Hello Roberta Buell,

Welcome to 2024! This year, we are blessed (???) with a plethora of codes that no one knows how to use. And, this has been going on for YEARS. When there is a big code drop, you folks out there just get frustrated and do not take advantage of new sources of revenue. And, I completely don't blame you. I swear that G-codes are getting on my last nerve.

I want to take this opportunity to say that i made a mistake in my webinars and live talks last year--there are TWO SETS of codes for Principal Illness Navigation---G0023 and G0024 AND G0140 and G146. The later is used for peer support for patients with behavioral disorders. Sorry for misleading you with my stupidity. Happens every year, much to my chagrin.

We also attempt to explain the unexplainable with the ubiquitous code G2211. For $16 and change on average, this is causing quite a stir.

We didn't cover the changes to Q1 OPPS last time because our friends at CMS (Can More Suck?) didn't release the changes until the very last of 2023. We have it for you in this edition.

If you need a belated Xmas present for the person that nerds out about billing and coding, we have the ideal gift, "The People's Guide to Buy and Bill". This updated, on-line book has everything you need to know about buying and billing drugs in 2024. It is also a fabulous reference source for all things related to drug billing and coding. It has so much content that we don't even remember what's in it. And, it is a super affordable price with generous discounts for medical societies, large group practices, and any other group. We are happy to set up a Demo for you and/or your group of any size. Contact us by clicking here.

No doc fix of the conversion factor yet--but, if there is one, there will be chaos.

It's our 34th year--next time you are having and cocktail or mocktail, please toast me for putting up with all this insanity since 1990.

Da' Mistress

I have gotten many many calls regarding what this code means, e.g. if specialists can use it, how to document it, and if billing this will cause audits, denials, or widespread pestilence. For my longtime friends out there, I have said for years that HCPCS codes for services are vague and there is no Coding Clinic or CPT Assistant to provide further instruction on codes that Medicare invents. We just have to wait for further instruction (if it is actually forthcoming from CMS).

What I do know is the code descriptor, which states (highlights mine): Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established). So, I have gleaned some of the following information from that descriptor:

• The patient must have a single complex OR serious condition.
• It can only be attached to Office/Outpatient visits. The code descriptor uses the words "visit complexity", which probably means that G2211 would be attached to 99204, 99205, 99214 or 99215. The payment is for the time, intensity and practice expense of providing these services to patients. But, there is no statement about code ranges for use, except 99211 which cannot be used with this add-on.
• The patient can be new or established.
• The biggest factor in using G2211 is the provider's relationship with the patient. The provider must have a longitudinal relationship with them and is in charge of coordinating care for the condition treated.  The goal of developing and paying for this service is to pay clinicians to address the focal problem with consistency and continuity over relatively long periods.
• There are instances where, even when the provider has a longitudinal relationship with the patient and this code cannot be used:
• With 99211
• With E/M visits utilizing Modifier -25
• With inpatient encounters
• As G2211 is used with E/M services, it can be billed with telehealth visits in 2024.
• Again, there are no published Guidelines for this code. Clinical examples are supposedly coming.

For those of you with your panties in a wad about cost, the Medicare payment is $16.04 per case on average across the U.S. And, there are specialties that will never use this code, ever--e. g. Surgeons, Hospitalists, and ED. Medicare estimates that 38% of services will add G2211 on. For those of you that administer drugs in the office, how many of your encounters carry Modifier -25? We did an analysis from our proprietary focalPoint® database for a rolling year. This analysis included over 6 million encounters in Community Oncology. Of those encounters, 1,611, 997 had -25 attached. That represents 26.83% of all encounters, if you need a benchmark.

For more info on G2211, see this article from AAPC. It is cool because it has a model note for this code.

These changes are in effect for hospital outpatient departments and hospital-owned clinic practices for encounters on or after January 1, 2024. These changes are documented in Transmittal 12421, if you want to know all other changes that are here right now.

