The Centers for Medicare and Medicaid Services (CMS) announced its Medicare Physician Fee Schedule (MPFS) Final Rule for 2024, including provisions for both Medicare reimbursement and the Quality Payment Program (QPP).

MPFS Payment Provisions

Reimbursement rates will be calculated by applying the statutory formula as required. This produces a fee schedule Conversion Factor (CF) of $32.7442, which is 3.37% lower than the $33.8872 CF used for the 2023 fee schedule, and slightly lower than the $32.7476 rate included in the Proposed Rule earlier this year. The CF calculation includes a 1.25% upward adjustment provided by the Consolidated Appropriations Act, 2023 (CAA 23) that was passed late in 2022 to help mitigate the effects of the formulaic calculation for 2023 and 2024. Without the CAA 23, the 2024 reimbursement rate would have been even lower. Note that the CAA 23 also included deferral until 2025 of the PAYGO rule that would lower the fee schedule by another 4%.

CMS estimates the following specific effects for radiology, which are unchanged from the Proposed Rule:

These CMS estimates could be understated because the 2023 rate used in their calculation did not include the 1.25% CAA increase, and so it does not match the final payment rate for the year.

According to CMS, approximately 90% of the negative fee schedule adjustment is attributable to activation of a new add-on code G2211 for Evaluation and Management (E/M) complexity. A primary policy goal of G2211 is to reimburse certain physicians, such as family medicine physicians, more appropriately for the care they provide to highly complex patients. The utilization assumption for this new code led to a significant projected increase in spending, yielding an approximate 2% reduction to the CF to maintain budget neutrality. While the CMS-estimated -4% overall impact in IR reimbursement is the biggest cut of any specialty, the CMS-estimated impact for family medicine is +3%.

Practices in some areas will feel the effect of changes to the Geographic Practice Cost Index (GPCI). Our review of the Proposed Rule for 2024 described these changes that will negatively impact 109 payment localities across the country, and the Final Rule did not revise what was contained in the Proposed Rule.

CMS confirmed its plan to suspend the AUC/CDS program that would deny payment to radiologists when the ordering physician fails to consult a Clinical Decision Support (CDS) system to obtain Appropriate Use Criteria (AUC). Accordingly, effective January 1, 2024, AUC consultation information including G-codes and modifiers should no longer be included on Medicare claims. CMS has not specified a timeframe within which implementation efforts will recommence.

As described in the Proposed Rule, direct physician supervision of Level 2 diagnostic exams, such as those requiring contrast administration, will continue to be allowed via real-time audio and video telecommunications through December 31, 2024. Audio-only telecommunication will not be allowed. CMS is considering whether to extend this definition of direct supervision beyond December 31, 2024.

Quality Payment Program (QPP)

Some QPP changes in the Proposed Rule that would have been onerous for radiology were not adopted in the Final Rule.  The performance threshold was proposed to increase from 75 points to 82 points for the 2024 performance year, but it will remain at 75 points. This is the minimum score that must be earned to avoid a payment penalty in the 2026 payment year. Radiology practices will also benefit from the retention for 2024 of Measure #436, “Radiation Consideration for Adult CT: Utilization of dose lowering techniques”, which was proposed to be eliminated. This Quality Measure is highly utilized by radiologists.

The category weighting will remain the same as it was for 2023, however the Data Completeness Threshold will be increased to 75% from 70% of total exam volume. The low-volume threshold criteria that benefits small practices of 15 or fewer clinicians will also remain unchanged for 2024 and the range of payment adjustments (for payment year 2026) will continue to be +/- 9%.

Several other Quality Measures that have been useful to radiologists will be removed for 2024, including:

• Measure #147, Nuclear Medicine: Correlation with existing imaging studies for all patients undergoing Bone Scintigraphy
• Measure #324, Cardiac Stress Imaging not meeting appropriate use criteria: Testing in asymptomatic, low-risk patients

One new measure will be added to the diagnostic radiology set beginning with performance year 2025:

• Measure #494: Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults.

Although five (5) new Improvement Activities will be added and three (3) removed, none of these will affect radiology. The Cost Category will have episode-based Low Back Pain added as a measure for 2024. The Promoting Interoperability performance period has been extended from 90 to 180 days, consistent with the Proposed Rule.

MIPS Value Pathways (MVP) are generally not an option for radiology practices as there are too few of them that are applicable. A minimum of 6 MVP measures are required for reporting, but there are only 4 currently available that are relevant to radiology. CMS is including five new MVPs for the 2024 performance year, none of which will be useful for radiology practices.

Complete information on the proposed changes to the QPP is available for download from CMS.

Possible Legislative Remedies

Our recent article reported on a study published August 31, 2023 in the Journal of the American College of Radiology which found that, “Between 2005 and 2021, the conversion factor declined 7.9%, and when adjusted for inflation, it declined 33.6%”. Additionally, the study concluded, “From 2005 to 2023, the inflation-adjusted conversion factor declined 43.1%”. A bill introduced in Congress, H.R. 2474, the Strengthening Medicare for Patients and Providers Act that now has 56 cosponsors, would permanently improve the methodology used in the calculation of the conversion factor for Medicare reimbursement. H.R. 2474 has bipartisan support in the House. Contact your representative and urge them to support H.R. 2474 by becoming a co-sponsor. For the most impact, be sure to have every member of your group contact their representative, and don’t forget to include the members of your management team as well.

Buried deep inside a Senate Finance Committee Discussion Draft released November 2 is Section 407 that would modify the 2024 conversion factor calculation. As mentioned above, the CAA 23 provided an increase of 1.25% to the 2024 CF; the Senate Discussion Draft would make that increase 2.50% instead. If it is introduced and passes, this bill would have the effect of making the CF $33.1485 rather than $33.7442. The decrease from 2023 would then be 2.18% instead of 3.37%.

The American Medical Association has a useful website, "Fix Medicare Now", that provides an easy way for you to send a message to Congress.

Conclusion

While radiology averted some big negatives in the QPP, Medicare payments will nonetheless continue to decline in 2024. Since many commercial payers tie their reimbursement to the Medicare fee schedule, whether immediately or at some future date, the impact will ultimately become more widespread than it might first appear. The full effect on your practice will depend on your modality mix, because individual procedure values are also adjusted upward or downward each year. We will continue to analyze the valuation changes using the published RVU tables and keep our readers apprised of the latest information. Subscribe to this blog for the latest information. 

Sandy Coffta is the Vice President of Client Services at Healthcare Administrative Partners.

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Why Support for H.R. 2474 Is Important to Your Radiology Practice

Radiology Practices Struggle to Avoid Penalties in the Medicare Quality Payment Program

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