Hi, everyone, and welcome to our webinar today. We're going to be talking about the 2024 final Medicare physician fee schedule and the hospital payment rules, the impacts on cardiology. We're going to give everyone just a little bit of time to get in since we just opened up the webinar. Just a couple of announcements as everyone is beginning to join. I'm joined by Linda Gates-Strippy, who you all know, and James and Matt from the American College of Cardiology and the Advocacy Division, so we're very excited. You may remember we did the proposed rule. So we're happy to be joining you today to go over what we think is final and get the latest updates of where we are. We have no disclosures. Just a reminder, if you have questions throughout the webcast, you can type those questions in the Q&A box, and we can answer those throughout the session. We should also have some time for questions. If we don't get to your questions, we will answer them after the webcast. Also, the presentation is available in the chat box. There's a link that you can click on to download that presentation. So that will be available to you as well. And a reminder for the coders that are joining us, for the AAPC CEUs, if you individually registered for the Academy for this webinar, you can claim your CEUs, and it's available within our Academy, and this is the instructions on how to retrieve those. And this is for one CEU, and it's usually available under your CEUs and your individual logins probably in about two days post-webcast. So we're happy to be able to offer that to our coders that are joining us. So we're going to start off talking about the final position fee schedule highlight. So Linda and I are going to tackle that, and then we're going to get into QPP with Matthew and James, and then the final hospital outpatient highlight and some advocacy updates. All right. So I'm going to get us started with where we are as of today, and then at the end, James is going to update us on some of the advocacy initiatives and what's going on in Washington as we speak today. So the conversion factor was reduced by 3.37% from last year, well, from 23. So for 24, it's reduced by that 3.37%. The projected overall reimbursement impacts for cardiovascular services are really flat compared to 23. You may see some different impacts depending on what patient populations and services you offer, but overall flat from where we are this year to next year. As expected from the proposed rule, they did finalize that they're going to rescind the appropriate use criteria program, the current regulations, and they're going to cease all educational and operational testing. So anything new around AUC appropriate use will be proposed in future rulemaking. So this is one thing that we've kicked the can down the road, and now it's pretty much unless there's some new future rulemaking, we don't have to think about AUC for now. For Medicare split shared services, they did postpone, it was supposed to effective in 2024 go to being based on time only as the definition of the substantive portion. CMS did finalize in the final rule that the definition of the substantive portion will be based on more than half of the total time spent by the physician or an NPP performing the split shared service or a substantive part of the medical decision making as defined by CPT. So the overall comments and the information in the final rule really talked about aligning the language of split shared services, which with what is outlined in the AMA CPT guidelines. So when you look at this, you can see that the history and exam are no longer part of the definition of meeting that definition of the substantive portion. And it's related to a part of the medical decision making. This causes some confusion because when you look at the AMA information around how do you determine a level of service, they do talk about split shared services. And they talk about, of course, the time based selection of the code. But when you look at the medical decision making, we don't know how all of the Medicare carriers are going to interpret that definition of substantive part of medical decision making. So does that mean if I want to build split shared services under the physician, that the physician has to document the complete medical decision making? It says substantive part, which is what causes the confusion. But when you look at the AMA guidance, this last sentence, it says that performing two out of three elements is what's used to select the code level of service. And that's based on the medical decision making. So in order to level the service, the physician or qualified health professional, which is our NPPs or APPs, has to perform two out of three of the elements as defined by CPT. The definition in the final rule is that that substantive part of the medical decision making can meet the criteria for billing split shared. So I think we can stay tuned for the first of the year. We're going to see some policies by our individual Medicare carriers. I did attend the national call, and it was still very vague. They're not saying they have to document the complete medical decision making. But I will tell you, in order to level the service, it is referred to and clear that it has to be two out of three of the elements. So we'll see how that goes. I know we're going to talk about this more when we do our coding boot camp in a couple of weeks as well. From a telehealth service perspective, a few things on telehealth. There are several things that have changed. There are several things that have been extended through the end of 24. I suggest you look at the telehealth list for the Medicare services. Also reference the website with all the different dates. Got a couple of wins here that I'll