindsey Baldwin from the Division of Ambulatory Services, Gift Tee from the Division of Practitioner Services, Michelle Cruse, the Deputy Director of the Division of Ambulatory Services, and Michele Franklin, who also is within the division of Ambulatory Services. Then, we'll have some speakers from the CMS Center for Medicare and Medicaid Innovation, and that includes Dr. Colleen Barbero, who serves as the Model Lead for the Medicare Diabetes Prevention Program, as well as Tina Cooley, who leads the marketing and outreach efforts on the Medicare Diabetes Prevention Program team in the Division of Healthcare Delivery. So, at this point, I will turn it over to you, Sarah.

Sarah Heppner: Thank you so much, Kristine, and also thank you to all of the great folks who work at RHIhub for hosting this webinar. And of course, I want to thank our colleagues at CMS for the work that you do day in and day out, as well as for taking the time to join us today. I would be remiss if I didn't pause here and mention that our partnership with CMS is absolutely integral to the work that we do within the Federal Office of Rural Health Policy, within our Section 711 authority to advise the Secretary of the Department of Health and Human Services on the potential impacts of Medicare and Medicaid policy on rural communities and providers.

Today, as you all know, we're going to be talking about the calendar year 2024 Physician Fee Schedule Final Rule, which was published late last year. This webinar is actually a follow-up to something that we tried to do a little over a year ago, or we actually did do a little over a year ago, where we pulled our CMS colleagues together to talk about the calendar year 2023 Final Rule. We received a lot of positive feedback from our stakeholders about that first webinar, so we're excited to continue this series with CMS by bringing information from the 2024 Final Rule to our rural stakeholders and partners.

This webinar, of course, is going to cover behavioral health and telehealth, but also community health integration services and the behavioral health billing codes for marriage and family therapists and mental health counselors, RHC and FQHC updates, the annual wellness visit, the Associated Optional Social Determinants of Health Risk Assessment, evaluation and management updates, caregiving services updates, and the Medicare Diabetes Prevention Plan. So, that is a lot to cover in 90 minutes and we really want to thank, again, for creating a forum where our CMS colleagues could talk about what they did, how they did it, why they did it around these topics. We also wanted to make sure that we were creating a space for you all to chime in and ask questions, to make sure that you have the best understanding possible for how these things could be implemented in rural communities. So given that, I'd like to once again thank our CMS colleagues for doing this webinar with us, and I will turn it over to you to get started.

Gift Tee: Thank you, Sarah, and good afternoon everyone. Thank you for your time and attention this afternoon. As Sarah mentioned, a bunch of us from CMS are here to present a lot of the topics that were covered in the CY 2024 Physician Fee Schedule. I'm going to start us off and you'll hear from a number of my colleagues to touch on different topics. So, on November 2nd, as most of you're aware, 2023, the CMS issue, the Final Rule, that includes policy changes for Medicare payments on the Physician Fee Schedule and other Medicare Part B issues effective for January 1, 2024. And we're in 2024, so a lot of those services are currently being furnished by practitioners out there.

Just as an overview, the Physician Fee Schedule announces policy changes for Medicare payments on their PFS for CY for all of the calendar years that we cover from a payment perspective, but specifically for 2024, a lot in this year's rule. As much as we're going to cover some topics, there's a lot that we're not covering because other parts of the agency also announced their policy changes in the rule. So, just for a full comprehensive review of what's in the rule, I advise you to go into the rule and certainly read that. But we'll cover the topics that Sarah had mentioned at the top of the call.

Okay. So as I mentioned, some of the topics covered in the rule include our Ratesetting Conversion Factor, which is important for converting our relative value units into dollars. As most of you know, our topic of evaluation management services, this year we implemented complexity add-on code, which is crucial to practitioners that maintain a longitudinal and serve as a focal point for care for a lot of the patients that are Medicare beneficiaries. Behavioral health services, dental and oral health services, certainly our policies around telehealth services which have been crucial during the pandemic.

And as we come out of pandemic, really understanding what CMS considers from a regulatory and statutory framework for what will happen next for those services. Caregiver training services, another crucial policy that we implemented this year. Our Social Determinants of Health Risk Assessment Policy that we implemented. And some of our newest services that I know a lot of you're interested in, community health integration, CHI, and principal illness navigation services. Also crucially, our policies around rural health clinics and federal qualified health clinics as it pertains to a lot of the topics that you see above and some others as well, too.

