Each summer, CMS (Centers for Medicare & Medicaid Services) releases its proposed physician payment and coding change guidelines for the upcoming year. After gathering feedback from the physician community, CMS published the final rule on November 1, 2022, which either confirmed or modified issues from the initial proposal. The provider comments have the potential to influence CMS to deviate from its original guidelines. It is of utmost importance for healthcare providers and their staff to be aware of the specific items that will be implemented in 2023 and those that CMS has decided not to move forward with. The aspects of the proposed rule that were not implemented for 2023 may signal issues that are still under consideration for 2024. Notably, this year brings significant changes to Evaluation and Management (EM) services, as well as prolonged services, necessitating a complete overhaul in coding practices outside of the office setting. Additionally, there are new criteria for determining prolonged services for Medicare patients. Being well-informed about these updates will be crucial for providers to navigate the evolving landscape of Medicare reimbursement and ensure optimal patient care. Register, https://conferencepanel.com/conference/cms-physician-final-rule-2023

1. Jan Rasmussen
PCS, CPC, ACS-OB, ACS-GI
Professional Coding Solutions
715.595.4278
janrpcs@aol.com
CMS 2023 Final
Rule
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2. • CY 2023 PFS conversion factor is
$33.06
–Decrease of $1.55 to the CY 2022 PFS
conversion factor of $34.61.
–Many E/M services had RVU reductions
from 2022 to 2023 due to category
deletions and combining of categories
2023 Conversion Factor
2

3. • Extended 2021 documentation guidelines to determine a
level of E/M service to all additional EM services i.e.,
hospital inpatient, hospital observation, emergency
department, nursing facility, consults, home services/
residence services and cognitive assessment
– CMS accepted new documentation guidelines and E/M
code changes except for prolonged services.
• Deleted several code categories in conjunction with new
combined EM categories.
• Eliminated codes with same decision making levels.
2023 CPT E/M Changes
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4. • Deleted Hospital Observation Services E/M
codes 99217-99220
• Deleted Domiciliary, Rest Home (e.g., Boarding
Home/Assisted Living), or Custodial Care
Services E/M codes 99324-99238, 99334-
99337, 99339, 99340
• Deleted Consultations E/M codes 99241 and
99251
Deleted Codes and Categories
4

5. • Hospital Inpatient/Observation Care Category
– Codes 99221-99223 and 99231-99233 now include both
inpatient and observation care
– Same day codes 99234-99236 also now apply to both
inpatient or observation care
• New CMS add on code G0316 for inpatient/observation
prolonged service to be reported in conjunction with 99223,
99233 or 99236
– Do not report G0316 for any time unit less than 15
minutes
– Do not report G0316 on the same date of service as
other prolonged services for evaluation and management
codes 99358, 99359, 99418, 99415, 99416)
Combined Categories
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6. • Split shared care may be billed by the provider that
furnishes the substantive portion of a hospital or
nursing facility visit.
• CMS requirements for split shared care in 2023
remain the same as 2022.
– Clinicians who furnish split (or 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
– Initially intended to require time as the determining factor
of “substantive portion” in 2023
Split Shared Care
6

7. • Expanded Medicare coverage for certain colorectal
cancer screening tests by reducing the minimum age
payment limitation to 45 years.
• Expanded the regulatory definition of screening
colorectal cancer tests to include a follow-up after a
Medicare covered non-invasive stool-based
colorectal cancer screening test, 82270 (Cologuard)
and 82272 (hemoccult) returns a positive result.
Colorectal Cancer Screening
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8. • Extended duration of time services are temporarily included
on the telehealth services list during the PHE, but are not
included on a Category I, II, or III basis for a period of 151
days following the end of the PHE
– Category 1: Services that are similar to professional consultations,
office visits, and office psychiatry services that are currently on the
Medicare Telehealth Services List.
– Category 2: Services that are not similar to those on the current
Medicare Telehealth Services List.
– Category 3. Services added to the Medicare Telehealth Services
List during the PHE for which there is likely to be clinical benefit
when furnished via telehealth, but not yet sufficient evidence
available to consider the services for permanent addition under the
Category 1 or Category 2 criteria.
• Continued through the end of CY 2023
Telehealth…
8

9. • Consolidated Appropriations Act, 2023 removed
the 151 day extension and changed the
following end of PHE criteria.
• Three things will occur at the end of PHE
– Some allowed services/flexibilities will end
immediately
– Some services/flexibilities will continue until
12/31/23
– Other services/flexibilities will be continued
until the end of 2024.
Public Health Emergency (PHE)