cover for us. Patients may receive Medicare telehealth services wherever they're located, such as their home or another setting, as allowed by state law. You'll see on another slide we have each state has different requirements. So you want to be sure you're following your state requirements. Use of audio only is billed with the telephone service codes, the 99441 to 443. This is what those are billed under, and that's when it's audio only. So you must use those codes when billing for audio only. For calendar year 24, this is the good news. I know many physicians were worried about reporting their home address. CMS did finalize that a distant site practitioner can use their currently enrolled practice location instead of their home address. And I know with Linda and I talking, this was huge, particularly in some of the primary care and other areas, when you look at reporting your home address on a claim. So this is truly a win, I think, to continue those flexibilities. One big reminder, if you're billing any telehealth services, as of January 1st, 24, the place of service 10, the patient's home, is for the non-facility, and place of service 2 is your telehealth, that facility rate. You'll no longer bill modifier 95. So you need to think about how's this going to change on January 1? How is that going to happen? How do you identify those on your schedule? How do you identify those for billing? And what does that workflow look like? Because the place of service changes, and you're no longer going to be appending that modifier 95. The direct supervision, this did go through in the final rule, and it does include the availability of the supervising practitioner with audio and video. So very important to remember, it has to be both. For telehealth services, just a reminder, under hospitals without walls flexibility, a patient home was allowed to serve as a provider-based department for cardiac rehab services. Now that the PHE has ended, hospitals are required to provide those cardiac rehab services within hospital departments. The cardiac rehab codes were added to the Medicare telehealth list on a provisional basis, and extended through the end of next year. And then as a reminder, I mentioned, make sure you're looking at your state rules for telehealth across state lines, and for services within your state, because it can vary. All right, this is my last one, and I'm going to transition to Linda, so she can take us through some additional Medicare Physician Fee Schedule final rule stuff. One thing to note, the G2066 was finalized in the final rule, and now it's no longer available, so it is deleted. So this is for reporting your remote monitoring services for your 93297 and 93298. They now have a professional and a technical component. There's no change in the work RVUs, but the PEs were updated. It's about a cost change of $6, so you'll look for that new fee for those two codes. And depending on how you're billing for your technical and professional services for your loop monitors, etc., you're going to want to make sure that if you need to bill globally, if you need to bill TC or PC components, and what that looks like for your organization based on the place of service, and how you're providing these services. So as of January 1, that G code is deleted, and you're only going to use that one code, the 93297 or 98. All right, Linda, you ready to go? I am. There were some questions in the QA box. I don't know if you want to mention some of those questions and responses real quick. I unfortunately cannot see the QA box because I'm running the slides and I have one screen, so let's see if I can. That's all right. I can speak to them if you'd like. Just a little, just some confusion on, you know, how do you pick the place of service? The place of service is where the patient is located at the time. And specific to like a hotel or maybe a group home or something like that, they do clarify that home also is okay for any type of like temporary housing, like the hotel. Correct. Where you reside the majority of the time, I believe is the language. Yeah. All right. Hey, so lots of chatter about this new add-on code for Visit Complexity. So we'll talk to you about what we know about it. You may remember that CMS actually proposed this in 21, and as part of the, part of passing, if you could go back one slide, if part of passing on the full effect of the reduction in the fee schedule, that Congress said, well, but we'll give you that pass, but you can't pay for this code before 2024. So this is the first year that they would be allowed to use it. They are not going to let us use it when we have an E&M code that has the 25 modifier on it. So we're going to have to think about what that means. I know with some Medicare carriers, we had to put the 25 on the E&M, even if all we're doing is like an EKG. Same thing with like device checks and such. So any visit that has a 25 on it won't be eligible. And this does only apply to those office or outpatient clinic visits. So one of the things to just keep in mind, that's going to be kind of, you know, which way do we go here? Get ready for it. But do we get excited? There's a thought that this is very closely linked to that conversion factor reduction. So if we get a pass on that reduction, it could also include the provision not to implement this. That's what happened in 21. So we do have to be aware that there are other organizations out there, some of the physicians that will be unlikely to build this code, that they're not a fan of this code and actually encouraging that it not get implemented. So it's going to be a little bit of a wait and see game. So if you look at the definition there, it's that visit complexity inherent to an E&M associated with medical care