As I mentioned, the first topic are PFS Ratesetting Conversion Factor. Just think of this as a grab bag for converting all of our policies into actual payment rates, including some of the technical changes that we make year over year to better reflect the resources that go into furnishing a physician service. This year marks the third year of a clinical labor pricing update. In essence, us updating information on the wage rates paid to clinical staff as part of the makeup for physician service. Then also, standard ratesetting refinements that we make year over year to take into account the RVU changes, changes in practice of medicine, and different resource costs allocations that we consider under the PFS.

It's also worth noting that the Consolidated Appropriations Act of 2023 provided for temporary 2.5% increase in PFS payments for CY 2023 and a 1.25% increase for CY 2024. So, it's a statutory provision that we implemented for 2024. As you can see, in 2023 it was 2.5, but for 2024, 1.25. So in essence, a decrease of 1.25%. We usually, well, typically, almost always make budget neutrality adjustments per statutory authority depending on if there is other statutory authority that we should also consider to the RVU. And so, in the combination of the RVU and the expiration of the update to the conversion factor results in a conversion factor of $32.74, which is a decrease of $1.15 from the CY 2023 PFS Conversion Factor of $33.89.

Our second topic touches on evaluation management services. It's specifically the Office Outpatient Evaluation Management Visit Inherent Complexity Add-On Code. Some of you may recall that CMS had first thought about this policy back in CY 2021, acknowledging that there are some instances that are not well accounted for in existing evaluation management coding. So, this add-on code is our policy to better recognize resource costs associated with E&M visits for primary care and longitudinal care. It's going to be applicable, as I've mentioned a couple of times, for outpatient office visits specifically, not for the other E&Ms that are out there, as an additional payment. Again, recognizing the inherent costs involved when a clinician is a continuing focal point for all needed services or part of ongoing care related to a patient's single serious condition or complex condition.

We've got a couple of examples that we threw into the rule for consideration and we continue to work on subregulatory materials that we think might be helpful, just given the conversations that we've had with a number of you interested parties, practitioners about when to think about billing for the service. But for example, a primary care clinician as a continuing focal point, while needed healthcare services for a patient, often there's a cognitive load responsibility and accountability for building the most effective trusting relationship possible amidst evaluating and managing other healthcare problems during a visit. So, building that longitudinal relationship is a key aspect of providing such care as we've described, and will make the patient more likely comply with treatment recommendations of the visit during future visits. So, just think primary care generally and what happens during those encounters. That's what we've recognized in the implementation of this add-on code, and certainly are hearing a lot of feedback on how the service might be implemented going forward on other considerations that we'll continue to think about as we gain more experience with the code.

Okay. So, as we also mentioned, there's a lot of policy that crosses over into the setting of rural health clinics and federally qualified health clinics. I will try to cover this at a high level, but we do have our RHC and FQHC experts here as well to hold me accountable. As most of you know, RHC and FQHCs are not paid according to the complexity of the patients. CMS pays a counter rate for each billable visit that accounts for all the services furnished to a beneficiary for the day, some exceptions. So, the services described by HCPCS code G2211 are accounting for in the payment of the billable visit for that day. RHC specifically are paid under the all-inclusive rate methodology and FQHCs are paid under the FQHC PPS. But HCPCS code G2211 is not paid separately in those accounts.

Okay? And with that, I will turn it over to my colleague, Lindsey Baldwin, who'll walk you through behavioral health services.

Lindsey Baldwin: Great. Thanks, Gift. Good afternoon, everyone. I'm going to walk through just a brief update on the policies in the behavioral health space that were included in the 2024 Physician Fee Schedule Final Rule. First up is the Medicare benefit for marriage and family therapists, or MFTs, and mental health counselors, or MHCs. These new benefits under Medicare were authorized by Section 4121 of the Consolidated Appropriations Act 2023, which provides for Medicare Part B coverage and payment under the PFS for the services of MFTs and MHCs, allowing these additional practitioner types to be able to enroll with Medicare and to bill independently for their services.

One thing to flag here is that we also proposed and finalized to allow addiction counselors or drug and alcohol counselors, who meet all of the applicable requirements to enroll in Medicare as mental health counselors. MFTs and MHCs were able to begin submitting their Medicare enrollment applications after the CY 2024 Physician Fee Schedule Final Rule was issued in November, and they're able to bill Medicare for services furnished on or after January 1st, 2024. The statutory benefit for enrolled MFTs and MHCs authorizes them to bill for services that are furnished for the diagnosis or treatment of mental illnesses, which can also include substance use disorders. Then lastly, we also made updates to the Behavioral Health Integration Codes under the Physician Fee Schedule to allow MFTs and MHCs to be able to bill for those services as well.

