Hello Roberta Buell,

It's official!! The Holiday Season is upon us; so, it's time for Egg Nog Lattes and getting in gear for 2024. Personally, I'm recuperating from 5 days of eating turkey, mashed potatoes, and stuffing. Hopefully, my scale will break in the next few days. Anyway, we have a thrill-packed episode in the continuing saga of preparing for 2024.

Our first article features all 36 new codes for Quarter 1 2024. You can see herein that there are many 505(b)(2) drugs listed. These drugs are associated with specific National Drug Codes ("NDCs"). Make sure that, when you update your charge entry for 2024, you match the HCPCS codes with the correct NDCs. We are seeing a lot of denials for wrong NDCs. And, by the way, we are still findng lots of denials for missing Modifiers -JW and -JZ.

Also, we attempt to explain the next iteration of Medicare's and CPT's version of split visits. Remember that, if your office or clinic is owned by a hospital, split visit criteria applies for Medicare patients even in the outpatient setting.

Our third article outlines the new drug Step Edits for Aetna and United Medicare Advantage for January 2024. Please note that even Immunotherapies have Step Edits for certain indications. Additionally, some of the"chosen" products are cutting discounts and rebates--even to the payers!!

Finally, there are new codes and services that apply to screening for and helping patients with Social Determinants of Healthcare (SDoH). We provide you with some tips and references to help you assess your patients who may need help as you can now be reimbursed just for being helpful.

And, on that note, I personally want to wish each and every one of you a happy, healthy, and perfect Holidays!!

Best.

Da' Mistress

This is a HUMONGOUS LIST! For your convenience, we have the 505(b)(2) drugs in BOLD so you know which ones met the criteria for this quarter. In the interest of time and space, we only listed the permanent HCPCS (no C-codes):

HCPC LONG DESCRIPTION

J0184 Injection, amisulpride, 1 mg

J0217 Injection, velmanase alfa-tycv, 1 mg

J0391 Injection, artesunate, 1 mg

J0402 Injection, aripiprazole (abilify asimtufii), 1 mg

J0576 Injection, buprenorphine extended-release (brixadi), 1 mg

J0688 Injection, cefazolin sodium (hikma), not therapeutically equivalent to j0690, 500 mg

J0750 Emtricitabine 200mg and tenofovir disoproxil fumarate 300mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv)

J0751 Emtricitabine 200mg and tenofovir alafenamide 25mg, oral, fda approved prescription, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv)

J0799 FDA approved prescription drug, only for use as hiv pre-exposure prophylaxis (not for use as treatment of hiv), not otherwise classified

J0873 Injection, daptomycin (xellia) not therapeutically equivalent to j0878, 1 mg

J1105 Dexmedetomidine, oral, 1 mcg

J1246 Injection, dinutuximab, 0.1 mg

J1304 Injection, tofersen, 1 mg

J1412 Injection, valoctocogene roxaparvovec-rvox, per ml, containing nominal 2 x 10^13 vector genomes

J1413 Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose

J1596 Injection, glycopyrrolate, 0.1 mg

J1939 Injection, bumetanide, 0.5 mg

J2404 Injection, nicardipine, 0.1 mg

J2508 Injection, pegunigalsidase alfa-iwxj, 1 mg

J2679 Injection, fluphenazine hcl, 1.25 mg

J2799 Injection, risperidone (uzedy), 1 mg

J3401 Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/ml vector genomes, per 0.1 ml

J3425 Injection, hydroxocobalamin, 10 mcg

J9052 Injection, carmustine (accord), not therapeutically equivalent to j9050, 100 mg

J9072 Injection, cyclophosphamide, (dr. reddy's), 5 mg

J9172 Injection, docetaxel (ingenus) not therapeutically equivalent to j9171, 1 mg

J9255 Injection, methotrexate (accord) not therapeutically equivalent to j9250 and j9260, 50 mg

J9258 Injection, paclitaxel protein-bound particles (teva) not therapeutically equivalent to j9264, 1 mg

J9286 Injection, glofitamab-gxbm, 2.5 mg

J9321 Injection, epcoritamab-bysp, 0.16 mg

J9324 Injection, pemetrexed (pemrydi rtu), 10 mg

J9333 Injection, rozanolixizumab-noli, 1 mg

J9334 Injection, efgartigimod alfa, 2 mg and hyaluronidase-qvfc

Q5132 Injection, adalimumab-afzb (abrilada), biosimilar, 10 mg

It's a lot o start chan. There are a few regulatory changes and deletions, so check those out as well. Here is where you can find the codes.