that serve as the continuing focal point for all needed health care services. So primary care and or with medical care services that are part of an ongoing care related to a patient's single serious or complex condition. I think it's that second part of that that pulls cardiology and it makes them eligible. Now, this last bullet, this is where Medicare really puts all their emphasis that this is a code that really is to be representative of that longitudinal relationship with the patient. Everything that we need to do to really maintain that good, close, functional relationship that we're going to keep addressing and keep seeing that patient over time and that continuity needed there. So what do we know about it? Well, what we know so far is based on what we see in that final rule. On the next slide there, Nicole, we can see what they say there. And they're saying that it might be billed like 90% of the time by certain specialties. They felt like the highest use is going to be by specialties who pretty much rely on E&M coding and that the lowest use would be maybe by surgeons who do a lot of procedures. And they stress that it's not to be billed if you don't have that longitudinal relationship. They say, you know, if that relationship with the patient is discrete, routine, you know, time limited, they mention a thing like fracture care or seeing a dermatologist for a particular, you know, cyst and that's it. They don't limit it to only the highest level E&Ms, nor are they limiting it to certain medical conditions. So they're not saying that it has to be serious or complex condition that's being addressed at that visit. And you'll see a couple examples that we saw there. It does have a work RVU of 0.33. So do we think cardiology is going to use it? Well, absolutely. You know, we many, if not most of our patients, we do have that long-term longitudinal relationship. You know, what comes to mind immediately are those heart failure patients and such. You know, that's not going to be a one and done consult. Are we rendering care that are part of an ongoing care? Yes. It's related to their single serious conditions, maybe even multiple or complex. So I think we meet that criteria. Those are the two pieces they stress most. So what's documentation going to need to look like? Well, you know, that's really not clear. I know we're getting a lot of questions. Nicole's mentioned that a lot of your coders are reaching out. Only thing we really know right at this point is what's coming from the final rule. We do think CMS said that they would consider releasing additional guidance. I think they'll probably get enough feedback that they'll know they need to do that. But at a minimum, we know the requirements are stressing that we have the patient has the condition that would qualify something that's serious and complex that we're going to have a longitudinal relationship with. So some sort of sentence to support that relationship and the impact of conditions, that's probably the best we can tell you right now. And we'll just have to wait to see what more may or may not be released. Next slide. These are the examples they give us. And I think these are the only two examples they give, except for the examples that would not qualify. But I think this one relates most to cardiology. And the example here is an HIV patient encounter with infectious disease where the patient does say that, you know, I'm not always taking my meds. I miss my medication doses. So now the physician has to weigh their response during the visit. And you can see what's in red here, you know, talking about the tone in their voice, their choice of words, you know, and communicating clearly that it's just not okay to miss this meds. But they've also need to make sure that they're not doing this in such a way that the patient perceives it as scolding them or that they're gonna get in trouble. So I'm not gonna tell my doctor that I actually haven't been taking my meds like I'm supposed to. That's where that relationship comes in. That how the physician chooses to respond, what they say and how they think about it, it's important that the patient say, hey, I'm not taking my meds. If they don't tell us that, we might change the meds or increase doses. I think that certainly has a cardiology implication for us as well. So they were saying that would be a time where you would add the complexity code because you're thinking about what I'm doing right now for this single condition or serious condition that I'm trying to work on all my interactions to maintain that relationship in the future as well. So I think that's a interesting example and one we can probably relate to in cardiology. Now, the next one, I looked at this one and I've using the word surprise there. This one to me, if we were thinking about how this code is intended to be used, this might've been one where I would have thought maybe we wouldn't use it, but yet Medicare gives it as an example where we would use it. And it's the patient that's being seen for sinus congestion. So it's not the complexity of the condition being addressed that day, but this one stresses that, how the physician responds here, what actions they're gonna take, their words, their tone, maintaining that relationship, that really it's not that visit for sinus congestion, but when they see the patient for something more serious, the patient has to be comfortable enough with the way this is being handled. So it's really talking about how you maintain that relationship. So this one's kind of surprising to me. And that's where when we say, we're not sure what the documentation needs to be, they really are just putting emphasis on, you have a longitudinal relationship with that patient. So it's not the diagnosis