12/14/2023 Part B POE Advisory Group Meeting

Meeting Minutes

Meeting Time: 10:00 a.m.‒12:00 p.m. ET

Member Attendees: Jennifer Asencio, Doris Barnes, Aurelio Barraco, Madelon Berger, Joanna Bielak, Brenda Bedard, Sheila Bembenek, Madelon Berger, Dawn Burchett, Ashlyn Caputo, Ilka Collier, Eileen Conlan, Renay Coonan, Pam D’Apuzzo, Tracy Essling, Stephanie Fiedler, Deb Gregoire, Darren Goodwin, Martha Harris, Christie Hewson, Stephanie Hirst, Allison Israelson, Kevin Kile, Cindy Kisselburgh, Jenny Kovich, Maud Lawrence, Virginia Leung, Vera Loftin, Sara Luther, Amanda Monger, Hannah Moreno, Sheila Mulka, Joyce Neurenberg, Mark Polge, Theodora Revelas, Maria Rivera, Gilbert Rosenblum, Ken Ryan, Wendy Shreve, Ekaterina Spirin, Stephanie Thebarge, Kathleen Tieppo, Susan Tucker, Carlina Valenzuela, Theresa Weiland, Katie Werner

National Government Services Associates: James Bavoso, Laura Brown, Michelle Coleman, Michael Dorris, Arlene Dunphy, Samantha Fisher, Linda Klug, Lori Langevin, Jen Lee, Phyllis McAdams, Christine Obergfell, Carleen Parker, Jean Roberts, Paul Root, Susan Stafford, Gail Toussaint

I. Welcome/Introductions

Lori Langevin, POE Consultant, NGS

Lori welcomed members and included three new members. Members received an invite with a link to the meeting and an email with the agenda and handouts. She reminded members they can call in or use computer audio, remembering to mute their phone lines if not speaking to avoid any unnecessary background noise. If joining by phone only, please send an email to let us know you attended. We understand the draft 2024 updates included a lot of slides to review and we appreciate your feedback on that presentation. We’ll take comments and feedback on that until 12/21/2023.

Lori advised of the meeting agenda and turned it over to Jim for opening remarks.

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II. Opening Remarks

Jim Bavoso, POE Manager, NGS

Jim thanked the new members for joining the POE AG and current members for their time and reminded everyone their lines were open to unmute and speak up or use the chat box to type in feedback or questions. Jim mentioned the meeting was being recorded for our own use to capture everything in the minutes.

As a reminder, Jim stated the purpose of this meeting is for members to provide feedback to the provider outreach team on all materials and activities. The information we offer to the provider community is provided by the POE team who are in this meeting today. POE conducts training programs (between 30 and 40 sessions a month) on our webinar series. We do a lot of partnership sessions with hospitals, medical groups, AAPC, HFMA, you name it, we do it. We're also responsible for information that goes on our website, on Medicare BLASTS and social media that's out there. As an advisory group member, we ask you to provide us with feedback on the information that we will be posting on our website. We have a couple of things that we're going to share today and we’d ask you to look these over and provide feedback. This is what we really look for during these types of meetings.

These meetings are held quarterly; but we do meet with individual members throughout the course of the year. There are times where I may ask for information from the group. I may send out emails, or if there’s something I'm working on quickly I'll point out a couple of people that I need assistance from. I'll contact you via email or by phone. The group is made up of about 75 members from across our ten-state jurisdictions. The group includes physicians, providers, billers, administrators, compliance people and consultants. We try to run the gamut of everyone to ensure the information we're providing to the provider community is accurate and hits the mark.

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III. NGSMedicare.com – Events Page Prototype

Phyllis McAdams, POE Consultant, NGS

We’ve received feedback from our POE AG members and our provider community suggesting improvements are needed to our website events page. We’ve heard the current layout of six upcoming opportunities is not enough for providers to effectively plan for future education, and having to page through a multitude of six sessions at a time is not user friendly and very time consuming.

We used this feedback and created two draft versions of possible improvements for the events page. Phyllis shared both versions with members. These versions change the layout of events into a list. The list contains the same information you see today, in a user-friendly format and introduces additional search features. Members commented favorably about the new proposed look. Phyllis shared as we move forward in developing this new page, we may reach out to you for more feedback and she thanked members for their input.

