United States: Congress Is Asked To Delay Implementation Of New Code That Could Cause Large Budget Neutrality Medicare Physician Fee Cut

With the arrival of crisp Fall temperatures, thoughts turn once again to looming Medicare payment cuts to physicians in the coming new year. And all eyes are on the fate of one new code set to go into effect in 2024 that is paid via the Medicare Physician Fee Schedule (MPFS). This month, a coalition of 47 organizations, representing over 1.2 million physician and nonphysician providers, wrote to urge Congress to halt the implementation of Healthcare Common Procedure Coding Systems add-on code G2211.

Three years ago, Congress intervened in the implementation of this same code. In December 2020, Congress enacted the Consolidated Appropriations Act, 2021, that delayed implementation of the complexity inherent to evaluation and management services add-on code (G2211) until CY 2024. As the new code is put into effect, its use is estimated to produce a significant increase in Medicare reimbursement for some physician specialties, with an opposite and negative impact on many others.

These anticipated cuts are due to the application of "budget neutrality" in determining physician fee schedule payments. MPFS payments are based on the number of relative value units (RVUs) performed, multiplied by a "conversion factor" that is adjusted annually to maintain budget neutrality in the MPFS. As the MPFS is regularly revised to add codes for new reimbursable services and to adjust the assigned RVU values for existing codes, budget neutrality offsets increased payments for some specialties and reduced payments for others - like radiologists. The classic pie. More for some means less for others.

The three-year Congressional moratorium on G2211 expires at the end of this year, and CMS is again proposing to move forward with the new add-on code. In the CY 2024 MPFS proposed rule, CMS estimated that G2211 will be responsible for roughly 90% of the proposed budget neutrality reductions in the coming year.

The organizations contend that the new code is both flawed and a likely candidate for overutilization. The code, they argue, is poorly defined, lacks detail regarding appropriate use, and is not resource based. At the same time, they believe use of G2211 will penalize clinicians who cannot, or do not, use it. The coalition, therefore, asks Congress to permanently halt the implementation of the new code.

Keep your eyes on this code. Will Congress decide to intervene and block G2111 as it did three years ago?

This article is presented for informational purposes only and is not intended to constitute legal advice.