10. • Medicare Telehealth Services Current List:
https://www.cms.gov/Medicare/Medicare-General-
Information/Telehealth/index.html.
• Services that may be allowed by audio only indicated on
telehealth list.
– Counseling or therapy services with their own specific code
would need to be reported with Modifier -93 such as
• Behavioral health services, AWWs, smoking cessation, MNT, self care
management training, advanced care planning, inpatient consults, diabetes
outpatient self management, chronic kidney disease education, alcohol and
depression screenings etc
– Telephone codes 99441-99443 now on telehealth list and would
need modifier -95 reported on them.
Telehealth…
10

11. • No existing CPT code that specifically describes the work
and potential resources of a clinician who performs
comprehensive, holistic CPM.
– Chronic pain generally defined as persistent or recurring pain lasting
longer than three months
– Often require longer office visit times, longer follow-up coordinating
care with social workers and case managers, mental and behavioral
health support, communications with emergency department
physicians and nurses, and numerous medication adjustments
• Prompt more practitioners to welcome Medicare
beneficiaries with chronic pain
• Expect most services to be billed by primary care providers
Chronic Pain Management
11 11

12. • CMS’s goal to reduce existing barriers to mental health
issues and make greater use of services of behavioral
health professionals, such as licensed professional
counselors (LPCs) and Licensed Marriage and Family
Therapists (LMFTs).
• Currently no separate benefit category under Medicare
statutes that recognizes the professional services of
licensed professional counselors (LPCs) and Licensed
Marriage and Family Therapists (LMFTs).
– Payment for the services of LPCs and LMFTs can only be made
indirectly when an LPC or LMFT performs services as auxiliary
personnel incident to, the services, and under the direct
supervision, of the billing physician or other practitioner.
Behavioral Health Services
12

13. • Increased overall payments non-drug component G2074
for medication-assisted treatment and other treatments
for OUD, recognizing the longer therapy sessions that
are usually required.
– Code description does not state 45 minutes
– Increase the current crosswalk to describing a 45
minute session rather than a 30 minute session
• Allow OTP intake add-on code, G2076 to be furnished
via two-way audio video communications technology
when billed for the initiation of treatment with
buprenorphine and for periodic assessments
• Increase of $24.39 codes G2067-G2075
Opioid Treatment Programs…
13

14. • Permit the use of audio-only communication
technology to initiate treatment with buprenorphine in
cases where audio-video technology is not available
to the beneficiary and all other applicable
requirements are met.
• Clarified OTPs can bill Medicare for medically
reasonable and necessary services furnished via
mobile units in accordance with SAMHSA and DEA
guidance.
– Locality adjustments for services furnished via mobile units
would be applied as if the service were furnished at the
physical location of the registered OTP
Opioid Treatment Programs…
14

15. • Allow direct access for certain diagnostic audiology
services, when appropriate, to an audiologist without
a physician referral by creating a new HCPCS code
(GAUDX).
– New Code GAUDX not in final rule due to comments
received.
– Instead initiated new modifier –AB to be used with codes
already used by audiologists to identify audiology services
furnished without the order of a physician or NPP.
– Establish system edits through usual change management
process to ensure that HCPCS codes billed with modifier –
AB is only paid once every 12 months per each
beneficiary.
Audiology Services
15

16. • Dental services are generally not covered by Medicare.
• Exception: Inpatient hospital services with treatment, filling,
removal or replacement of teeth or structures supporting
the teeth when the patient has an underlying medical
condition or the severity the procedures
• Dental services may be paid as necessary treatment,
performed as part of a comprehensive workup prior to
organ transplant surgery, or prior to cardiac valve
replacement or valvuloplasty procedures, that are
inextricably linked to, and substantially related and integral
to the clinical success of certain other covered medical
services
– Eliminate oral or dental infection prior to the above procedures
Dental & Oral Health Services
16

17. • Finalized an approach for payment of each of 10 synthetic
skin substitutes in the physician office setting for which we
had received a HCPCS Level II coding application,
• Finalized that those products would be payable in the
physician office setting as contractor priced products that
are billed separately from the procedure to apply them.
• Ensure all skin substitute products are assigned an
appropriate HCPCS Level II code
– Currently carrier priced with wide variability
Skin Substitute
17

18. • Requiring Manufacturers of Certain Single-dose
Container or Single-use Package Drugs to
Provide Refunds with Respect to Discarded
Amounts
– Many drugs and biologicals (hereafter referred to as a
drugs) payable under Medicare Part B are dosed in a
variable manner such that the entire amount identified
on the vial or package is not administered to the patient
• Often times, these drugs are available only in single-dose
containers designed for use with a single patient as a single
injection or infusion
Discarded Drugs
18

19. • Now covered in RHC and FQHC chronic
pain management (G3002) and
behavioral health
integration services(G0323) under G0511.
– When CPs and CSWs furnish the services described in HCPCS
code G0323 in an RHC or FQHC, they can bill HCPCS code
G0511.
– May be billed alone or with other payable RHC or FQHC
services
RHC & FQHC
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