Next is Psychotherapy for Crisis Services. These updates were also based on another section of the Consolidated Appropriations Act. This was Section 4123, which required the secretary to establish new payment codes for Psychotherapy for Crisis Services that are furnished in particular sites of service, which we defined really broadly as any place of service that's assigned a non-facility rate under the PFS. So, that's anywhere other than the office setting. It can include the patient's home or a mobile unit. These codes also took effect on January 1st, 2024. The CAA specified that these new Psychotherapy for Crisis codes, which the code numbers are G0017 and G0018, that these new codes would pay at 150% of the rate that is assigned to the existing codes describing Psychotherapy for Crisis.

Okay, just a couple of other updates that were included in this final rule on behavioral health. We also finalized an increase in the payment for timed behavioral health services under the PFS. Specifically, we finalized an adjustment to the worker RVUs for all of the psychotherapy codes payable under the PFS. Specifically, that was a 19.1% upward adjustment, which we are implementing over a four-year transition. Also, in response to the public comments that we received back on the proposed rule, we also finalized the application of this adjustment to the psychotherapy codes that are built along with an evaluation and management visit, and also to the Health Behavior Assessment and Intervention Codes, or HBAI codes. We believe these finalized changes will begin to address some distortions that had occurred in evaluating time-based behavioral health services over the years.

We also finalized a proposal to allow the Health Behavior Assessment and Intervention, or HBAI, services to be billed by clinical social workers, marriage and family therapists and mental health counselors in addition to clinical psychologists who were already able to bill for those codes.

Okay, and with that, I will pass it off to my colleague, Michele Franklin, to go over behavioral health services furnished in RHCs and FQHCs.

Michele Franklin: Thank you, Lindsey. Good afternoon, everyone. I'm going to go over the behavioral health services as it relates to RHCs and FQHCs. As mentioned earlier, Section 4121 of the CAA 2023 established coverage of MFT and MHC services and extended the scope of RHC and FQHC services to include those furnished by MFTs and MHCs. For RHCs and FQHCs, MFTs and MHCs are under the same umbrella as all other RHC and FQHC practitioners, and the services that they furnish will be billable visits. I would also like to mention that since MFTs and MHCs are now considered practitioners in RHCs and FQHCs, they do not have to enroll in Part B separately if they are an employee of RHC or FQHC. And since they are considered practitioners in the same way as other RHC and FQHC practitioners, such as PAs, MPs, CPS and clinical social workers, the RHC and FQHC will receive the RHC AIR payment amount or the FQHC PPS payment amount for their services.

In addition, we finalized our proposal to revise the health and safety standards for RHCs and FQHCs with provisions that advance access to behavioral health in rural communities. Also, in wanting to be consistent with certain supervision policies under the Physician Fee Schedule, we changed the requirement level of supervision for behavioral health services, furnished incident two in RHCs and FQHCs from direct supervision to general supervision. I'm going to turn it over now to Gift Tee to talk about dental and oral health services. Thank you.

Gift Tee: So, picking up where Michele left off, I'm going to quickly touch on our updates to our policies for Dental and Oral Health Services. Over the last several years, we've clarified CMS's payment policy for when there are dental services that are inextricably linked to medical services, covered medical services. And so, this year we've picked up our work in that space. Specifically, we codified previously finalized payment policy for dental services for head and neck cancer treatments, whether primary or metastatic. The connotation to permit Medicare Part A or Part B payment for dental oral examinations performed as part of a comprehensive workup prior to medically necessary diagnostics and treatment to eliminate an oral dental infection prior to or contemporaneously with those treatment services, and to address dental oral complications after radiation, chemotherapy and/or surgery when used in the treatment of head and neck cancer. So, our proposal generally and what we finalize, permits payment for certain dental services that are strictly linked to cover services used to treat cancer prior to and during chemotherapy services, Chimeric Antigen Receptor T- (CAR T) Cell therapy and use of high-dose bone modifying agents (antiresorptive therapy).

Additionally, in the rule we saw comments on circumstances where evidence supports dental services being integral to the clinical success of the covered medical service. And that's become part of our process for discussing and meeting and capturing information from the healthcare delivery environment that we should consider under our payment exclusion. So, in February of this year, and we are almost all the way through February, we have accepted and we'll be considering public submissions for potentially analogous clinical scenarios under which we can make payment for such dental services. As I mentioned, the submissions help us think about what payment we should consider and certainly that we can take through our rulemaking process.