Member Feedback:

That looks good that way. Easier to see things
I like this, it seems a much cleaner look
Looks good and user friendly
I like this idea
Looks great!
I like the condensed look so you can see things all at once
The more options to search the better

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IV. Medicare Part B Overpayment Tip Sheet

Carleen Parker, POE Consultant, NGS

Carleen presented information to the group pertaining to the Overpayment Tip Sheet that was shared with all. She indicated the ORU receives many requests and it was decided a tip sheet may be helpful and beneficial for providers. The tip sheet was created using data and what is received in the ORU. It includes pertinent information about what to do with a certain situation, links to needed documents or other necessary information to complete the task at hand and a timeframe of overpayment debt collection activities. Carleen reminded the group if you are on an automatic immediate recoupment, you need to do nothing. One issue we have are forms being submitted as services billed in error, when those corrections can be done through the NGSConnex portal via initiating clerical error reopening. When you do that at the claim line level, you’ll edit and select overpayment. The NGSConnex portal will read that as billed in error, interface with the Multi-Carrier System and generate a new remittance advice with a correction on that claim.

Carleen welcomed comments from the members and also advised they could email their comments/suggestions as well.

Member Feedback:

Members stated this was an excellent tip sheet.

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V. Virtual Conference Feedback

Lori Langevin, POE Consultant, NGS

Lori reminded members we held our virtual conference from 11/6-11/8/2023. She shared the topics presented with and advised there were over 5,200 attendees. We realize a few sessions had little time for questions and we will be sure to extend times in the future.

Jim reminded all that we used to hold this event in person. Years ago, we would rent a hotel in the various states and do full day(s) of session after session, and people would come attend and interact with us. There was a minimal cost involved to the registrants.

The problem was many providers were telling us they couldn't send staff because they didn't have the luxury of leaving the office for a full day. So, we started doing these on a virtual platform a couple of years back and now we do two large ones a year, one in the spring and one in the fall. This time we did one dealing with compliance topics and things that we heard from the provider community. Our question to you is. if you attended, what feedback, good or bad do you have about the sessions? Is there anything that we should do to fix them when we start again in the spring? We haven't scheduled them yet and we'll come up with a theme and we'll ask you for topics as well. We also do mini virtuals throughout the year. We did one on preventive services, care management and MSP just to name a few.

Member Feedback:

More time for questions and answers.
Offer the same session more than once.
Members that attended said sessions were great and very helpful.
A lot of positive feedback from staff who attended.
Would like to see these recorded and playback available.
I like the compliance stuff and I think it's really helpful, especially because there's been so many changes in different things, like with the E/M structures, I think it's a really good idea to have more of those compliance things.
Post all the questions received during these sessions.
Medicare Advantage Plans, can you educate?

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VI. 2024 Medicare Updates

Arlene Dunphy, POE Consultant, NGS

Before Arlene began, Jim reminded all:

The final rule came out early in November and was actually published on November 16th. We sent information out about it. This is CMS' way of telling you what they plan to do as far as the fee schedule goes, information about what's going on with it and so on. CMS sent it out as a press release. It goes out for everybody to review and so on, but the actual workings, the mechanics of how things get done come to us separately, via instructions from CMS. There are some portions of this that we do not yet have so we may not have answers for you on certain things.

Arlene is going to run through the slide presentation that we shared. Since there are over 200 slides, we’re just going to review the main topics and then we ask that you provide feedback on the presentation. We do many presentations to groups that we deal with, associations, societies, AAPC, etc. Some ask us speak only for an hour, others ask for three hours. To touch on everything that's going on, Arlene takes these slides, and she works with the POE staff and creates a formal document that we could use for a three hour session. When someone asks us to talk only for an hour, we only pull out those topics that are changing.

This slide deck that we're going to quickly go through will touch on the major topics. We ask you to look at this and provide us any feedback you possibly can so that we can update this presentation and make sure that we're getting the right information out to the community. Again, the feedback from you is what we’ll incorporate into the presentation. As we go along, we ask that you provide feedback either via the chat box, verbally, or send us what you have later.

Arlene reminded the group to keep in mind that this is a work in progress and the information provided is from CMS MLN 13452, the final rule and the federal register. She then proceeded to mention pertinent updates and changes for 2024 that were contained throughout the slides. A number of slides contained additional hyperlinks for additional information.

The following questions and feedback from members is listed below. Most dealt with the new add-on code G2211, modifier 25, the definition of “substantive” in split/shared visits, place of service for telehealth and RPM codes.

G2211: This is a separate add-on code for applicable outpatient office visits. CMS expects this to be used mostly by primary care specialists. Surgical specialties will have a lower utilization rate. It should be used by medical professionals, regardless of their specialty and the G2211 would not be considered duplicative of care management services since the inherent complexity better recognizes the professional work within the visit, while the care management services recognize what's happens outside of that visit. We're hearing a lot of people want to use this and we're going to see them start using it on day one for every patient that comes in. So, we're looking to see what we're going to be needing, what kind of documentation and so on.