One of the worst aspects of E/M coding over the past few years are the coding differences between Medicare and CPT®, particularly in E/M coding .Previously, Medicare has steadfastly clung to its own definitions and rules--one of the issues was the 2021-2023 phase in of Split Visit coding. Another problem, based on reviewing many inpatient charts this year, is the documentation of these visits to evidence WHO the billing provider is. Basically, it is pretty unclear from most charts.

Word to the wise: split visits are not reported in office settings (where the office is not owned by a hospital or health system). These visits, when both a physician and NPP perform a portion of the visit can be billed 'incident to'.

In this year's Proposed rule, CMS planned to keep its 2022-2023 criteria for 2024, but noooo — CMS has slightly changed its definition of split/shared visits and the additional decision to implement that definition beginning January 1, 2024. Much to the relief (???) of all billers, coders, and practitioners, CMS has at last decided to finalize its definition to make the “substantive portion” of a split/shared visit “align … with the CPT® [evaluation and management] E/M guidelines for this service.” The final rule adds, “These guidelines should be applied to determine whether the physician or [non-physician practitioner] NPP [QHP] may bill for the service.”

Per CPT®, 2024, the guideline. states “if code selection is based on total time on the date of the encounter, the service is reported by the professional who spent the majority of the face-to-face or non-face-to-face time performing the service.” Pretty simple, but note that the Office/Outpatient codes in 2024 no longer have ranges but a single time which is the minimum for the code.

The biggest single change is the 'substantive portion' guidelines to code selection based upon medical decision making (MDM) is a little trickier. Isn't MDM always trickier??? Per CPT® 2024, “performance of a substantive part of the MDM requires that the “physician or other [qualified healthcare professional] QHP “has performed two of the three elements used in the selection of the code level based on MDM.” To me, this means that the assessment and treatment plan going forward is determined by the eventual billing provider.

If the physician or other QHP uses the amount and/or complexity of data element as one of the elements to determine the MDM level for the reported code level, however, CPT® requires that “an independent interpretation of tests and discussion of management plan or test interpretation must be personally performed by the physician or other QHP.” Conversely, “assessing an independent historian’s narrative and the ordering or review of tests or documents do not have to be personally performed by the physician or other QHP, because the relevant items would be considered in formulating the management plan,” per CPT®.

Again, the documentation of split visits has been notoriously bad in the FACILITY (non-office) charts I reviewed. To be sure your providers are documenting and billing correctly, please follow the following steps:

1. Review the 'new' Medicare and CPT® guidelines with your providers before January.
2. Each chart should clearly show who performed the substantive portion of the visit. In 2021, 2022 and 2023 practices can use time OR a whole one of these elements--history, physical exam or medical decision-making (MDM).
3. It should be obvious from documentation who will be the billing physician or QHP and, just to be sure that any auditor on the planet can tell who this is, the billing provider should sign and date the note and, if providers want to be crystal clear, they can document 'this visit will be billed by me (or your name)".
4. Ensure that all split or shared services are billed with modifier FS (Split [or shared] evaluation and management visit) whether the facility billed the visit under the physician or QHP’s name.

Your facility should also check private payer policies to make sure they are aligned (or not) with Medicare and/or CPT.

We have been telling practices for a while now that Step Therapy of office-administered drugs is stepping up and limiting choices, unless you go "peer to peer".. On/after January 1, 2024, payer choice has increased. with Aetna Medicare Advantage Plans preferring certain immunotherapy drugs for some indications and United Healthcare also has a very long list of MA preferred drugs. We encourage you to read these documents carefully. While you may be able to keep existing patients on non-preferred drugs, check out the following information that was sent to my colleagues last week. This information been edited to exclude contract pricing information.

"On January 1, 2024, Amgen will modify their pricing structure for Neulasta®, Neulasta Onpro® Kit and Kanjinti® across the industry, moving to a singular price point for these products. These changes will impact contract pricing and eliminating rebates.

What your practice can do to prepare for this change:

You should respond to this price change the same way you would with any other drug you buy for your practice.

For your patients:

• Patients may need to switch to other products due to convenience or frequency of treatment.
• Educate patients on therapy alternatives to Neulasta PFS, the Onpro Kit and Kanjinti
• Neulasta is primarily covered under a patient’s medical benefits but may be available to some under their pharmacy benefits, depending on payer or plan (but not Medicare FFS).

