The Centers for Medicare and Medicaid Services (CMS) released the 2024 Medicare Physician Fee Schedule (PFS) final rule on Nov. 2. Of note, the 2024 PFS conversion factor is $32.7442, reduced 3.37% from $33.8872 in 2023. Overall reimbursement for cardiovascular services is projected to remain flat compared with 2023, with changes to policies and individual services roughly balancing out. Individuals and groups will see different impacts depending on patient populations and services offered.

The confluence of conversion factor cuts for budget neutrality, statutory cuts on the horizon from sequestration 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. (See below for opportunities to engage on this issue.)

The final rule also addresses Appropriate Use Criteria (AUC), split-shared billing rules, telemedicine flexibilities extensions, the G2211 outpatient/office E/M visit complexity add-on HCPCS code, new and revised CPT code valuations, and a new Heart Failure Cost Measure along with numerous updates to the Medicare Shared Savings Program (MSSP), Merit Based Incentive Payment System (MIPS) and Quality Payment Program (QPP).

Other notable cardiovascular-related highlights include:

• Implementation of the AUC Program is paused indefinitely and current AUC program regulations are rescinded, aligning with feedback provided by the ACC. CMS indicates it will continue efforts to identify a workable approach to implement the program, which would be proposed in subsequent rulemaking.
• Regarding split/shared billing, CMS walked back its prior plan to require the clinician who spent the most time with the patient to report the service. It instead finalized a change in its definition of “substantive portion” of a split/shared service to match that of the revised CPT E/M definition.  That definition now allows “more than half of the total time spent by the physician and NPP performing the split (or shared) visit, or a substantive part of the medical decision making (MDM) as defined by CPT” to determine which clinician can bill the service. This nullifies the prior, postponed policy that would have eliminated MDM as a deciding factor in billing. 
• Final work relative value units (RVUs) and practice expense inputs for new and revised codes are included in the final rule, which will determine payment rates in 2024 and can be found in these various addenda tables. New or revised cardiovascular-related codes include: 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. An updated calculator tool will be available soon.
  • Codes for Venography of venovenous collaterals originating above and below the heart had their work RVUs lowered by CMS in the proposed rule but were finalized at the RUC-recommended work RVUs in response to comments from the ACC, Society for Cardiovascular Angiography and Interventions and others.
  • CMS had proposed significant reductions to all five new Intra-Operative Ultrasound codes. Following comments from the ACC and other stakeholders, two of the five (76987, 76988) were finalized at the RUC-recommended work RVUs. The remaining three (79684, 76998 and 76989) were finalized at the reduced work RVUs that CMS initially proposed. 
  • All other cardiovascular work RVUs were finalized at the proposed amounts, which were consistent with RUC recommendations.
• CMS finalized its proposal to change the status of the G2211 Office/Outpatient E/M Visit Complexity Add-on HCPCS code to “active” effective Jan. 1, 2024. Despite comments from ACC and others warning that the code was vaguely defined and the estimated utilization was too high, no changes were made to the utilization assumptions or code definition. This change drives a significant portion of the budget neutrality conversion factor reduction.
• Starting Jan. 1, 2024, advanced practice practitioners may supervise cardiac rehabilitation, intensive cardiac rehabilitation and pulmonary rehabilitation. CMS finalized 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

• The final rule implements several telehealth-related provisions of the Consolidated Appropriations Act, 2023 that will 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 provisionally on the Medicare Telehealth Services List.
• Direct supervision will include 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.
• Teaching physicians may 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 did not add these services 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.
• Through CY 2024, CMS will continue to permit a distant site practitioner to use their currently enrolled practice location instead of their home address when providing telehealth services from their home. CMS will consider this issue further in future rulemaking.

2024 QPP Performance Period

CMS finalized several updates to the QPP and MSSP for 2024. Highlights include:

• The addition of five new MIPS Value Pathways (MVPs) to be available with the 2024 performance year, along with revisions to all previously finalized MVPs. The new 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.
• CMS modified the previously finalized Advancing Care for Heart Disease MVP within the quality performance category to include four additional MIPS quality measures. 
• The performance threshold will remain at 75 points for the 2024 performance period. CMS initially proposed an increase to 82 points. 
• Minor changes to the Cost, Quality, Improvement Activities and Promoting Interoperability performance categories have been finalized. 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 finalized a total of 198 quality measures, down from the proposed 200, for the 2024 performance period by addressing changes to 59 existing MIPS quality measures, partial removal of three quality measures, removal of 11 quality measures, and the addition of 11 quality measures.
• Finalized measure additions for cardiovascular care include: Episode-Based Heart Failure (Cost Category); Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography in Adults (Clinician Level), to be implemented in performance year 2025; Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument. One measure was finalized for removal due to its topped-out status: Cardiac Stress Imaging Not Meeting AUC: Testing in Asymptomatic, Low-Risk Patients.
• CMS finalized the elimination of the health information technology (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 updated qualified registry and QCDR self-nomination and approval policies for CY 2024.
• CMS finalized a delay of the mandatory electronic clinical quality measure (eCQM) adoption by MSSP participants who can continue to use the CMS web interface in 2024. New participants in MSSP can choose to use eCQMs under the Alternative Payment Model Performance Pathway. 
• CMS will apply a symmetrical cap to risk score growth in an Accountable Care Organization’s regional service area to mitigate the impact of negative regional adjustments on benchmarks beginning Jan. 1, 2024.
• CMS initially proposed to remove the Shared Savings Program Certified Electronic Health Record Technology (CEHRT) threshold requirements beginning performance year 2024. This proposal has been finalized with a modification to delay the implementation of CEHRT threshold requirements until the 2025 performance year and for subsequent years. 

Additional information on the rule can be found in the Medicare PFS Press Release, Medicare PFS Fact Sheet, MSSP Fact Sheet and the QPP Fact Sheet. Look for updated information on ACC.org/Advocacy and in upcoming issues of The Advocate newsletter.