Medical coding: the basics of CPT® |
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In the second installment of our series on medical coding, we consider Current Procedural Terminology.
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Current Procedural Terminology (CPT®) comprises nearly 11,000 five-digit alphanumeric descriptors which succinctly represent medical procedures. From routine check-ups to complex surgeries, CPT codes are essential to medical documentation in the United States.
CPT facilitates the exchange of information between healthcare professionals. It allows for the identification of trends in medical treatment, provides the basis for spending comparisons, and enables the study of variations in access to treatment options by geographic region and socioeconomic class.
Perhaps most importantly, CPT serves as the linchpin in communication between healthcare providers and payers, ensuring that services rendered can be accurately documented and billed and that providers are properly reimbursed.
The American Medical Association, which maintains and holds the copyright on CPT, describes it as "the language of medicine today." And, like any language, CPT has its nuances and complexities.
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Applied Policy's latest rules summaries |
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CMS proposes CY 2025 policy changes for Medicare Advantage and Part D plans impacting patient protections, utilization management, and formularies |
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On November 6, 2023, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Program: Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly; Health Information Technology Standards and Implementation Specifications (CMS-4205-P). The proposed rule contains policies for Medicare Advantage (MA) and Medicare Part D plans in contract year (CY) 2025.
The policies proposed in this new rule include:
- New MA and Part D plan agent and broker compensation policies to guard against anti-competitive and anti-consumer steering,
- Improvements in MA plan enrollee access to behavioral health care providers,
- Requirement of MA plan mid-year enrollee notifications for available supplemental benefits,
- New standards for MA special supplemental benefits for the chronically ill (SSBCI),
- Requirement that MA plans incorporate health equity into their analyses of utilization management (UM) policies and procedures,
- Improvements in MA beneficiary access to fast-track appeals currently available to traditional Medicare beneficiaries, and
- Changes to the current quarterly special enrollment period (SEP) and creation of a new integrated care SEP to increase the number of dually eligible MA plan enrollees who are in plans that also cover Medicaid.
CMS has not yet addressed all proposals from its prior December 14, 2022 proposed rule (CMS-4201) and has indicated that it intends to address several remaining provisions in future rulemaking, including in the final version of this rule. Specifically, CMS does not address its previously outlined proposals for new Part D plan formulary flexibility regarding immediate formulary substitutions for interchangeable biological products, authorized generics, and unbranded biological products or the addition of new requirements for Part D Medication Therapy Management (MTM) programs to improve patient access.
The rule will be published in the Federal Register on November 15, 2023. Comments are due January 5, 2024.
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CMS finalizes payment cuts for physicians in 2024, updates several payment policies (CMS-1784-F) |
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On November 2, 2023, CMS issued the final calendar year 2024 Physician Fee Schedule, which finalizes policies for physician payment and other outpatient services covered under Medicare Part B.
The rule finalizes the following:
- Decrease the conversion factor for 2024 by 3.4 percent from the conversion factor for 2023,
- Extend pandemic era telehealth policies through December 31, 2024, as mandated by Consolidated Appropriations Acts of 2023,
- Clarify who can provide outpatient therapy, Diabetes Self-Management Training (DSMT) and Medical Nutrition Therapy (MNT) telehealth visits and expand DSMT telehealth access,
- Update caregiver training services,
- Expand coverage of diabetes screening tests to include HbA1c test,
- Relax direct supervision requirements for certain provider types and services,
- Create a new code, G0136, for social determinants of health risk assessment,
- Update the Quality Payment Program, including changes to the Merit-based Incentive Payment System Value Pathways (MVPs),
- Revise the provider and supplier Medicare enrollment requirements,
- Update vaccine administration payment,
- Clarify policies regarding COVID-19 vaccine and monoclonal antibody products,
- Add polices to implement required manufacturer refunds for discarded drugs,
- Codify previously finalized covered dental services, and
- Responds to comments on request for information on digital therapeutics.
This final rule is scheduled to be published in the Federal Register on November 16, 2023.
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CMS releases Final Hospital Outpatient and Ambulatory Surgical Center Update for CY 2024 (CMS-1786-FC) and Final Remedy for the 340B-Acquired Drug Payment Policy for calendar years 2018-2022 (CMS 1793-F) |
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On November 2, 2023, CMS issued the Hospital Outpatient Prospective Payment (OPPS) and Ambulatory Surgical Center (ASC) Payment Systems final rule with comment period, which finalizes updates to the OPPS and the Medicare ASC payment system for calendar year 2024.
CMS additionally issued the Hospital Outpatient Prospective Payment System: Remedy for the 340B-Acquired Drug Payment Policy for Calendar Years 2018-2022 Final Rule, addressed in the 340B section of Applied Policy’s summary.