Once we receive further information from CMS, we’ll post it on the website and send out an email update. We also plan to put together FAQs.

G2211 Questions/Comments

Member: I've heard CMS states, emergency department and surgeons should not use G2211.

NGS: That is correct. It's really where the primary care physician is creating a relationship with the patient. So that's where they're looking for it to be used. For this G code, they're saying you can't bill the G code if you're billing for a visit on the same day with modifier 25. See MLN Matters® MM13272 Revised: Edits to Prevent Payment of G2211 with Office/Outpatient Evaluation and Management Visit and Modifier 25. The important thing to remember with that complex code is that it's an add on to any of the outpatient E/M codes 99202 through 99215.

G2211 is the visit complexity inherent to the E/M associated with medical care services and CMS intent is to serve as a continual continuing focal point for all needed healthcare services, medical care that's ongoing and the term CMS uses is longitudinal.

Member: I recommend including information about resident with a teaching physician applying G2211.

Member: We have complicated complex cancer patients, where sometimes providers perform an E/M the same day the patient gets treatment, we can't append G2211? We do this so patients don't have to come back separately (long drive, can't afford gas, etc.). Kind of a bummer a patient would qualify for the G2211 if they come back another time, but not good for our patients who are fighting cancer.

NGS: CMS instructs the G2211 is only used with outpatient E/M codes 99202-99215

Modifier 25 Questions/Comments

Member: Billing shops are reporting NGS requires a modifier 25 on the E/M not only when a procedure is done during the visit, but when a diagnostic test or lab is done.

NGS: If you can get us some examples of where they're saying they need the 25 modifier on the visit when a diagnostic tester lab is done, we can review that.

(After receiving examples from the member, it was found the combinations being billed on the claims were hitting against NCCI edits, not NGS edits).

Split Shared Visits Questions/Comments

NGS: Split or shared visits is when the service is provided in part by the physician and in part by another nonphysician practitioner in hospitals and other institutional settings. They changed the definition for this to mean more than half the total time spent by the physician or nonphysician practitioner performing the split shared visit or a substantive portion of the medical decision making. That exclusion does include critical care, which does not use the medical decision making and only uses time, which can be used for new or established patients. Documentation in the medical record must identify the physician and NPP who performed the visit. The individual who performed the substantive portion of the visit (and therefore bills for the visit) must sign and date the medical record. “Substantive portion” means more than half of the total time spent by physician and or nonphysician practitioner performing split (or shared) visit, or substantive part of medical decision making. See MLN Matters® M13452: Medicare Physician Fee Schedule Final Rule Summary: CY 2024 and CMS IOM Publication 100-04, Claims Processing Manual, Chapter 12, Section 30.6.18 (E).

Member: Shared/Split Visit Final Rule 2024 states CMS will follow CPT guidance which states: "For the purpose of reporting E/M services within the context of team-based care, performance of a substantive part of the MDM requires that the physician(s) or other QHP(s) made or approved the management plan for the number and complexity of problems addressed at the encounter and takes responsibility for that plan with its inherent risk of complications and/or morbidity or mortality of patient management."

Member: PT has specific guidance on what elements of MDM must be personally performed by the billing clinician and which elements do not have to be personally performed by the billing clinician. Since Medicare indicated they will follow CPT, it would be very helpful if NGS would provide this guidance.

Telehealth Questions/Comments

NGS: POS codes for 1/1/2024. POS 02 is for telehealth services provided in places other than the patients home, these are paid at the facility rate. Telehealth services provided in the patient’s home are paid at the nonfacility rate. There's also clarification when the clinician is in the hospital and the patient is at home. In this situation, you should be using the hospital place of service and modifier 95 for outpatient therapy services furnished by PT, OT or speech language pathologists.

A distant site practitioner will continue to use modifier 95 to identify the telehealth service rather than using the telehealth POS. They report with the services rendered and use modifier 95. From the Part B perspective, when we say Part B, meaning on the CMS-1500 form, everything that we’ve seen has been it's going to be POS 10 if the patient’s originating site is from their home and POS 02 if it's any other place other than their home.

I think we need further clarification because a lot of us are thinking that the clinician is part of the hospital setting so the patient is in their home, but the physician is located in the hospital.

The requirements for telehealth services furnished in a teaching setting do have to meet at least one of those criteria that's listed. So, throughout the end of 2024, teaching physicians will be able to use the audio, visual, real time communication technology when the resident furnishes Medicare telehealth services in all residency training locations, virtual presence would meet the requirement that the physician be present for the key portion of the services.

