July 18, 2024
On July 10, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2025 Medicare Physician Fee Schedule (MPFS) proposed rule. This rule, which CMS issues annually, updates payment policies for services furnished under the MPFS on or after January 1, 2025.
The Agency estimated a CY 2025 conversion factor of $32.36, which is a decrease of nearly 3% from the CY 2024 conversion factor—as such, absent Congressional intervention, general surgery will face a 2.8% cut in Medicare Part B payments.
In the rule, CMS introduced new coding and billing requirements for global surgical packages. The Agency proposed that, in all transfer of care scenarios, practitioners must report the applicable existing transfer of care modifiers for 90-day global surgeries in any case when a practitioner—or a practitioner from the same group practice—expects to furnish only the preoperative (modifier -56), procedure (modifier -54), or postoperative (modifier -55) portions of a global package.
CMS also proposed the establishment of an evaluation and management (E/M) add-on code, GP0C1, when no formal transfer of care occurred to account for resources involved in postoperative care for a global surgical package provided by a practitioner who did not furnish the surgical procedure.
Additionally, CMS intends to expand access for colorectal cancer (CRC) screening by adding coverage for computed tomography colonography and eliminating beneficiary cost-sharing for follow-on colonoscopies furnished after a positive blood-based biomarker test or non-invasive stool-based test.
The Agency also extended several flexibilities for telehealth services through 2025. These include the suspension of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations furnished via telehealth; the waiver allowing practitioners to report their enrolled practice address instead of home address when performing telehealth services from their homes; and the waiver allowing the virtual supervision of residents and auxiliary personnel by a supervising physician in certain clinical scenarios.
The ACS is evaluating these and other proposals to determine the impact on surgery and will submit comments to CMS to help protect surgeons, their practices, and their patients. The rule and related fact sheet are accessible online for public review. Contact regulatory@facs.org with questions.
As part of the MPFS proposed rule, CMS provided annual updates to the Medicare Shared Saving Program (SSP) and 2025 Performance Year of the Quality Payment Program (QPP), which encompasses the Merit-Based Incentive Payment System (MIPS) and participation in Advanced Alternative Payment Models (APMs).
These programs were implemented to incentivize the transition from fee-for-service to value-based care by tying payments to quality and cost. CMS stated that multiple proposals in this rule align with its goal of having all individuals with traditional Medicare in a care relationship with accountability for quality and total cost of care by 2030.
As part of the QPP, CMS proposed various updates to the traditional MIPS, including:
CMS also proposed implementing six new MIPS Value Pathways (MVPs), three of which are relevant to surgical care: ophthalmology, urology, and surgical care. MVPs are a reporting option that includes a subset of measures and activities related to a specific specialty or medical condition to offer a more connected assessment of quality and reduce complexity.
If CMS finalizes these new MVPs, there will be a total of 22 MVPs available for reporting in 2025. While participation in MVPs is currently voluntary, the proposed rule includes a request for information (RFI) as to how the Agency can best achieve full MVP adoption and ultimately sunset traditional MIPS reporting, potentially by 2029.
In addition, the Agency includes proposals for the SSP that intend to drive growth in Accountable Care Organization participation, particularly in rural and underserved areas.
CMS also included an RFI on the potential future development of a model through the CMS Innovation Center to increase engagement of specialists working in ambulatory settings in value-based payment by leveraging the current MVP framework.
The rule and related QPP fact sheet and SSP fact sheet are accessible online for public review. Contact regulatory@facs.org for more information.
CMS also has released the calendar year (CY) 2025 Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule. In this rule, CMS proposed to update OPPS payment rates for hospitals and ASCs that meet applicable quality reporting requirements by 2.6%.
To align with policies introduced in the CY 2025 MPFS rule, CMS proposed several coverage changes for colorectal cancer (CRC) screening services. In addition, CMS proposed to streamline prior authorization (PA) processes and shorten the timeframe under which payors must render PA decisions from 10 business days to 7 calendar days.
The Agency also proposed the addition of several measures to the Hospital Outpatient Quality Reporting (OQR) program and the ASC Quality Reporting (ASCQR) program. Three proposed measures address health equity and social determinants of health, while others reflect patient understanding of key information and patient-reported outcomes.
The rule and related fact sheet are accessible online for public review. Contact regulatory@facs.org with for more information.
The Office of the National Coordinator for Health Information Technology (ONC) released the Health Data, Technology, and Interoperability: Patient Engagement, Information Sharing, and Public Health Interoperability (HTI-2) proposed rule on July 10.
This proposed rule includes provisions for new and revised standards and certification criteria in the ONC Health IT Certification Program, such as an update to elements within the United States Core Data for Interoperability; standards and criteria related to e-prescribing and public health exchange; and expand the use of Application Programming Interface (API) technology in electronic prior authorization, access to billing and payment transactions, and public health exchange.
Finally, the HTI-2 rule includes proposals to provide further clarification around information blocking regulations.
The ACS is evaluating these and other proposals to determine the impact on surgery and will submit comments to ONC. The rule and related fact sheet are accessible online for public review. Contact qualityDC@facs.org for more information.