The OPPS and ASC rule also solicits comment on behavioral health topics under consideration for measure development.
The finalized policies in the OPPS and ASC final rule are effective January 1, 2024. Comments on the rule are due January 1, 2024.
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CMS finalizes payment update for home health agencies & changes to DME policies in CY 2024 |
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On November 1, 2023, CMS released the calendar year 2024 final payment rule for home health agencies (HHAs). The final rule includes the annual payment update and changes to the home health quality reporting program and value-based purchasing model. The final rule also includes provisions on durable medical equipment, prosthetics and orthotics supplies as well as provider and supplier enrollment requirements. |
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CMS finalizes payment increase for ESRD facilities in CY 2024, new add-on payment adjustments, and quality reporting program changes |
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On October 27, 2023, CMS issued the End-Stage Renal Disease (ESRD) Prospective Payment System final rule for calendar year 2024. This rule finalizes the following changes:
- Increases ESRD payment rates by 2.1 percent,
- Finalizes a new transitional add-on pediatric ESRD dialysis payment adjustment,
- Finalizes a payment adjustment for certain new renal dialysis drugs and biological products after the Transitional Drug Add-on Payment Adjustment (TDAPA),
- Makes several changes to the ESRD Quality Incentive Program, and
- Makes additional changes to the ESRD Treatment Choices Model.
This rule is scheduled to be published in the Federal Register on November 6, 2023, and is effective January 1, 2024.
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Carl Mallory named VP of Healthcare Services |
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Applied Policy has announced the appointment of Carl Mallory as Vice President of Healthcare Services, effective November 1.
In addition to leading the company's Healthcare Services vertical, Mallory will provide independent executive leadership to manage client relationships, including working with C-suite contacts to develop strategy and tactics to address client needs.
“Carl’s extensive experience in both the public and private sectors makes him uniquely qualified for this role,” said Applied Policy President and CEO Jim Scott.
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Carl was most recently Vice President of Government Relations for Mercy Health System, where he was responsible for directing the government relations team. In this role, he focused on developing and implementing strategies, tactics, and activities to address federal, state, and local government-driven legislation, advocacy, policy, and regulatory affairs for 40 acute care hospitals, 345 clinics, 900 physician groups, 35 urgent care sites, and four heart hospitals with 45,000 co-workers in eight states.
Prior to his work with Mercy, Carl served as Deputy Commissioner and Chief Operating Officer with the State of Tennessee Department of Health. During his tenure, he was responsible for the budget, human resources, information technology systems, facilities management, and safety and security for 126 clinics in 95 counties.
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Applied Policy welcomes additional intern |
Applied Policy's fall intern class has increased to four with the addition of Tangala Nore.
Tangala holds a master’s degree in healthcare administration and is currently pursuing a Ph.D. in healthcare administration with a specialization in healthcare policy and advocacy at Capella University.
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Tangala's 17 years’ experience in healthcare and policy includes an internship as an agency liaison for the Executive Office of the President at the White House.
Tangala expects that her internship with Applied Policy will give her a better appreciation for the practical application of health policy and prepare her for her long-term career goal of a policy position at the White House or on Capitol Hill.
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Native American participation in medical research |
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As the United States observes Native American Heritage Month in November, we consider the causes and implications of underrepresenting American Indians and Alaskan Natives in clinical research and examine strategies for addressing this deficit. |
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Disparities in Native American health are well documented. American Indians (AI) and Alaskan Natives (AN) have higher rates of diabetes and heart disease than other Americans and an average life expectancy 10 years shorter than the U.S. average.
Despite these critical issues, AI/AN populations continue to be significantly underrepresented in biomedical research—even for treatments for conditions which disproportionately impact them.
A variety of factors contribute to this disparity. Healthcare providers serving Native populations are often unaware of research opportunities. Tribal members living in rural locales may not be able to overcome the challenges of distance and transportation access. Clinics serving urban AI/AN populations may not be affiliated with research groups.
The most significant barrier to AI/AN participation may be a legacy of cultural misunderstandings and distrust.
Many Tribes have experienced or witnessed violations of trust in medical research. In the Havasupai diabetes project, for example, academic researchers used blood originally collected for diabetes research from members of the Havasupai Tribe in subsequent, unrelated studies. Participating Tribal members did not knowingly consent to the use of their blood for additional studies, and some of the subsequent research topics, such as schizophrenia, were considered culturally taboo.
One genetic study based upon the collected blood samples suggested that the Tribe’s ancestors had originally migrated from Asia. This publicly challenged the Havasupai’s religious belief that they had originated in their Grand Canyon home and been entrusted with its care.
