2024 HOPPS & MPFS Final Rules Released – Industry News, November 2023

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2024 HOPPS & MPFS Final Rules Released

On November 2, 2023, the Centers for Medicare and Medicaid Services (CMS) issued the final rules for calendar year (CY) 2024 for both the Medicare Physician Fee Schedule (MPFS) and the Hospital Outpatient Prospective Payment System (HOPPS). The highlights of the rulings are outlined below but it is recommended to review the documents in their entirety, which are linked under Resources.

MPFS

  • 2024 conversion factor (CF) = $32.7442, a decrease of 3.37% from 2023.
  • Retiring of fee schedule localities 06, 07, and 26 in California effective January 1, 2024, with no payment impacts.
  • G2211 Office/Outpatient E/M visit complexity add-on code finalized to be separately payable effective January 1, 2024.
  • Finalized revised definition of “substantive portion” of a split (or shared) visit to reflect the revisions to the CPT® E/M guidelines.
  • Telehealth finalized policies:
    • CMS will allow practitioners to provide telehealth services from their home without enrolling their home address through CMS through December 31, 2024.
    • Modifier 95 will be reported with either place of service (POS) code:
      • 02 – Telehealth Provided Other than in Patient’s Home; paid at the MPFS rate
      • 10 – Telehealth Provided in Patient’s Home; paid at the MPFS nonfacility rate
      • If the physician is working in the hospital and the patient is in their home, the physician will report modifier 95 and POS code for the hospital.
    • Originating site fee, Q3014, finalized at $29.96.
  • Dental services were added to Medicare’s covered services list to include:
    • Chemotherapy
    • Chimeric antigen receptor (CAR) T-cell therapy
    • Antiresorptive therapy when used in the treatment of cancer
    • Clarified dental service required in the period following direct treatment for head and neck cancer
  • New Codes
    • Community Health Integration (CHI) Services
      • G0019 – CHI 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…
      • G0022 – …each additional 30 minutes per calendar month (List separately in addition to G0019)
    • Social Determinants of Health (SDOH)
      • G0136 – Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months…
    • Principal Illness Navigation (PIN) Services
      • G0023 – PIN services b 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,…
      • G0024 – PIN services, additional 30 minutes per calendar month (list separately in addition to G0023).
      • G0140 – PIN – Peer Support by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a certified peer specialist; 60 minutes per calendar month,…
      • G0146 – PIN – Peer Support, additional 30 minutes per calendar month (List separately in addition to G0140).
    • Appropriate Use Criteria (AUC)
      • CMS indicated they believed there was value in referring to the clinical support decision tool, there was no reason to continue the operations and testing period as there were too many issues to overcome to make the program successful. CMS stated it was possible they would develop a revised AUC in future rulemaking for advanced diagnostic imaging.

HOPPS

  • 2024 conversion factor (CF) of $87.382 for hospitals that meet the Hospital OQR reporting requirements and $85.687 for those that do not, a 3.1 percent increase.
  • 5 percent cap on any decreases to a hospital’s wage index from the previous year’s wage index.
  • Continuation of HOPPS complexity-adjusted comprehensive ambulatory payment classifications (C-APCs).
  • Continuation of multiple imaging composite APC payment methodology.
  • Continue reimbursement of not otherwise specified (NOS) brachytherapy sources, C2698 and C2699, at a rate equal to the lowest rate for such sources on a per source basis.
  • Continuation of payment for drugs and biologicals at ASP+6 percent to include drugs purchased through the 340B program.
  • 2024 drug packaging threshold at $135 per day, a decrease from the proposed $140.
  • 340B Drug Discount Program
    • Continuation of payment of average sales price (ASP) plus 6 percent.
    • Implementation of single modifier, “TB”, effective January 1, 2025. “JG” will continue to be utilized until the end of 2024.
  • Hospital Price Transparency (HPT)
    • Finalized many updated requirements for HPT to include (but not limited to):
      • Use of CMS template.
      • Payer and plan required as separate data elements for payer-specific negotiated charges.
      • Requirement of hospitals to acknowledge receipt of warning notices, work to address noncompliance, and publicize CMS enforcement activities.
      • Excessive Radiation eCQM voluntary reporting for CY 2025 followed by progressive mandatory reporting beginning with the CY 2027 reporting period.

ASTRO Updates PBI for Early Invasive Cancer

The American Society for Radiation Oncology (ASTRO) has recently updated their guidelines on partial breast irradiation (PBI) for patients with early-stage invasive breast cancer or ductal carcinoma in situ (DCIS).