• New COVID Vaccine and Admin Codes--Table 2, Attachment A of this Transmittal will tell you all you need to know.
• New HCPCS Codes Describing the Biology-Guided Radiation Therapy Service--Table 10, attachment A will give you the long descriptors of C9794 and C9795.
• These drugs received new HCPCS for OPPS and they also receive pass-through status starting October 1, 2023:
• C9159 Injection, Prothrombin complex concentrate (human), balfaxar, G 0702 per i.u. of factor ix activity
• C9160 Injection, daxibotulinumtoxinA-lanm, 1 unit G 0703
• C9161 Injection, aflibercept hd, 1 mg
• C9162 Injection, avacincaptad pegol, 0.1 mg
• C9163 Injection, talquetamab-tgvs, 0.25 mg
• C9164 Cantharidin for topical administration, 0.7%, single unit dose applicator (3.2 mg)
• C9165 Injection, elranatamab-bcmm, 1 mg
• J0217 Injection, velmanase alfa-tycv, 1 mg
• J1412 Injection, valoctocogene roxaparvovec-rvox, per mL, containing nominal 2 × 10^13 vector genomes
• J1413 Injection, delandistrogene moxeparvovec-rokl, per therapeutic dose
• J2508 Injection, pegunigalsidase alfa-iwxj, 1 mg
• J3401 Beremagene geperpavec-svdt for topical administration, containing nominal 5 x 10^9 pfu/mL vector genomes, per 0.1 mL
• J9072 Injection, cyclophosphamide, (dr. reddy’s), 5 mg
• J9286 Injection, glofitamab-gxbm, 2.5 mg
• J9333 Injection, rozanolixizumab-noli, 1 mg
• Existing HCPCS getting pass-through status starting January 1, 2024
• A9601 Flortaucipir f 18 injection, diagnostic, 1 millicurie
• J0174 Injection, lecanemab-irmb, 1 mg
• J0349 Injection, rezafungin, 1 mg Intravesical instillation
• J9029 Injection, nadofaragene firadenovec-vncg, per therapeutic dose
• There are 11 HCPCS codes for certain drugs, biologicals, and radiopharmaceuticals in the outpatient setting that will have their pass-through status end on December 31,2023
• A9592 Copper cu-64, dotatate, diagnostic, 1 millicurie
• J0699 Injection, cefiderocol, 10 mg
• J1427 Injection, viltolarsen, 10 mg
• J1437 Injection, ferric derisomaltose, 10 mg
• J1554 Injection, immune globulin (asceniv), 500 mg
• J9037 Injection, belantamab mafodontin-blmf, 0.5 mg
• J9198 Injection, Gemcitabine hydrochloride, (Infugem), 100 mg
• J9223 Injection,lurbinectedin, 0.1 mg
• J9316 Injection, pertuzumab, trastuzumab, and hyaluronidase-zzxf, per 10 mg
• J9349 Injection, tafasitamab-cxix, 2 mg
• Q2053 Brexucabtagene autoleucel, up to 200 million autologous anti-cd19 car positive viable t cells, including leukapheresis and dose preparation procedures, per therapeutic dose
• This HCPCS code that was deleted effective 12/31/2024: J9160 Injection, denileukin diftitox, 300 micrograms.
• Drugs receiving E2 status, defined as "non-allowed item or service for which pricing information and claims data is not available — not paid by Medicare when submitted on outpatient claims (any outpatient bill type)". These include:
• J9029 Injection, nadofaragene firadenovec-vncg, per therapeutic dose
• J9172 Docetaxel (ingenus), not therapeutically equivalent to J9171, 1 mg
• J9255 Injection, methotrexate (accord) not therapeutically equivalent to j9250 and j9260, 50 mg
• J9324 Injection, pemetrexed (pemrydi rtu), 10 mg

For more information (and there is more), check out the full Transmittal.

Since our last edition, I have obviously learned a lot more about the G-codes. I also have learned a lot more about PIN (Principal Illness Navigation). In my presentation, I only included ONE SET OF CODES when there are actually TWO SETS OF CODES. So, there is G0023 and G0024, plus G0140 and G0146. We included G0140 and G0146 in our webinar, so here is an explanation of what they are and the similarities and differences.