For your practice:

• Evaluate the financial impact of these changes for your practice ASAP.
• If you anticipate needing product in 2024, start to order additional inventory now while the current pricing and discounts are available ahead of January 1.
• Ensure you have adequate storage for refrigerated products.
• Plan for therapy alternatives. Consider numerous products available in this space and have your prescribing providers evaluate what may be best for your situation.
• Change prescribing patterns now to avoid a potentially negative economic impact.

For Payers:

• Some payers may continue to require use of these products despite the price changes. We recommend that your practice identifies payers that exclusively prefer Neulasta and/or Kanjinti currently, and initiate negotiations or.appeals with payers if you plan to prescribe these products in 2024."

but bear in mind that, to our knowledge, Aetna/ CVS and United (and quite possibly many more) are still recommending Neulasta and Kanjinti as preferred drugs. While with both insurances there are some limited product substitution choices, the impending lack of rebates for drugs will have a negative impact, particularly for smaller practices. In order to ensure that practices are making decisions based on their financial health, it is URGENT that these product choices are evaluated carefully before the beginning of the year--so you do not get caught between payers and pricing.

Lately, due to the the Enhancing Oncology Management and the new Medicare G-codes, practices and clinics are more often discussing SDoH with their patients/caregivers. So, we thought we would help you out!

We also have noticed that many of you think that SDoH simply means homelessness or lack of food. So, herein we will define (1) SDoH for you; (2) provide you with some tips about talking to your patients; and (3) finally provide some tools that can help you out including training for your facility.

What are the Social Determinants of Health?

Social Determinants of Health (SDOH) are environmental andor economic factors that significantly impact an individual’s well-being and, possibly, their treatment plan. Unlike medical conditions or illnesses treated with medication or therapy, SDOHs are shaped by the societal and economic conditions that impact daily living.

The five domains of Social Determinants of Health

How do you know if a patient might have SDoH. A comprehensive outline of all Social Determinants of Health (SDOH) would be extensive, but almost all determinants fall into five distinct categories.

• Economic stability--Economic stability is tied to an individual’s socioeconomic status and ability to fulfill basic needs of daily living with income. Arguably, poverty is the most profound social determinant, with consequences that negatively impact an individual’s life. It magnifies the influence of other determinants, leading to poorer health outcomes and perpetuating a cycle of disadvantage. As providers of specialty meds, you know there are many impoverished people that qualify for free drugs and transportation. Examples of economic stability challenges
• Housing instability: This means patients who are about to be evicted with nowhere to go; patients who live in shelters on and off; and those who actually live on the streets.
• Food insecurity and nutritional challenges: Living in poverty (or on Social Security) often forces individuals to make difficult choices such as whether to buy toilet paper or food. Food insecurity also can result in unhealthy diets and/or emaciation.
• Employment and income barriers: While many of the unemployed qualify for Medicaid, the underemployed may not qualify for Medicaid OR employer-sponsored healthcare. Numerous social determinants of health, including factors such as education and discrimination, can influence a person’s ability to secure sufficient income and provide for themselves and their families.
• Education access and quality--When I was in business school, the famed health economist, the late Victor Fuchs, stated in class that the greatest contributory factor in a person's health was a quality education. Patients with substandard educations often do not understand living a healthy life and, when they get sick, their comprehension of self-care and treatment compliance can be quite limited.
• Healthcare access and quality--This may be a big "duh" for all of us. But, here are some examples:
• No insurance:In 2022, 26 million people — or 7.9 percent of the population – were uninsured, according to a report in September 2023 from the Census Bureau. These patients may never access preventative or therapeutic healthcare.
• Underinsurance: But, even more people are underinsured and they may delay care or not get care at all due to high co-pays, medical debt, or failure to pay premiums.
• Rural manpower shortages: Even crazier, patients in rural areas may not have access to primary care physicians at all. Medicare has long recognized the physician shortages in these areas, but they still exist. Additionally, the volume of patients seeking care may also result in delays in screening, testing, and vaccines. 
• Physical environment--This can include the patient's home and/or their neighborhood.
• Homelessness: Obviously, if a patient is housing deprived, residing in a tent (welcome to San Francisco); or, living in their car, this is not good for their health and may significantly affect health outcomes.
• Violence. They may live in a violent or drug infested area where going out to get food or medicine is a dangerous option.
• Food availability: In addition, there are areas called "food deserts" where healthy foods are not available When residents lack access to fresh and nutritious foods, they are more likely to rely on processed and unhealthy alternatives, which can lead to a higher prevalence of diet-related chronic diseases, such as obesity, diabetes, and cardiovascular problems.
• Ability to get to necessary care: Public transportation is not accessible in all areas and facilities may be too far for patients to access often or at all. Neighborhood pharmacies and even some of the chains (looking at you, Walgreen's) are dwindling in rural and high crime areas. This leads to lack of preventative and/or ongoing treatment.
• Social and community context--A community may be a support system when other factors, like economic status or neighborhood quality, are more challenging to control. Having community centers, elder care, church/synagogue outreach, or just a lively, engaging social environment can provide a better sense of well-being for the patient as well as possibly providing a source of caregiving when they get sick. Patients without a spouse, child, other relative, friend, or neighbor to care for them are more likely to be re-hospitalized than patients with a supportive caregiver.

