The Centers for Medicare and Medicaid Services (CMS) on July 13 released the 2024 Medicare Physician Fee Schedule (PFS) proposed rule, addressing Medicare payment and quality provisions for physicians in the coming year. Under the proposal, physicians will see a decrease to the conversion factor of 3.36% on Jan. 1, 2024, going from $33.8872 to $32.7476. CMS projects that overall reimbursement for cardiovascular services will remain flat compared to 2023, with changes to policies and individual services roughly balancing out. This estimate is based on the entire cardiology profession and can vary widely depending on the mix of services provided in a practice.

The confluence of conversion factor cuts for budget neutrality, statutory cuts on the horizon from sequestration and PAYGO rules and a 0% payment update that fails to account for significant inflation in practice costs, creates long-term financial instability in the Medicare physician payment system, threatening patient access to Medicare-participating physicians and services.

The ACC, along with other medical societies, has aligned with the American Medical Association on a set of principles to guide advocacy efforts on Medicare physician payment reform. The ACC strongly supports H.R. 2474, the Strengthening Medicare for Patients and Providers Act, which would provide a permanent, annual update equal to the increase in the Medicare Economic Index, allowing physicians to invest in their practices and implement new strategies to provide high-value care.

The ACC will also continue its ongoing work to explore approaches that promote health care system stability and foster a successful, widespread transition to value-based care, reflecting the needs of cardiovascular patients and clinicians in every setting. Visit the ACC's grassroots page for ways to advocate for the financial stability of physician practices and preserving Medicare beneficiaries' access to care.

Highlights from the proposed rule regarding payment policy, rate setting, and quality provisions include:

Physician Fee Schedule

• A proposal to pause implementation of the Appropriate Use Criteria (AUC) Program for reevaluation and to rescind the current AUC program regulations. CMS will continue efforts to identify a workable approach, which may be proposed in subsequent rulemaking.
• A proposal to further delay implementation of the split/shared billing changes, allowing history, exam, medical decision making or time to determine who bills the visit. CMS proposes to postpone implementation of prior changes through at least Dec. 31, 2024. The prior proposal would have redefined the definition of "substantive portion" to mean more than half of the total time. Clinicians who furnish split/shared visits will continue to have a choice of history, physical exam, or medical decision making, or more than half of the total practitioner time spent to define the substantive portion, instead of using only total time.
• Inclusion of work and/or practice expense (PE) values for new/revised codes describing Venography Services for Congenital Heart Defects, Phrenic Nerve Stimulation System implantation, removal, and programming, Fractional Flow Reserve Computed Tomography, Intravascular Lithotripsy and Intra-Operative Ultrasound. More information is available in supporting data tables.
• A proposal to implement a separate add-on code and payment for enhanced visit complexity of primary care and longitudinal care of complex patients. G2211 would generally be applicable to outpatient office visits as an additional payment, recognizing the costs clinicians may incur when longitudinally treating a patient's single, serious or complex chronic condition. If finalized, establishing payment for this add-on code would have redistributive impacts for all other calendar year 2024 payments. While those effects are less than estimated for this policy when first proposed for 2021, it still drives a significant portion of the proposed conversion factor reduction.
• Starting Jan. 1, 2024, advanced practice practitioners may supervise cardiac rehabilitation, intensive cardiac rehabilitation, and pulmonary rehabilitation. CMS proposes new regulations implementing the statutory changes made by the ACC-backed Improving Access to Cardiac and Pulmonary Rehabilitation Act that passed as part of the Bipartisan Budget Act of 2018.

Telehealth Provisions and Inflation Reduction Act Implementation

• A proposal to implement several telehealth-related provisions of the Consolidated Appropriations Act, 2023 that would be in effect until Dec. 31, 2024.
• Policies in place until Dec. 31, 2024 include the temporary expansion of telehealth originating sites for services furnished via telehealth to include any site in the U.S. where the beneficiary is located at the time of the telehealth service, including an individual's home; delaying the requirement for an in-person visit with the physician or practitioner within six months prior to initiating mental health telehealth services; and the continued coverage and payment of telehealth services included on the Medicare Telehealth Services List.
• A proposal to continue defining direct supervision to permit the presence and immediate availability of the supervising practitioner through real-time audio and video interactive telecommunications through Dec. 31, 2024, to avoid an abrupt transition at the end of 2023.
• A proposal to allow teaching physicians to use audio/video real-time communications technology when the resident furnishes Medicare telehealth services in all residency training locations through Dec. 31, 2024.
• After consideration of requests to permanently add cardiovascular and pulmonary rehabilitation services to the Medicare Telehealth Services List, CMS does not propose making those additions because the submissions emphasized the utility of the services in patients' homes, a flexibility that will not exist beyond 2024 absent a change in statute.
• Telephone E/M codes 99441-99443 and 98966-98968 will remain actively priced through 2024 under flexibilities included in the Consolidated Appropriations Act, 2023.
• A proposal to extend current Opioid Treatment Programs flexibilities for periodic assessments that are furnished via audio-only telecommunications through the end of CY 2024.

