Author: Tony Mira
There are a few changes in store for chronic pain providers in 2023 based on the most recent government proposals. Today’s alert summarizes some of the key pain-specific provisions coming from CMS.
The Centers for Medicare and Medicaid Services (CMS) is proposing new HCPCS codes and valuation for chronic pain management and treatment services (CPM) for 2023. The agency believes the proposed CPM HCPCS codes would, if finalized, facilitate payment for medically necessary services, prompt more practitioners to include beneficiaries with chronic pain into their practices, and encourage practitioners already treating patients with pain to help them better manage their condition.
The proposed codes include a set of services furnished during a given month that CMS envisions as a starting point for holistic chronic pain care. Such codes would align with similar bundled services in Medicare, such as those furnished to people with suspected dementia or substance use disorders. Accordingly, the PR includes within the proposed CPM code set the following elements: diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and maintenance of a person-centered care plan that includes strengths, goals, clinical needs and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and coordination between relevant practitioners furnishing care, such as physical and occupational therapy and community-based care, as appropriate.
Evaluation and Management
The AMA CPT Editorial Panel approved revised coding and updated guidelines for the category of “Other E/M” visits, effective January 1, 2023. Similar to the approach CMS finalized in the 2021 PFS Final Rule for office/outpatient E/M visit coding and documentation, the agency is proposing to adopt most of these changes in coding and documentation for Other E/M visits (which include hospital inpatient, hospital observation, emergency department, nursing facility, home or residence services, and cognitive impairment assessment), effective January 1, 2023. This revised coding and documentation framework would include CPT code definition changes (revisions to the Other E/M code descriptors), including:
- New descriptor times (where relevant).
- Revised interpretive guidelines for levels of medical decision making.
- Choice of medical decision making or time to select code level (except for a few families like emergency department visits and cognitive impairment assessment, which are not timed services).
- Eliminated use of history and exam to determine code level (instead there would be a requirement for a medically appropriate history and exam).
CMS is proposing to maintain the current billing policies that apply to the E/M services while they consider potential revisions that might be necessary in future rulemaking. The PR also creates Medicare-specific coding for payment of Other E/M prolonged services, similar to what CMS adopted in 2021 for payment of Office/Outpatient prolonged services.
Split (or Shared) E/M Visits
The PR calls for a delay in the split (or shared) visits policy CMS finalized in 2022 relative to the definition of “substantive portion” as more than half of the total time, for one year with a few exceptions. This means that, for CY 2023, as in CY 2022, the substantive portion of a visit may be met by any of the following elements:
- Performing a physical exam
- Making a medical decision
- Spending time (more than half of the total time spent by the practitioner who bills the visit)
Under this proposal, 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, instead of using total time to determine the substantive portion, until 2024.
CMS is proposing a number of policies related to Medicare telehealth services, including making several services that are temporarily available as telehealth services for the public health emergency (PHE) available in 2023 on a Category III basis, which will allow more time for collection of data that could support their eventual inclusion as permanent additions to the Medicare telehealth services list. The PR would extend the duration of time that 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, in alignment with the Consolidated Appropriations Act, 2022 (CAA, 2022).
The PR would implement the telehealth provisions in the CAA, 2022 via program instruction or other sub-regulatory guidance to ensure a smooth transition after the end of the PHE. These policies extend certain flexibilities in place during the PHE for 151 days after the PHE ends, such as allowing telehealth services to be furnished in any geographic area and in any originating site setting, including the beneficiary’s home, allowing certain services to be furnished via audio-only telecommunications systems, and allowing physical therapists, occupational therapists, speech-language pathologists, and audiologists to furnish telehealth services.
Per the PR, telehealth claims will require the appropriate place of service (POS) indicator to be included on the claim, rather than modifier “95,” after a period of 151 days following the end of the PHE and that modifier “93” will be available to indicate that a Medicare telehealth service was furnished via audio-only technology, where appropriate.
Opioid Treatment Programs (OTPs)
In order to stabilize the price for methadone for CY 2023 and subsequent years, CMS is proposing to revise its methodology for pricing the drug component of the methadone weekly bundle and the add-on code for take-home supplies of methadone. Under this proposal, the agency would base the payment amount for the drug component of HCPCS codes G2067 and G2078 for CY 2023 and subsequent years on the payment amount for methadone in CY 2021 and update this amount annually to account for inflation using the PPI for Pharmaceuticals for Human Use (Prescription). Additionally, based on the severity of needs of the patient population diagnosed with opioid use disorder (OUD) and receiving services in the OTP setting, the PR would modify the payment rate for the non-drug component of the bundled payments for episodes of care to base the rate for individual therapy on a crosswalk code describing a 45-minute session, rather than the current crosswalk to a code describing a 30-minute session. This would increase overall payments for medication-assisted treatment and other treatments for OUD, recognizing the longer therapy sessions that are usually required.
The PR would allow the OTP intake add-on code to be furnished via two-way audio-video communications technology when billed for the initiation of treatment with buprenorphine, to the extent that the use of audio-video telecommunications technology to initiate treatment with buprenorphine is authorized by the Drug Enforcement Administration (DEA) and Substance Abuse and Mental Health Services Administration (SAMHSA) at the time the service is furnished. CMS is also proposing to 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.
Additionally, the PR clarifies that 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 OTP registered with DEA and certified by SAMHSA.
The proposals to implement section 90004 of the Infrastructure Act include how discarded amounts of drugs are determined, as well as a definition of which drugs are subject to refunds (and exclusions). Of special note for chronic pain practitioners is a new modifier the PR requires for drug claims. Specifically, on all claims for single-use vials or single-use packages payable under Part B, either the JW modifier would be used (on a separate line) to identify any discarded amounts or the new JZ modifier (on the claim line with the administered amount) would be appended to attest that there were no discarded amounts.