We also, as part of the process, engage with the agency for research and health quality. There are good partners in helping us to establish what evidence does exist for the clinical scenarios that folks submit to us for review. Certainly encourage folks to go out there and review ARC's July 2023 report on the efficacy of dental services for reducing a adverse offense. And those receiving chemotherapy, there's certainly other reports that we'll be developing over time as we continue to review additional submissions under this process. Okay?

Now, I'm going to switch gears and hop into our Telehealth Services Policy under the Physician Fee Schedule. So, as you all no doubt know, telehealth has been transformative from a number of perspectives over the last several years, four years if anyone's counting. Since the pandemic started back in 2020, there's been a lot for us to consider informed by legislative and statutory refinements to existing authority. And also our review of regulations and where we could be flexible, just given our objective of allowing continued access to services as appropriate for Medicare beneficiaries.

So for 2024, we're having to really think about what comes next and the idea that as practitioners have gained experience furnishing these services, what makes sense to maintain balancing safety, access and, frankly, making sure that the beneficiaries in the middle of all our considerations. So, we've certainly listened to interested parties, practitioners, and others that have thoughts for us to consider. This year, as part of our proposal and what we finalized, we added health and well-being coaches services to the Medicare telehealth services list on a temporary basis for CY 2024. We also finalized the addition of GO136, the Administration of a Standardized Evidence-Based Social Determinants of Health Risk Assessment Tool. I talked about that a little earlier, and likely get into it in later slides, to the Medicare telehealth services list. This is an annual process that we continue to take in request and consider each year, and also consider the evidence that folks submit as part of the process.

We also refined our process to analyze such requests given just continued conversation with interested parties, making the process a little bit more streamlined as telehealth continues to grow as a payment policy topic. And so, now we consider whether a service could be added to the telehealth list on a permanent basis because of the evidence that we have or provisional basis given that the evidence might still be under development. And allowing time for experience to be gained and shared with CMS.

We also finalized that claims billed with placement service 10, which refers to when telehealth services are provided in the patient's home, would be paid at the non-facility PFS rate. Under the PFS, we usually think about the resources involved in furnishing a service and pay differentially based on how much resource we think overlaps what we would be paying a facility under an applicable other payment system versus what we would pay on the PFS. And so, we make that distinction by saying non-facility versus facility. We believe this policy as we've implemented, will protect access to mental health and other telehealth services by aligning with some of the telehealth related flexibilities that were extended via the Consolidated Appropriations Act in 2023.

We also discussed removal of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits and critical care consultations for 2024. We received a lot of comments from interested parties on how practitioners have been ensuring that Medicare beneficiaries receive inpatient and nursing facility visits, as well as critical care consultation services since the expiration of the PHE. So again, a lot of consideration for what is practically happening as practitioners are furnishing care to beneficiaries and making sure that there is appropriate balance with, again, the beneficiary at the center of all of our considerations.

We also finalized a continuation of our Revised Direct Supervision Policy to permit the presence and immediate availability of the supervising practitioner through real-time audio and visual interactive telecommunications through the end of this year. We have solicited comment on whether we should consider extending the definition of direct supervision to permit virtual presence beyond 2024. We received a lot of interest and input from interested parties on potential patient safety and quality concerns when direct supervision occurs virtually, which we'll consider for future rulemaking. Again, balancing access to care and appropriate care, and what the practitioners have learned during the pandemic.

Additionally, we also extended flexibilities to allow practitioners furnishing telehealth services from their home to report their office addresses on their enrollment forms. This extension aligns with other flexibilities that were extended via the CAA 2023, and we certainly are taking very seriously practitioners' concerns about privacy and safety, including their home addresses as practical locations on their enrollment forms.

We also finalized our policy to allow teaching physicians in all training settings to be present using AV real-time communications technology when a resident is providing Medicare telehealth services consistent with other applicable telehealth policies. So, think of that as a resident doing telehealth services being supervised by a teaching physician virtually. This virtual presence meets the requirements that the teaching physician can bill under the PFS for the services involving the resident if they're present for the key portion of the service. The policy applies in all teaching settings through December 31, 2024. So, another topic that we're actively thinking about as we move forward in rulemaking.

Okay, and with that, I'll turn it over to Michelle Cruse to quickly cover telehealth services for hard RHC and FQHCs.