2024 Quality Payment Program Performance Period

CMS is proposing several updates to the Quality Payment Program (QPP) and Medicare Shared Savings Program for 2024. Highlights include:

• The addition of five new proposed MIPS Value Pathways (MVPs) to be available with the 2024 performance year, along with revisions to all previously finalized MVPs. The newly proposed MVPs are: Focusing on Women's Health, Quality Care for the Treatment of Ear, Nose and Throat Disorders, Prevention and Treatment of Infectious Disorders Including Hepatitis C and HIV, Quality Care in Mental Health and Substance Use Disorders, and Rehabilitative Support for Musculoskeletal Care.
• Modifying the previously finalized Advancing Care for Heart Disease MVP within the quality performance category to include four additional MIPS quality measures.
• An increase in the performance threshold from 75 to 82 points. This modest increase would be applicable to all three MIPS reporting options (traditional MIPS, MVPs, and the APP).
• Minor changes to the Cost, Quality, Improvement Activities and Promoting Interoperability performance categories have been proposed. For the CY 2024 performance period/2026 MIPS payment year, the scoring weights are as follows: 30% for the quality performance category; 30% for the cost performance category; 15% for the improvement activities performance category; and 25% for the Promoting Interoperability performance category.
• CMS proposes a total of 200 quality measures for the 2024 performance period by addressing changes to 59 existing MIPS quality measures, partial removal of three quality measures from the MIPS quality measure inventory, removal of 12 quality measures, and the addition of 14 quality measures.
• Proposed measure additions include: Episode-Based Heart Failure (Cost Category); Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults (Clinician Level); Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument. One measure is proposed for removal due to its topped-out status: Cardiac Stress Imaging Not Meeting AUC: Testing in Asymptomatic, Low-Risk Patients.
• A proposal for several Requests for Information seeking feedback on the future of MVPs, the alignment across QPP and the Medicare Shared Savings Program, and recommendations on publicly displaying data on Care Compare.
• A proposal to eliminate the health IT vendor category of third-party intermediaries, beginning with the CY 2025 performance period. Instead, CMS would require health IT vendors who wish to submit data on behalf of clinicians to meet the requirements and self-nominate as a qualified registry or qualified clinical data registry (QCDR). CMS also proposes updating qualified registry and QCDR self-nomination and approval policies for CY 2024.
• A proposal to establish the Medicare Clinical Quality Measures (CQMs) for Accountable Care Organizations (ACOs) Participating in the Medicare Shared Savings Program as a new collection type for Shared Saving Program ACOs under the Alternative Payment Model (APM) Performance Pathway (APP).
• A proposal to apply a symmetrical cap to risk score growth in an ACO's regional service area to mitigate the impact of negative regional adjustments on benchmarks beginning Jan. 1, 2024.
• A proposal to add a third step to the beneficiary assignment methodology to recognize nurse practitioners, physician assistants and nursing specialists in delivering primary care services.
• A proposal to include a new track to the Shared Savings Program that offers a higher level of risk and reward, currently included in the ENHANCED track. This new track will refine the three-way benchmark update factor and the prior savings adjustment and focus on increasing collaboration between ACOs and community-based organizations.
• A proposal to remove the Shared Savings Program Certified Electronic Health Record Technology threshold requirements beginning performance year 2024. Instead, CMS proposes adding a new requirement that all MIPS eligible clinicians, Qualifying APM Participants (QPs), and Partial QPs participating in an ACO, regardless of track, are to report the MIPS Promoting Interoperability (PI) performance category measures and requirements for performance years beginning on or after Jan. 1, 2024.

Additional information on the rule can be found in the Medicare PFS Press Release, Medicare PFS Fact Sheet, Medicare Shared Savings Program Fact Sheet, and QPP Fact Sheet. ACC Advocacy staff will continue to provide more detailed information on elements of the proposed rule in the weeks ahead and develop comments for submission within the 60-day comment period. Look for updated information on ACC.org/Advocacy and in upcoming issues of The Advocate newsletter. For more on the Medicare PFS regulatory process, access ACC's Physician Fee Schedule Roadmap.

Not long before the final rules are released in the fall, experts will discuss federal legislative and regulatory topics at ACC Legislative Conference 2023 on Oct. 15-17 in Washington, DC. Don't miss this opportunity to learn about hot button issues facing cardiologists and to ensure the voice of cardiology is heard on Capitol Hill. Access online registration here.

Clinical Topics: Noninvasive Imaging, Angiography, Nuclear Imaging

Keywords: ACC Advocacy, United States, Centers for Medicare and Medicaid Services, U.S., Medicare, Area Under Curve, Medicaid, Outpatients, Fee Schedules, Physicians, Policy, Decision Making, Phlebography, Fractional Flow Reserve, Myocardial, Cardiology, Office Visits, Lithotripsy, Health Services Accessibility, Internship and Residency, Telemedicine, Analgesics, Opioid, Telephone, Pregnancy, Benchmarking, Cardiologists, Heart Disease Risk Factors, Feedback, Pharynx, Community Health Services, Registries, Heart Diseases, Reward, Postpartum Period, Postpartum Period, Electronics

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