Securing AI/AN participation in medical research after violations of trust is not easy, but it is essential for reducing health disparities and moving towards health equity.
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The Medicare Payment Advisory Commission (MedPAC) held a virtual public meeting on October 5, 2023. The meeting included sessions on considering current law updates to Medicare’s payment rates for clinician services, examining staffing ratios and turnover rates in nursing facilities, an alternative method to establish Medicare payments for select conditions treated in inpatient rehabilitation facilities, and its workplan for prices of generic drugs under Part D. |
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CMS allows for 90-day billing for CGM supplies |
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On October 19, CMS issued a Change Request (CR) instructing Durable Medical Equipment Medicare Administrative Contractors (DME MACs) to make adjustments to their local edits to allow for continuous glucose monitor (CGM) supplies to be billed in 90-day increments.
The change comes six months after the DME MACs implemented expanded coverage for CGMs.
The CR will become effective on January 1, 2024.
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Applied Policy completes media training |
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Applied Policy team members recently completed a media training with communications consultant Louisa Hart.
The session emphasized the importance of maintaining mutually respectful relationships with members of the media and included strategies for remaining "on message" in interviews.
Hart, who previously worked as a producer for DC-based television news programs, observed that Applied Policy's expertise in health policy and reimbursement makes it a trusted source for reporters seeking background on and understanding of health policy issues.
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"People recognize the depth of this team," she said. "Whether it is Jim's (Scott) work drafting the Medicare Prescription Drug, Improvement and Modernization Act, John's (Voorhees) leadership at CMS, or Alison's (Falb) experience at the Food and Drug Administration, Applied Policy has an invaluable understanding of legislative and regulatory environments. Journalists know that they can turn to you for honest and accurate information."
In the course of the training, Hart acknowledged that Applied Policy will frequently need to represent client interests without divulging client identities. She assured the team that honesty and discretion are not mutually exclusive. "It all comes back to respect and relationships," she said. "Professional journalists will recognize and appreciate the limits on what you can say. And they will trust you even more for your own professionalism."
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Highlights from NVHPF's October panel on
The Future of Diagnostic Testing
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On October 24, the Northern Virginia Health Policy Forum hosted Anna Scrimenti, Associate Director of Public Policy and Advocacy for the Association for Molecular Pathology, and Zach Rothstein, Executive Director for AdvaMedDx, in a discussion of recent advances in diagnostic testing and the challenges government regulatory bodies face in keeping pace.
Applied Policy President and CEO Jim Scott moderated the conversation. Key topics included proposed regulation of laboratory developed tests, the Saving Access for Laboratory Services Act (SALSA) Act, and the Verifying Accurate, Leading-edge IVCT Development (VALID) Act.
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Watch highlights of the event above,
watch the full event here, or download a summary here.
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November 7
November 8-9
November 10
November 14
November 23-24
Applied Policy Office closed for Thanksgiving holiday
November 28-30
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Under review/On the docket |
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Applied Policy is following these rules under review at the Office of Management and Budget:
- Occupational Exposure to COVID-19 in Healthcare Settings
- HHS Notice of Benefit and Payment Parameters for 2025 (CMS-9895)
- Disclosures of Ownership and Additional Disclosable Parties Information for Skilled Nursing Facilities and Nursing Facilities (CMS-6084)
- Interoperability and Prior Authorization for MA Organizations, Medicaid and CHIP Managed Care and State Agencies, FFE QHP Issuers, MIPS Eligible Clinicians, Eligible Hospitals and CAHs (CMS-0057)
See all rules under OMB review here.
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Bloomberg
MIT Technology Review
nature
The New York Times
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Insight joke of the month for November |
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What happened to the ophthalmologist's jokes over time? |
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November book recommendation:
Most Delicious Poison: The Story of Nature’s Toxins — From Spices to Vices
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Whiteman, a professor of evolutionary biology at UC Berkley sets the stage with the intriguing assertion that a "deadly secrets lurk within refrigerators, pantries, medicine cabinets, and gardens." He then proceeds to describe them in captivating detail.
But, fear not. As Whiteman observes, certain toxins “can also be the cure in the right context,” and humans have learned to use many of nature's poisons to our own advantage. This has included finding inspiration for the development of Coumadin in fungus-infested sweet clover that killed cattle and isolating Digoxin from the foxglove plant.
Kirkus Reviews called Most Delicious Poison a "fascinating discussion of how nature’s toxins can affect us all." Publishers Weekly described as "an amusing debut" that is "worth a look."
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Applied Policy, L.L.C., is a health policy and reimbursement consulting firm strategically located minutes from Washington, D.C.
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