Michelle Cruse: Thanks, Gift. I'm going on what you just heard from Gift. As required by the Consolidated Appropriations Act of 2023, we extended payment for telehealth services through December 31, 2024 and delayed the in-person requirements under Medicare for mental health visits until January 1, 2025. That is, for medical visits furnished via telehealth services using HCPCS code G2025, these services will be paid through December 31, 2024. The rates for G2025 are based on the average for all PFS telehealth services on the approved telehealth list. The calendar year 2024 payment rate for G2025 is $95.29. Also as a reminder, for calendar year 2022, we finalized to pay for mental health visits furnished via telehealth the same as an in-person visit.

Then, regarding direct supervision requirements, we are adopting the definition of immediately available to include virtual presence through the use of real-time audio and video interactive telecommunications through December 31, 2024 as well. I believe I'm turning it back to Gift to discuss advancing health equity.

Gift Tee: Thanks, Michelle. So, a lot of crucial work in this space in this year's rule, and in truth it did begin last year with our recognizing specific coding that have been established by the AMA CPT, but it is consistent with a lot of work that CMS has done over several years. We're just doubling down on what makes a lot of sense from a number of perspectives, consistent with our mission as an agency and certainly the administration's broader policy objectives.

So, building on the agency's commitment to health equity and the Biden-Harris administration's executive orders to support caregivers, we did follow a separate coding and payment for several new services to help underserved populations, including addressing unmet health related social needs that can potentially interfere with the diagnosis and treatment of medical problems. 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. Taking holistically some of the largest policy changes in Medicare payment, again, putting patients at the center of the care they receive.

Specifically on the caregiver training services, we finalize a proposal to make payment when practitioners train caregivers to support patients with certain diseases or illnesses and carrying out a treatment plan. We will pay for these services when furnished by a physician or a non-physician practitioner, nurse practitioners, clinical nurse specialists, certified nurse midwives, physician assistants and clinical psychologists. Or therapists, physical therapists and occupational therapists or speech language pathologist, as part of the patient's individualized treatment plan or a therapy plan of care. Again, consistent with recent Biden-Harris administration executive orders on increasing access to high quality care and supporting caregivers.

We also formalized coding and payment for Social Determinants of Health Risk Assessment to recognize when practitioners are spending time and resources assessing SDOHs that may be impacting their ability to treat the patients. We finalized the addition of the risk assessment to the annual wellness visit as an optional additional element with additional payment and no patient co-insurance or deductible when provided with the AWV. We also finalized coding payment separately for the SDOH Risk Assessment when it's furnished with an E&M or behavioral health visit.

We also finalized coding and payment for monthly community health integration and principal illness navigation services to account for when clinicians involve auxiliary personnel, such as community health workers and care navigators to support patients who have unmet needs of effective diagnosis and treatment of their medical problems. When certain patients with high-risk conditions need assistance connecting with appropriate clinical and other resources. Again, navigating their treatment plans. So these services, as I've mentioned a couple of times, are all lockstep with broader agency goals. Just our ongoing mission, of course the Biden-Harris's initiatives, including the Cancer Moonshot Initiative with the idea of improving the outcomes for patients.

So, the CHI and PIN services involve a patient-centered assessment to better understand the patient's life story, care coordination, contextualizing health education, building patient self-advocacy skills, navigating health system. So, all the things that you would think matter in the context of putting the patient in the center of the care they're receiving, empowering the patient in ways that we have done before but are emphasizing more recently.

We also finalized an additional set of PIN codes practitioners can bill when specifically supervising auxiliary personnel such as peer support specialists to support patients with behavioral health conditions that meet the qualifications of a serious high-risk illness as outlined in our PIN discussion. These services generally match the PIN requirements with some changes in the types of services provided to align with the existing standards of peer support work. Okay? With that, I think I'll turn it back over to Michelle.

Michelle Cruse: Thanks, Gift. For RHCs and FQHCs, when the Social Determinants of Health Risk Assessment, which is G0136, is furnished as an additional element of the annual wellness visit, one visit will be paid. That is, under the RHC all-inclusive rate methodology for RHCs or under the FQHC PPS with the annual wellness visit adjustment for FQHCs. The same as in the PFS, there's no beneficiary cost sharing.

When the SDOH Risk Assessment is furnished with a billable visit other than the annual wellness visit on the same day in an RHC, one visit will be paid under the AIR methodology and beneficiary co-insurance and deductible are applicable. For FQHCs, the SDOH Risk Assessment is not considered a qualifying visit. When the assessment is furnished in conjunction with a qualifying visit other than the annual wellness visit on the same day in an FQHC, one visit will be paid under the FQHC PPS and beneficiary co-insurance is applicable.