Institutional providers are able to continue to bill for these services provided remotely in the same way that they could during the PHE and through the end of 2023.

They also finalized that hospitals or other providers, the PT, OT speech language pathologist, the DSMT or MNT provider services that remain on the medical telehealth service list can continue to bill for these services when provided remotely for outpatient hospitals.

Member: POS 10 will not be used for hospital-based providers rendering telehealth when patient is at home. Professional billing will report 99214 -95 with POS 22 for hospital-based providers rendering telehealth to patient at home.

NGS: We have to look at that and come back with some clarification from CMS. However, that make sense and the confusion is that CMS also stated modifier 95 would no longer be utilized in 2024 but then other information came out for when the patient is in the hospital setting, we are not sure why because before the PHE they used POS 02.

Member: I understand POS 02 is when the patient is at separate facility/office then the provider, and the patient location can bill for providing the space and other resources. It used to be the Q-code for the office or facility, maybe it still is.

NGS: Correct Q3014 cannot be billed when patient is presenting from the home.

Member: Right, and the clinician bills an E/M with POS 02. POS 10 indicates the patient is at a location that cannot submit a charge to CMS. What if they are at their child's home instead of their home, can we still use home? what if they are in a car, can we still use home?

NGS: Yes, CMS said that is allowed.

RTM/RPM Questions/Comments

NGS: We have services for Remote Physiological Monitoring and Remote Therapeutic Monitoring. The remote monitoring codes are designated as care management services, so general supervision does apply. You can bill RTM or RPM services concurrently with other care management services listed on the slide, but you cannot bill both of them, RPM/RTM together. All requirements to report each service must be met without time or effort being counted more than once, so the RPM or RTM services may be billed in conjunction with any of those care management codes. The RPM or RTM services are prohibited to be furnished during a global period by the billing practitioner who's receiving the global payment. Practitioners such as therapists who are not receiving that global payment would be permitted to furnish an RPM or RTM service during a global surgery period.

For the RPM or RTM, only one practitioner can bill for the codes listed during the 30-day period, and only when at least 60 days of data has been collected on at least one medical device. So even if multiple medical devices are provided to the patient, we're not paying for multiple devices for that, it's only for one provider.

For the supervision policy for physical and occupational therapists and private practice, general supervision of therapy assistants by the private practice PTs, OTs for remote therapeutic monitoring services. That’s where the general supervision will apply but all other services still require that direct supervision to be provided.

Member: My question is, my endocrine group got something from the endocrine society saying that they could bill a 99457, 20 minutes of communication if they're discussing with the patient, their CGM results. So, they bill CGM for the interpreting report and then they were told they could bill a 99457 for the 20 minutes of communication over the course of the month. Can you bill that 99457 independently of the other two codes the 99453 or 99454? They'd have to use the CGM interpret report code, which they are doing, but they were told 99457 is applicable for the communication portion and I just didn't know. Can that 99457 be used independently outside of any of the other RPM codes and do RPM parameters have to be met? Almost every single specialty has the capability of RPM and it's a hot topic.

NGS: I'm going to ask you to send me some of these things that you have and we'll bring in our medical directors to take a look and make sure that we we're explaining this correctly. We’ll work with you separately.

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VII. Open Discussion

Lori Langevin, POE Consultant, NGS
Lori advised it was time for open discussion if anyone else had anything to discuss.

Member: Will cancer navigation services be a benefit in 2024. I have a lot of doctors asking that question, but I don't see it on the physician fee schedule.

NGS: That’s the principal illness navigation codes that will be available for 2024. In addition to that, the Community Health Integration codes, so that's an update for 2024 along with caregiver training services and I believe those were in the presentation slides as well.

Member: Is there a code for IOP? Intensive outpatient services and is it a Medicare covered benefit for 2024?

NGS: I believe this is dealing with the opioid use addiction services. G2086 G2087 and G2088, opioid treatment programs and substance use disorder codes. We will pull those out and take a look.

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VIII. POE Advisory Meeting 2024 Dates

Lori Langevin, NGS POE Consultant

Lori advised of the Meeting dates for 2024:

3/13/2024
6/12/2024
9/18/2024
12/12/2024

Members were thanked for their input and attendance. We had a great conversation today and we look forward to working with you again in 2024. Thank you all for all you've done for us over this year and past years. We really appreciate all the feedback you've provided. Happy Holidays everyone!

Meeting adjourned

Posted 1/18/2024