PIN relates to when an individual has one high-risk condition that is expected to last a minimum of three months. "The condition requires development, monitoring, or revision of a disease- specific

care plan, and may require frequent adjustment in the medication or treatment regimen, or substantial assistance from a caregiver.”

Other aspects:

• CMS believes may be most important at time of initial treatment;
• Incident to service under General Supervision; may be performed by contractors as long as their is an ongoing relationship with the patient and practice;
• Informed consent is required, verbal or written, documented in the medical record; and
• Requires an initiating visit
• Patients do not have to have SDoH

CMS finalized FOUR codes. The first set contains two G codes — G0023 ($79.24 Average Non-Facility $) and G0024 ($49.44 Average NF $) — for PIN services by certified or trained auxiliary personnel under the direction of a physician or other practitioner, including a patient navigator or certified peer specialist for 60 minutes (and for each additional 30 minutes) per calendar month, in the following activities:

• Person-centered assessment,
• Identifying or referring patient (and caregiver or family, if applicable) to appropriate supportive services,
• Practitioner, home, and community-based care coordination,
• Health education,
• Self-advocacy skills,
• Health care access/health system navigation,
• Facilitating behavioral change,
• Facilitating and providing social and emotional support, and
• Leveraging lived experience of others.

People constantly ask me what TRAINED PERSONNEL means. CMS leaves that up to YOUR state. But, in some areas, training does not require a whole lot of hours. Google these for your area.

In response to stakeholder feedback, CMS also finalized two more new codes — G0140 and G0146 — specific to PIN-Peer Support (PIN-PS). Given the nature of work typically performed by peer support specialists in certain diagnoses, CMS limits these codes to the treatment of high-risk behavioral health conditions. The activities are similar to G0023 but exactly the same. If you perform these services, check out the descriptor here.

Example of how G0023 and G0024 can be used— In the case of the cancer diagnosis, the patient's treatment will be complex in terms of information, treatment visits, and physical/mental health challenges. You have multiple physicians involved with care and it is challenging to coordinate and get the patient to understand what is ahead. PIN services can be used to help you and your patient to navigate, set individual goals, and work with others who have also lived through a cancer diagnosis.

Btw, the AMA sees Principal Care Management codes as being Navigation codes that you might use for other payers. See the article here.

For more information about PIN, see the CMS Fact Sheet.