Talking to your Patients

Many healthcare facilities require healthcare staff to complete regular sensitivity trainings on cultural competency, bedside manner, and similar topics. There are lots of trainings available and we even have our. own Social Worker at onPoint (contact Cassidy Lewis by email) who will be happy to train you and your staff! to find and speak to these patients. These trainings can help providers deliver compassionate care for diverse patients.

But, as more healthcare facilities are screening for a social determinants of health (SDoH) to care for patients’ non-medical social needs, you might need a few tips to get started. The following is what i have learned from my experience running Patient Assistance Programs and from reading several sources.

• Do not make the patient feel "singled out". When we used to screen patients for free drug and/or if they qualified for their state Medicaid, patients or caregivers often would respond that with embarrassment and shame. To avoid this situation, we told the patients that this screening was routine for everyone who was uninsured. And, if they qualified, they had coverage not only for their drugs, but for other elements of their care. Again, we reassured them by telling them their state was generous and that qualifying did not mean they were impoverished.
• Put it at arm's length: You should also consider if patients would prefer to be screened for social needs verbally or through a paper or an electronic questionnaire, which may offer more privacy. It will make the patient think this is a routine activity and they are not singled out at all. In order to get paid by Medicare for G0136 in 2024, this determination must be done by via an evidence-based tool. Having an objective way to determine the patient's situation may facilitate your screening patients.
• Stand in the patient’s shoes: Many patients are sick and scared. They may have gotten a diagnosis that is difficult to face. Now, someone is asking them about their living situation, what they eat, if they have transportation, etc. This is the very last thing they want to think about. However, if they talk to someone who 'knows where they are coming from, i.e. their demographic in terms of culture, language, or locale, it is quite helpful. If you cannot hire these folks, it might be wise to someone with lots of experience dealing with less fortunate patients (social workers, Financial Counselors, etc.) and/or speaks their language. A warning from experience, translators can be too impersonal in this situation--it really depends on personalities.
• Combine drug financial assistance determinations with SDoH screening: This way, you can position the situation as providing assistance for all dimensions of their care. And, this may reinforce that your facility considers the 'whole patient'. You might posit the key to their getting well is not worrying about the cost of their drug or need for transportation.
• R-E-S-P-E-C-T: If you find out that the patient needs help in some aspect of their life, involve the patient and family in the assistance strategy. For example, if the patient has no transportation to your facility, you can say: "We have a foundation that sponsors Uber or Lyft from your neighborhood, Is that something you would like to try?" Self-determination may give them a better feeling of control, while their disease may be doing the opposite.

Resources You Can Use

• Reading material: These are some of the references I used for this article and/or were recommended by the authors:
• A Practical Approach to Screening for SDOH, American Academy of Family Physicians
• Care of Homeless Patients Requires More than Just Referrals, Purple Health
• Discussing social determinants of health with a patient, Violet--This one is excellent!!
• Social Determinants of Health Improve Health Outcomes Beyond the Clinic Walls: American Medical Association
• Social determinants of health: how to navigate sensitive patient conversations: Wolters Kluwers
• Screening tools: The first three are Evidence-Based and recommended by Medicare for G0136:
• The Accountable Health Communities Health-Related Social Needs Screening Tool
• The PRAPARE Screening Tool from the AHA
• Instruments identified for Medicare Advantage Special Needs Population Health Risk Assessment--Tools identified here
• Social Needs Screening Tool, American Academy of Family Physicians
• Kaiser Permanente’s Your Current Life Situation (YCLS) Survey

One other thing--they don't call me the Codemistress for no reason. So, I'm here to remind you that, if you find that your patient has some of these SDoH issues AND they impact medical decision-making, document it! SDoH can bump up your E/M. And, even though the. Z-codes for aspects of SDoH do not impact outpatient reimbursement as yet--code them. First, it will inform the payer of the patient's complex situation. And, I predict they will impact payment in the future as well as upping your HCC score.

Again, if you feel you need help talking to your patients about SDoH, please contact Cassidy Lewis and set up a live or web-based training!!

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