Medicare Physician Fee Schedule Expands Access to Comprehensive & Coordinated Care
Earlier this month, CMS released the final 2024 Medicare physician fee schedule (PFS), a rule that describes policies as of January 2024 that will be used by Medicare to reimburse physicians and other providers.
With annual updates, the PFS is intended to maintain care standards and drive health policy changes. This year’s rule does just that, for the first time recognizing social care’s importance as part of health care to improve Medicare beneficiary health. CMS is finalizing several provisions - summarized below and in this CHaSCI slide deck - that will advance health equity by enabling more care teams across the country to provide social care.
“We believe that social workers, CHWs, and [others] are currently performing some of these activities and that the resources involved in these activities are not consistently appropriately reflected in current coding and payment policies.
As such, we believe it would be appropriate to create codes to separately identify and more accurately value this work. ”
Developments from the CY2024 PFS that support comprehensive and coordinated care include:
Social Determinants of Health (SDOH) Risk Assessment: For the first time, Medicare will reimburse clinics for screening patients for social needs using a validated tool, much like it reimburses for depression screening. This will help clinics plan a sustainable way to screen their patients every six months.
Community Health Integration (CHI) and Principal Illness Navigation (PIN): To help clinics respond to reported social needs and provide care coordination, Medicare created new HCPCS codes to describe a set of interventions provided by team members under general supervision of a physician or other billing provider. These are a big deal for clinics working to integrate staff or partners who provide social care - including social workers and community health workers - onto their primary care and outpatient specialty care teams! Each of the codes recognizes work when there are 60 minutes or more of qualifying time spent with or on behalf of a given beneficiary in one single calendar month.
Health Behavior Assessment and Intervention (HBAI) Services: HBAI Services are a set of CPT codes that describe services to help patients manage physical health problems. The focus of the assessment and intervention is on factors complicating medical conditions and treatments, including behavioral and social factors. These are key payment mechanisms to support health equity interventions, yet utilization has been very low historically due to Medicare only recognizing clinical psychologists as eligible providers. In this final rule, CMS is expanding access to HBAI services by recognizing clinical social workers, marriage and family therapists, and other mental health counselors. CHaSCI is working closely on implementation best practices; please reach out if you are interested in collaborating!
Caregiver Training Services: In recognition of the importance of training and supporting family caregivers to Medicare beneficiary health, Medicare will now reimburse for individual and group caregiver training services when delivered under a therapy plan of care from a physician, nurse practitioner, physician assistant, clinical nurse specialist, clinical psychologist, physical therapist, occupational therapist, or speech-language pathologist. Note that clinical social workers are not eligible.
Mental health services valuation: CMS finalized a 19.1% increase in valuation and reimbursement for psychotherapy and HBAI services from 2024-2028.
Helpful Links:
Read more about each of these developments in this overview slide deck, including details on the CPT codes and specific pages to reference in the final rule.
See the full physician fee schedule.
Contact us if you’d like to talk further!