In addition, well, with regard to the other health equity services. In addition, when community health integration services, principal illness navigation services, and principal illness navigation services that are geared for peer support specialists are furnished, RHCs and FQHCs may bill the general care management HCPCS code G0511 either alone or with a payable service. We'll talk a little bit more about how to bill these services in the next couple of slides.

In 2024, we expanded use of G0511. So, when remote physiologic monitoring services and/or therapeutic monitoring services are furnished, RHCs and FQHCs may bill that general care management HCPCS code G0511, either alone or with another payable visit. CMS revised the methodology to calculate the payment rate for general care management code G0511 to take into account how frequently the various services are utilized. That payment rate for calendar year 2024 is $71.71.

CMS also clarified in the same context of general care management services that direct supervision is not needed for beneficiary consent for chronic care management and virtual communication services. The general care management HCPCS code G0511 is comprised of the services listed in the table below. Only the codes listed below that correspond with these services can be billed as general care management under that HCPCS code G0511. When RHCs and FQHCs furnished services described by the codes below, they may bill G0511 multiple times in a calendar month as long as all of the policy and quoting requirements for each service are met and there is no overlapping of resource time. Each code listed below can be billed using HCPCS G0511 only once per calendar month for a single patient. For example, an RHC or an FQHC may bill RPM services using HCPCS code G0511 four times in a calendar month, once for each CPT code listed for RPM in the table below.

I will now turn it over to Michele Franklin to discuss IOP. Thank you.

Michele Franklin: Thank you, Michelle. So in the next two slides, I will go over Intensive Outpatient Program services. Intensive Outpatient Program is a new benefit under Medicare. These services can be furnished in outpatient departments, community mental health centers, federally-qualified health centers, rural health clinics, and in opioid treatment programs for the treatment of OUD. In the rule and in subsequent guidance, we discussed the policies regarding the scope of benefits, physician certification and plan of treatment requirements and payment policies. In terms of the scope of benefits, an IOP is a distinct and organized outpatient program of psychiatric services provided for individuals, who have an acute mental illness or substance use disorder consisting of a specified group of behavioral health services that are paid on a per diem basis. Some of those items and services include individual and group therapy, occupational therapy, services of social workers, trained psychiatric nurses and other staff that are trained to work with psychiatric patients, drugs and biologicals which cannot be self-administered, individualized activities, therapies, family counseling, patient training and education, and diagnostic services.

Regarding the physician certification and plan of treatment requirements, physicians must determine that each patient needs a minimum of nine hours of IOP services per week, and that determination must occur at least every other month. Regarding the IOP payment rates, we know that hospital outpatient departments and community mental health centers are paid IOP payment rates for three services and four or more services per day, and those rates are based on cost per day using OPPS data. For RHCs and FQHCs, the law specified that the payment rate is the same as under the hospital setting. RHCs and FQHCs are paid an IOP payment rate of $259.13 based on three services per day. We plan to review further whether a four or more services day may be applicable in the future.

It's important to note that for FQHCs, the payment amount is the lesser of the FQHC's actual charges or the IOP payment rate. This is consistent with the payment rates under the FQHC PPS. For certain tribal FQHCs, payment is also based on the lesser of a tribal FQHC's actual charges or the Medicare outpatient all-inclusive rate established by the Indian Health Service. The law also requires that costs associated with IOP services are not used to determine the RHC AIR or the FQHC PPS payment amounts. IOP services furnished by OTPs are paid based on a weekly payment adjustment via an add-on code for the treatment of OUD. The payment rate for a minimum of nine IOP services per week is $777.39.

I will now turn it over to my colleagues in CMMI. Thank you.

Colleen Barbero: My name's Colleen Barbero. I'm MDPP, Medicare Diabetes Prevention Program Model Lead. I'm here with Tina Cooley, our Outreach and Marketing Lead, to talk about the changes to our program in 2024. So, I'll very quickly go through some background and then Tina will talk about the changes. Pre-diabetes is a very serious but very common problem. Many are at risk, but few are aware. Nearly half of adults age 65 and older have pre-diabetes, but only one in four adults age 65 and older with pre-diabetes are aware of their condition. The prevalence is growing. Diabetes is expected to double by 2050 among adults. The disease burdens our nation with high cost. Diabetes costs individuals to spend 2.6 times more on healthcare per year. Medical care for diabetes for a person's age 65 and older cost the nation about 205 billion in 2022, and most of this expenditure was paid by Medicare.

