Medicare’s covered services and service limits are constantly changing to reflect the needs of members and the costs of care. The changes earlier this year in the 2024 Medicare final rule can impact how plans like yours provide, manage and are reimbursed for health care services.
But it takes time to adapt, so has your plan gotten up to speed? Here’s a refresher on this year’s updates and what you need to do to stay in compliance.
Specifics for your plan to incorporate
The Centers for Medicare and Medicaid Services (CMS) 2024 Medicare final rule sets policies for Medicare payments under an updated Physician Fee Schedule (PFS) and other Medicare Part B issues. Bottom line? Clinicians face 3.37% in cuts in 2024. These updates — while not exhaustive — identify some of the key priorities for the future of Medicare:
New evaluation and management (E/M) add-on code
The 2024 Medicare final rule includes code G2211 to help determine the party responsible for billing when a patient is seen by multiple practitioners. It’s intended for complex patients because only one clinician can bill for a full service.
G2211 clarifies that when more than half of the total time in a split E/M visit is spent with a particular physician or non-physician practitioner or they hold a “substantive portion” of the medical decision-making, billing is their responsibility. Other practitioners involved in a patient’s total care may bill for the same service but only receive 85% of the Medicare rate.
Telehealth benefit extension
Telehealth was a lifeline during the peak of the COVID-19 pandemic, and providers are revisiting how they want to deal with it moving forward. The 2024 final rule clarifies this for Medicare members, regardless of any individual medical facility’s preferences. It stipulates that, per the Consolidated Appropriations Act of 2023, members can get telehealth services anywhere in the U.S. through Dec. 31, 2024, but lays the groundwork for upcoming changes.
After this year, most covered care shifts to on-site visits, with exceptions for rural residents or those with severe care needs, including:
- Monthly end-stage renal disease visits
- Acute stroke services, including diagnosis, evaluation or treatment of symptoms
- Substance use disorder or co-occurring mental health disorder services
- Behavioral health services, including diagnosis, evaluation or treatment, including in-home services
Social determinants of health (SDOH) risk assessment code
You can’t underestimate the importance of members’ SDOH needs, and CMS agrees. Its 2024 final rule implements a new G0136 code for administering an SDOH risk assessment when medically necessary during an E/M visit.
SDOH risk assessments help obtain a comprehensive social history and are permanently covered on the Medicare telehealth list as of 2024. This coverage is designed to work in conjunction with behavioral health office visits used to diagnose and treat mental illness and substance use disorders.
Expanded mental health coverage
We’re in the midst of a mental health and loneliness epidemic that doesn’t discriminate by age or any other demographic. CMS is helping Medicare plans accommodate increasing care needs with broader coverage for:
- Marriage and family therapists
- Mental health counselors
- Partial hospitalization
Under the provisions of the 2024 final rule, Medicare members have access to more than 400,000 therapists and counselors, while plans become empowered to cover more hours per week for severe mental illness care.
Five new MIPS value pathways
A merit-based incentive payment system (MIPS) provides rewards for continuously improving patient care. Although reporting on MIPS value pathways (MVPs) is voluntary, it helps clinicians move toward reporting on an aligned set of measures designed to be meaningful to patient care. The latest guidance adds MVPs pertaining to:
- Women's health
- Infectious disease prevention and treatment
- Quality mental health/substance use disorder care
- Quality ear, nose and throat care
- Musculoskeletal rehabilitative support and care
How are you handling the 2024 Medicare final rule?
Because these changes went into effect in January, we’re well underway. But if you’re just getting started, it’s all the more vital to navigate successfully to avoid obstacles.
Considerations as new standards are in play
Need a leg up as Medicare pivots once again? A few helpful best practices can guide you as you manage the implications of the 2024 Medicare final rule:
- Evaluate your compensation methodology at the provider, specialty and group levels.
- Craft a transition to move from the 2020 Medicare PFS to 2024 guidelines.
- Factor in economic adjustments to ensure financial success for medical groups and providers.
Offer the most to your Medicare members
Medicare coverage can’t remain static because people’s needs change. CMS works to reflect that with updates that keep both plans and members in mind. The inclusion of mental health and SDOH provisions in the 2024 Medicare final rule represents a breakthrough for treating loneliness, and Pyx Health can support your efforts even more.
We’re passionate about helping members conquer loneliness, using a winning combination of human compassion and evidence-based technology. The Pyx Health app provides engaging activities and proven screenings to identify loneliness and isolation, while our empathetic peer mentors offer companionship and connections to the Medicare population. Are you curious about how this works and how to find the right platform for your needs? Download our checklist for expert guidance.
