The Centers for Medicare and Medicaid Services (CMS) released the 2024 Medicare Physician Fee Schedule Final rule on November 2. The 2,414-page final rule is the document that informs what Medicare payments will be for the following year.

Physician Fee Schedule Conversion Factor

As expected, the conversion factor, a dollar amount which, when multiplied by the relative value units assigned to a code, determines the payment amount, is expected to drop by 3.39 percent. The estimated impact on emergency medicine will be minus two percent to offset increases in new payments to maintain statute-driven budget neutrality across the entire fee schedule.

However, ACEP is lobbying Congress to step in with new funding to prevent or lessen these cuts. HR 2474, the Strengthening Medicare for Patients and Providers Act, would provide an annual update of the conversion factor equal to the increase in the Medicare Economic Index (MEI), but the cost of this legislation may be too high for broad support under our current national fiscal situation.

ED E/M RVUs Remain Stable

CMS did not make changes to the Work RVUs for the ED E/M codes, but there were a few small changes to the Practice Expense and Professional Liability Insurance RVUs at the second decimal place.

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If we apply the revised 2024 final conversion factor of $32.7442 the ED E/M codes payments should look like Figure 1.

Split or Shared Services

CMS has finalized its policy on split or shared E/M visits by a physician, when the visit is performed in part by a physician and in part by an advanced practice provider (APP) who are in the same group, and when the physician meets certain criteria termed the “substantive portion” of the visit. CMS has accepted new language in the 2024 CPT code set, so the rules are aligned for both CPT and CMS in 2024. CMS is continuing to limit the split or shared concept to E/M codes only, not procedures.

In 2024, the definition of “substantive portion” means more than half the total time spent by both the physician and the APP for the encounter, or a substantive part of the medical decision making. CPT uses the example: the physician made or approved the number and complexity of problems addressed at the encounter (known as COPA) and takes responsibility for the inherent risk of complications and/or morbidity or mortality of patient management; thereby performing two of the three categories of medical decision making and the substantive portion of the visit.

CMS is proposing to allow split/shared visit billing for critical care because it believes the practice of medicine has evolved towards a more team-based approach to care, with greater integration of physicians and APPs into the clinical practice, particularly when care is furnished by clinicians in the same group in the facility setting. Since critical care is a time-based service, CMS requires practitioners to document in the medical record the total time that critical care services were provided and identify the provider who performed the majority of the patient-care time. The physician that provides more than 50 percent of the total time should be the one to report the critical-care code.

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Look for updated FAQ sets in the coming weeks both on the resource-based relative value scale equation and on split or shared services at acep.org/reimbursement-FAQs.

Telehealth

While no new codes were permanently added to the Medicare Telehealth Services list, the new rule finalizes a new process for adding, removing or otherwise changing codes on the list, and creates differential payment based on the place of service.

In this rule, CMS decided to maintain all five ED E/M codes (99281 to 99285). These codes are listed as provisional in Table 11 of the 2024 PFS Final Rule, meaning that they may be reported via telehealth at least through the end of 2024.

Additionally, some observation codes on the list of approved telehealth services are included at least through the end of calendar year 2024:

• Initial Hospital Inpatient or Observation Care—99221 to 99223
• Hospital Inpatient or Observation Care Services, Same Day Admission and Discharge—99234 to 99236
• Discharge from Hospital Inpatient or Observation Care—99238 to 99239

Additional Resources

Resources for these and other topics can be found on the reimbursement section of the ACEP website. Mr. McKenzie can also answer ACEP members’ specific, individual questions at dmckenzie@acep.org.

Dr. Granovsky is President of LogixHealth, an ED coding and billing company, and currently serves as the Course Director of ACEP’s annual Coding and Reimbursement Conferences.

Mr. McKenzie is the reimbursement director at ACEP.