The Medicare Diabetes Prevention Program is an expanded model in the Center for Medicare and Medicaid innovation. It became a Medicare Part B covered service in April of 2018. It's a structured behavioral change program that aims to prevent the onset of Type 2 diabetes among Medicare beneficiaries with pre-diabetes. In MDPP, Medicare pays organizations, called MDPP suppliers, to provide up to one year of sessions. Coaches are trained to deliver a CDC-approved curriculum and only organizations, not individuals, can enroll as MDPP suppliers.

MDPP is an expansion of the CMS-funded model test with the national YMCA of the USA, otherwise known as the DPP Model Test. That tested CDC's National Diabetes Prevention Program in the Medicare population. The CDC's National DPP is an evidence-based program with over 20 years of evidence showing that participants can decrease their risk of Type 2 diabetes through behavioral modification and weight loss. CDC remains a critical partner in MDPP. They administer the Diabetes Prevention Recognition Program, which that recognition is necessary to become an MDPP supplier.

So MDPP, this slide covers an overview of what is covered. Medicare will cover up to one year of MDPP sessions for eligible beneficiaries. These sessions are broken down into two six-month phases, in which beneficiaries work with coaches to achieve at least 5% weight loss. The first phase lasts six months with a maximum of 16 sessions, and then the second phase in the second six months includes a maximum of six monthly sessions. These sessions reinforce what has been learned in the first six months. It's important to note that all beneficiaries who start the program are eligible for the entire first year of services. No referrals are required for MDPP, however, blood tests in the pre-diabetes range is required.

This slide shows some of the beneficiary eligibility requirements. They must have Part B coverage and they also must have a body mass index or BMI of at least 25, or 23 if self-identified as Asian. And they must present at least one of three accepted blood tests showing elevated glucose levels. They're not eligible if they have been diagnosed with Type 1 or Type 2 diabetes or currently have end stage renal disease. MDPP is limited to once per lifetime for a beneficiary.

This slide shows the roadmap to enrolling as an MDPP supplier. There are several steps shown here, and you can take a look at this on our website as well if you're interested in learning more. So, I'll pass it over now to Tina Cooley to discuss the PFS change.

Tina Cooley: Thanks, Colleen. The calendar year '24 Physician Fee Schedule changes to MDPP have been made with the intent of increasing access and equity to the program. We've done this by extending the public health emergency flexibilities until December 31st of 2027. This will allow flexibility in how the MDPP services are delivered, whether in person or via distance learning. We expect and hope to increase access to MDPP among at-risk populations who reside in communities underserved by healthcare providers.

We've also simplified our payment structure expected to result in more regular payments to MDPP suppliers. We've done this by reducing the number of HCPCS G-Codes from 15 to 6. We've allowed for fee for service payments for session attendance. We've removed the virtual modifier and replaced it with a distance learning G-Code, and we've retained the performance payments for weight loss.

An exciting enhancement added in calendar year 2024 to MDPP is the option for suppliers to offer any number of sessions to a beneficiary using the CDC distance learning modality. Virtual delivery of MDPP is limited to the CDC DPRP definition of distance learning. The term distance learning in the MDPP program refers to a session that is delivered live or synchronously by a trained coach in one location and participants call in or video conference from another location. The term combination delivery refers to the set of sessions being delivered by trained coaches through distance learning and in-person sessions for each individual participant. Online delivery is not currently allowed in MDPP, and this term refers to sessions that are experienced through the internet, via phone, tablet, laptop, and an asynchronous classroom where participants are experiencing the content on their own time without a live coach teaching the content.

This slide provides this calendar year 2024 fee schedule for MDPP. This new fee schedule on this slide is applicable to claims with a date of service on or after January 1st, 2024. Medicare pays up to 22 sessions billed with codes G9886 and G9887, combined in a 12-month for a beneficiary referred to as the MDPP services period. A maximum of $768 in calendar year 2024 is available if a beneficiary meets all of the performance goals. In other words, if they achieve 9% weight loss by the end of the program year.

Moving on to some of our resources, we've worked hard over the past year to update our general resources on our website. We invite you all, please, to visit to see and get access to our latest materials, webinars, and other general information. We continuously update these materials and we have FAQs on there as well. You can seek support if you're a current MDPP supplier through our Supplier Support Center. If you're interested in learning more about our program, you can also reach out to the MDPP Model Team, and our email address is on here. And we highly encourage you to join our listserv to get up-to-date information on current events that are planned as well as resources that have become available. Again, if you are interested in learning more about the final rule, here's the link for that. I encourage using Control F and putting in "diabetes" to learn more about specific rule changes and updates that have been made impacting diabetes care and pre-diabetes care.