Multiple resulted randomized controlled trials, including more than 10,000 women with about 10 years of follow-up have been taken into account in developing the new guidelines, which have not been updated since 2017. ASTRO’s guideline task force members stated the trials demonstrated “oncologic equivalence” between PBI and whole-breast irradiation (WBI) for the treatment of early-stage breast cancer and DCIS.

The key difference to the updated guidelines is regarding the age in which PBI may be considered appropriate. The 2017 guidelines considered women 50 years and older “suitable” for PBI while women ages 40-49 were considered “cautionary” and those under that age 40 were “unsuitable” for the treatment.

The updated guidelines state PBI is strongly recommended for patients aged 40 or older with early stage, small tumor, node-negative invasive breast cancer as an alternative to WBI. This recommendation also includes the patient having favorable clinical features and tumor characteristics including grade 1 to 2 disease, and estrogen receptor (ER)-positive status.

PBI is also conditionally recommended if the patient has an indication of higher recurrence risk, ER-negative, or larger tumor size. However, it is not recommended for patients with positive lymph nodes, positive surgical margins, or germline BRCA1/2 mutations, or those who are younger than 40.

3-D conformal radiation therapy, intensity-modulated radiation therapy (IMRT), and multi-catheter interstitial brachytherapy are the recommended PBI treatment techniques. The guidelines also outline dose-fraction regimens for the varying recommended PBI treatment techniques.

Artificial Intelligence Executive Order Issued

The Executive Order, issued October 30, 2023, aims to establish standards for privacy protection, safety and security, protecting consumers and workers, and advancing equity and civil rights all while promoting innovation and competition and advancing American leadership.

The Medical Imaging & Technology Alliance (MITA) supports the Executive Order, welcoming the government-lead initiative to establish AI systems that are safe, secure and trustworthy through the development of standards, tests, and tools.

The Executive Order directs action under eight major categories.

  • New Standards for AI Safety and Security
  • Protecting American’s Privacy
  • Advancing Equity and Civil Rights
  • Standing Up for Consumers, Patients, and Students
    • Advance the responsible use of AI in healthcare and the development of affordable and life-saving drugs. The Department of Health and Human Services will also establish a safety program to receive reports of—and act to remedy – harms or unsafe healthcare practices involving AI. 
  • Supporting Workers
  • Promoting Innovation and Competition
  • Advancing American Leadership Abroad
  • Ensuring Responsible and Effective Government Use of AI

The Administration notes more steps will be taken to work towards bipartisan legislation but the current actions taken regarding AI safety align with ongoing international discussions with several countries as well as the United Nations.

“We welcome the President’s executive order which should help to consistent oversight of FDA-regulated algorithms and those that currently aren’t. We look forward to working with the Administration to foster innovation that improves patient care equitably.”
— Patrick Hope, MITA’s Executive Director

ACS Updates Lung Cancer Screening Guidelines

The American Cancer Society (ACS) recently released updated lung cancer screening (LCS) guidelines, the first in a decade.

The updated guidelines recommend a yearly low-dose computed tomography (LDCT) lung cancer screening for people aged 50 to 80 years old. The previous recommendation restricted age eligibility from 55 to 74 years old. The new guidelines also update the pack-year (PY) history, previously set at 30+ PY, now recommended at 20+ PY. Additionally, there is no longer a required amount of years since quitting (YSQ) to be eligible for screening, which was previously set at no more than 15 years.   

The ACS has provided how its 2023 recommendation differs from the previous 2013 version below:

Lung cancer recommendations

Lung cancer is the second most frequently diagnosed malignancy in both men and women and is the overall leading cause of cancer death in the United States. The updated guidance expands recommended screenings to nearly 5 million additional Americans.

Coincidentally, the International Early Lung Cancer Action Program (I-ELCAP) released a first-of-its-kind study reporting LDCT screening significantly improves long-term survival rates. The decades long study tracked more than 89,000 international participants between 1992 and 2022 who were at least age 40, were former or current smokers or had been exposed to secondhand smoke.

Of the 1.4% (1,257) participants who were diagnosed with lung cancer, 81% were diagnosed with stage 1 cancer which had not spread to the lymph nodes. The long-term survival rate of these individuals was approximately 87%. Unfortunately, even with such high long-term survival rates, only 16% of lung cancers are diagnosed at an early state.

“Lung cancer can be cured if you enroll in an annual screening program using a well-defined protocol and comprehensive management system. It is important to return for annual screening.”
– Claudia Henschke PHD, MD