As you probably remember AETNA released a very restrictive policy for office-administered drugs effective for dates of service January 1 and beyond. For PD-1s in particular, please make sure you read and complete THE PRE-CERT form thoroughly as there is exception criteria e.g. being an existing patient for the PD-1... Earlier this year, the United States Departments of Health and Human Services, Labor, and the Treasury (the Departments) together with the Office of Personnel Management issued a proposed rule with new requirements for group health plans and health insurance issuers; providers, facilities and providers of air ambulance services; and certified Independent Dispute Resolution (IDR) entities as they relate to the Federal IDR process under the No Surprises Act (NSA).The proposed rule, if finalized, would aim to facilitate communication between payers, providers, and certified IDR entities; adjust specific timelines and steps of the Federal IDR process; establish new batching provisions; create additional efficiencies; and change the administrative fee structure to improve accessibility...More than 19 million people are set to have an Obamacare insurance plan next year, shattering 2023’s record 16.3 million enrollment. The Biden administration announced Wednesday that as of Dec. 15 more than 15.3 million people have signed up for a plan under the Affordable Care Act through the HealthCare.gov website. HHS projects another roughly 4 million have enrolled through state-run marketplaces as of Dec. 9. Verify all new patient insurance...A study in Health Affairs Scholar found that hospitals rarely use Z codes for social drivers of health aside from the code for housing insecurity, and researchers note that training programs are one step hospitals can take to increase use of the codes and better address patients' social needs. A separate study in the same journal found that Z codes were more often used for people who have Medicaid than for those who have commercial insurance, and Medicaid patients were more likely to have Z codes related to economic hardships, while patients with commercial insurance had a higher likelihood of codes related to social relationships. Maybe the fact you do not get paid for them, nor do they change your HCC risk score are good reasons for non-usage..CNBC (12/28, Constantino ) reports US patients and drugmakers “will get a first glimpse of how much Medicare can negotiate down drug prices in 2024, setting the precedent for a controversial process that may affect what seniors pay for dozens of medications by the end of the decade.” While the outcomes of the talks “will have huge stakes for the pharmaceutical industry,” the final agreed-upon prices “are also significant for patients, who will get a first look at how much money the talks will save them at a time when many older people increasingly struggle to afford medications.”..I have been aware of scams related to Remote Physiological Monitoring and Remote Therapeutic Monitoring for the past 2-3 years. This one involves YOUR PATIENTS. The OIG (the Oy General) warns that this scam involves signing up Medicare enrollees for remote patient monitoring (RPM). Legitimate RPM involves using medical devices such as scales, glucose monitors, blood pressure cuffs, cardiac rhythm devices, and other equipment to remotely monitor for anomalies in patients with chronic medical conditions. This new treatment is beneficial for those whose condition might deteriorate quickly, where monitoring can reduce complications, hospitalizations, or death. Unscrupulous companies are signing up Medicare enrollees for this service, regardless of medical necessity. Scammers have several ways to make contact. It may involve phone solicitations (“cold calling”), internet ads (“click bait”), or television advertising...NBC News (12/30, Choi, Aguasvivas, Essamuah ) reported that many families over the last eight months have had to navigate the process known as Medicaid “unwinding,” as “states have been re-evaluating the eligibility of the program’s enrollees on a vast scale following a three-year pause on eligibility checks during the Covid pandemic.” According to an analysis by KFF, “at least 13 million people had been disenrolled from Medicaid in 2023.” Notably, “just over 70% of Medicaid disenrollments in states with available data were for procedural reasons, such as missing paperwork, the KFF analysis found...SOME GOOD NEWS (Maybe)! Congress’s legislative agenda for 2024 will include industry-backed bills aiming to permanently extend flexibilities that patients and providers came to rely on during the Covid-19 public health emergency. Flexibilities on the line include provisions that address the scope of Medicare reimbursement to telemedicine providers, telehealth access for underinsured Americans, and online controlled substance prescribing, along with several other policies that were instrumental in growing telehealth to an industry of over 81 million visits in 2022. The flexibilities also ensured that doctors would get paid at parity regardless of whether they chose to conduct their appointments in an office or virtually. After the introduction of these relaxed policies, telemedicine visits under Medicare exploded, growing from 860,000 in 2019 to over 53 million a year later...According to Drug Channels, for 2023, brand-name drugs’ list prices again grew at mid-single-digit rates. However, net prices dropped for an unprecedented sixth consecutive year. What’s more, after adjusting for overall inflation, brand-name drug net prices plunged by more than 7%...CMS is entering the 21st century at long last! The Centers for Medicare & Medicaid Services (CMS) continuously strives to improve the adoption of exchanging healthcare documentation electronically. As a part of these efforts, CMS has developed the CMS Health Information Handler (CMS HIH) to provide, at no cost, services and support to providers and other organizations interested in exchanging medical documentation such as portable document format (PDF) or extensible markup language (XML) documents through the CMS Electronic Submission of Medical Documentation (esMD). Using the CMS HIH will allow for the processing of all esMD lines of business such as Prior Authorization (PA) requests and Additional Document Requests (ADR) responses with the following benefits:..Over the past few years, healthcare providers, both large and small, have experienced a surge in audits, with commercial payers and CMS scrutinizing provider claims. We are looking at you, Ambetter and other Centene plans. If irregularities are detected, the consequences can be financially devastating. In a free (with sign up) webinar, AAPC will offer expert guidance on how to navigate these audits and safeguard your revenue. 

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