If you are interested in enrolling in MDPP, we have a variety of resources available on our website, and we have guides as well as checklists and videos to help support any enrollment into the program, if you are interested. We also did a billing and claims webinar back in January, and the link for that recording is on our website as well as other payment and billing information regarding the changes that have been made to the 2024 PFS rule, as well as the transition from 2023 to 2024 payment guidance is available on that site. There's also other additional learning activities calendar and we hope that we see you in the near future at some of our events.

Turning it back now to our colleagues. Thank you so much for your time.

Kristine Sande: All right. Thank you so much to all of our speakers. That was really great information. We do have a few questions already, and it looks like most of them are related to billing of the G0511 codes and how many times they can be billed a month in an RHC or FQHC setting. So, maybe we could review that a little bit?

Michelle Cruse: Hi, this is Michelle again. So just to be clearer, since G0511 is comprised of several care management services or care management-like services, anytime any of those base code services are furnished, RHCs and FQHCs can bill using G0511. We do not have a frequency limit on the per month. It's just the point of as long as there's no overlapping of resource time and that each code's requirement are met. I think in the example we gave for RPM, we said that's where the four services came in, and that was just an example. There was no limit on four services. So, if I can just kind of restate what we said. G0511 can be billed multiple times in a calendar month as long as all of the policy and coding requirements for each service are met, and there are no overlapping of resource time.

Kristine Sande: Can G0511, can that be billed twice on the same day?

Lindsey Baldwin: Yes.

Kristine Sande: Yes, okay. Great.

Lindsey Baldwin: Yeah, and again, provided that I think if one looks at the table on page 25, provided that the code, the services related to this specific service is met, like the policy and coding. If one provides chronic care management CCM, that those policies and coding rules would be met and then the RHC or FQHC could bill G0511. And the same with any of the other services on that chart.

Kristine Sande: All right. Here's another question about G0511. Is the policy effective now?

Michelle Cruse: Yes. Yes, it is.

Lindsey Baldwin: G0511 has been a code in play for a number of years. This year, we added all of the additional services described in the final rule for the calendar year. So, the G0511 services now also include the additional services in the chart on page 25.

Kristine Sande: This looks like a clarification. It says for multiple units?

Michelle Cruse: It can be billed multiple times on the same day, but we'll get back on if it can be the one line with multiple units.

Kristine Sande: All right, so if G0511 payment was calculated based on a weighted average to all the services it includes, but now it can be billed for each service, doesn't that make the weighted average rate potentially incorrect?

Michelle Cruse: Let's say that we discussed how we set the payment rate for G0511 in the rule for this year, where we discussed the appropriateness of it. But just to recap briefly, we included utilization from the Physician Fee Schedule for the base code and for the add-on code to come up with what the appropriate cost may attribute to, to get at all of those services that comprise the code. So, I wouldn't categorize that as potentially incorrect, but more that we believe it's appropriate for Medicare payment in RHCs and FQHCs for those services.

Kristine Sande: All right. Next question is, there are many COVID-related billing that were permitted till the end of 2024. When do you expect RHC policies that are ending in 2024 to be updated, allowed to continue, and when will those be sunsetted?

Michelle Cruse: I think you're referring to the telehealth policies.

Kristine Sande: I believe so.

Michelle Cruse: Would expect potentially discussion in this year's rule. If we would have a place to discuss that, it would be in the PFS rulemaking cycle.

Kristine Sande: All right, and another question. For multiple G0511, is it billed once per service category or multiple times by 20-minute increments?

Michelle Cruse: The service category is defined by the amount of time that's being furnished, I believe. So, once the requirement for the service is met, then it can be billed for that day. Does that get at that question?

Lindsey Baldwin: But I think something like CCM is 20 minutes a month, so we wouldn't expect to see multiple.

Michelle Cruse: Oh, if it's a monthly code.

Lindsey Baldwin: Of a monthly code.

Michelle Cruse: The particular service would only be billable once a month.

Lindsey Baldwin: And I think we have someone else who thought they might want to touch on that question as well.

Kristine Sande: Okay. Another question is, are the separate coding and payment rules for the new services to help underserved populations available in the final role?

Michelle Cruse: Yes, and there is also, I believe, an MLN that we would be providing along with this webinar that's helpful in understanding that information.

Kristine Sande: Thanks so much to our speakers today for sharing this information with us, and thanks to all our participants for joining us. The slides that were used in today's webinar are currently available at In addition, a recording and transcript of today's webinar will be made available on the RHIhub website, so you can listen again or share the presentation with your colleagues. Thanks again and have a great day.