On June 28, the US Centers for Medicare & Medicaid Services (CMS) announced that the Final Score Preview period for the 2023 Merit-Based Incentive Payment System (MIPS) performance period is now open. As a reminder, final scores for the CY 2023 MIPS performance period (2023 final scores) will determine 2025 MIPS payment adjustments.
During this period, MIPS participants and/or authorized representatives may review both the data associated with the final score attributed to the individual clinician, group, virtual group, subgroup, or APM entity, and the data required to calculate the final score, including:
The Final Score Preview does not include any payment adjustment information but will include the supplemental reports for administrative claims-based measures for the quality and cost performance categories. Additionally, clinicians should note that scores may change prior to the release of the Final Performance Feedback in August if CMS identifies any issues during the preview period that require system-wide scoring changes.
To access their Final Score Preview information, surgeons should:
The ACS encourages clinicians to review their Final Score Previews as soon as possible to identify any potential errors with the data displayed. If you believe there is an issue with the information, contact the QPP Service Center at 1-866-288-82398 (TRS: 711) or at QPP@cms.hhs.gov.
Final Score Preview FAQs and 2023 Final Score Preview Supplemental Reports are available for more information. You also can contact qualityDC@facs.org.
The 2024 Annual Meeting of the American Medical Association (AMA) House of Delegates (HOD) took place June 7–12, where the ACS played a part in significant actions that will shape the future of healthcare.
The AMA HOD elected Bobby Mukkamala, MD, FACS, an otolaryngologist—head and neck surgeon from Flint, Michigan, as president-elect.
Following his first year as Vice-Speaker of the AMA HOD, John Armstrong, MD, FACS, was re-elected for a second 1-year term. In this capacity, he is instrumental in ensuring the House of Delegates deliberations are inclusive, fair, and complete.
Four additional Fellows were endorsed by the ACS in competitive elections for Board of Trustee and Council positions. All four surgeons won positions in their respective offices:
The ACS looks forward to greater collaboration with its endorsed candidates to further critical issues affecting surgeons and their patients.
Daniel Dent, MD, FACS, declared his candidacy for a position on the AMA Council on Medical Education at the next AMA HOD Annual Meeting. We look forward to supporting Dr. Dent in his efforts to further advocate for improvements to quality patient care and surgical issues.
The ACS delegation to the AMA consists of Jacob Moalem, MD, FACS (Chair); Dr. Armstrong; Ross Goldberg, MD, FACS; Leigh Neumayer, MD, MBA, MA, FACS; Naveen Sangji, MD, MPH; Kenneth Sharp, MD, FACS; Daniel Dent, MD, FACS; Michael Visenio, MD, MPH; and Luke Selby, MD, MS, FACS.
With ACS staff support, the delegation studied and debated content regarding 202 resolutions and 72 council reports, totaling over 1,800 pages of material. These items of business were grouped and subdivided by theme into reference committees pertaining to Bylaws, Legislation, Medical Education, Public Health, Science and Technology, Finance and Governance, and Medical Practice.
The delegates actively participated in crafting and shaping AMA policy to align with ACS policy through active involvement in specialty and state-specific caucuses, Reference Committee hearings and HOD’s Business Sessions.
The ACS delegation testified in the reference committees regarding policies affecting:
Resolution 116, “Increase Insurance Coverage for Follow-Up Testing After Abnormal Screening Mammography,” established AMA support for public and private payer coverage for additional screening and follow-up testing after an abnormal screening mammography.
The delegation also spoke on Resolution 118, “Public and Private Payer Coverage of Diagnostic Interventions Associated with Colorectal Cancer Screening and Diagnosis,” putting into place language for adequate payment and the elimination of cost sharing in all health plans for the full range of colorectal cancer screening and all associated costs.
Finally, Resolution 711, “Insurer Accountability When Prior Authorization Harms Patients,” advocated for increased legal accountability of insurers and other payers when delay or denial of prior authorization leads to patient harm.
For the full content of the meeting, refer to the AMA HOD’s page.
The ACS looks forward to continuing its partnership with the AMA and other medical societies to champion the causes that matter most to surgeons and their patients. Fellows who are interested in authoring resolutions with the AMA delegation may contact Cory Bloom at cbloom@facs.org.
Medicare and third-party payor policy and coding changes make it imperative that surgeons and their coding staff have accurate and up-to-date information to protect reimbursements and optimize efficiency. The next in-person ACS/KZA General Surgery Coding Course, August 16-17 at the Loews Vanderbilt Hotel, can help.
ACS members and their staff receive a registration discount, so register today! The Coding Course includes two all-day sessions and up to 6.5 AMA PRA Category 1 Credits™ for each day.
Participants will learn how to properly apply elements of medical decision-making when selecting levels of evaluation and management (E/M) codes; correctly use E/M modifiers; identify key issues in nonphysician practitioner and critical care billing; and accurately code and document common office procedures.
Attendees will learn how to select correct codes for common general surgery procedures; recognize the impact of modifiers on global periods and reimbursement; identify areas for improvement in surgical documentation; and manage precertification and preauthorization.
For more information about the ACS/KZA General Surgery Coding Course, contact KZA or email practicemanagement@facs.org.