that's attached to the visit, nor necessarily the primary issue that you're addressing on that day. So it's kind of interesting. I think we'll see more information about this. Next slide. So what are some other good things? Well, on the left-hand side of the slide here, you'll see that CMS, even though all the E&M codes have been redone and re-looked at, the medical decision-making, all the things that's taken into consideration, there are so many things that it's like, well, that's not separately billable. That's just part of the E&M. When we help the patient get their prescriptions through a drug company, maybe, that's not separately billable. That's just one of those things we do. Well, CMS is trying to acknowledge that there are a lot of things that our nurses and MAs and physicians may be doing not necessarily during the E&M or at the time of the E&M, or that are really well-represented in the E&M codes and their current values. So they came up with these four new categories of services. And really, I think we're gonna need to think through how might we take advantage of some of this in cardiology? Each one of these, and we'll give you just a brief on each one, they all have elements and they're listed there, and I'll give you the pages where you'll find it in the final rule, but it basically boils down to the person who would render this service needs to be able, educated and training-wise, to address each of the elements that are expected to be done. So social workers, nurses, clinical health workers, axillary personnel. We all say, well, what's that mean to an MA? Well, I think you have to look at that list, look at those services, and they pretty much defer to state guidelines. And when the state doesn't have any guidance available, they do give some minimums. So they do make distinction here. As we go through these, you may think, well, gosh, I think we're doing that when we do chronic care management. You might be. And some of the things that they list are very similar to that, except that what's added here are basically social issues. They, you know, that we're focusing on, is there a social determinant of health of some sort that's impacting that care? And am I doing something more to address that? We're kind of getting down to the medical condition itself. Each one of these, there has to be what's called an initiating visit. And that initiating visit has to be shown at, you know, that's gonna kind of service your relationship. The physician's gonna say, hey, my treatment plan is being impacted by something here. And I need more information. So they're wanting that patient-specific treatment plan. Let's take a little bit more of a glance at each one of these individually. Go to that next slide. So starting off with caregiver training, I think we went one too far, Nicole, maybe. There we go. So caregiver training. So caregiver, you'll see on that first line, unpaid family, friend, neighbor, guardian, someone who's helping the patient with some type of chronic health condition, disability, limitation, chronic illness. I think, you know, for cardiology, we're looking at that chronic illness. It is gonna require that we have the patient's consent because these are services that we're rendering to their caregiver. The patient themselves doesn't have to actually attend. Now they do give a whole list of conditions they feel like would kind of qualify, but they also confirm that it's the clinician's determination. There are codes for group training and you bill it per each patient who's represented. So if you had the spouse, the son, the daughter, three people there that support and rotate care of mom and dad, well, you only bill it once for the patient, even though three people are there. So the codes do have to be very specifically linked to a patient-centered treatment plan. You know, maybe we would do this, you know, think about where do we spend time educating now? You know, our heart failure patients and LVADs and, you know, some of those conditions. Once we get to the point where we're thinking, gosh, I'm just not sure you're following the diet. I don't know that you're taking your daily weights and, you know, things that we are, our nurses may spend that one-on-one time or maybe our physicians and APPs. What would happen if we could carve that out and turn it into a group education session that's done virtually or face-to-face? The codes themselves are gonna change and how much time you have to spend also changes based on the codes, but really it's anything that's just gonna help that patient with their adherence and helping the caregiver understand the importance of some of those elements. So once the physicians or APPs get the feel that, you know, I'm not sure they're really following my care plan, this might be something that we would consider. Next slide. So if we look at, oops, there we go. Did you have a question, Nicole? No, I was gonna say, is that the one, Linda? I don't know what's wrong, the computer's skipping ahead a little bit, so I just wanna make sure I'm on the right one. You are, we are now ready for social determinants of health. So this is just kind of a brief of this and I think the bottom line here, you can see the G-code, it's five to 15 minutes. They're thinking that we don't really need to do it more often than every six months because they're thinking that, you know, once we've identified that social risk factor, it may take a little bit of time, you know, to actually have that impact on their medical condition. So this too, the emphasis is on the risk assessment, not a screening. So we all know that, you know, for our quality programs, a lot of us are doing a social determinants of health set of questions on every visit. That is not what this is for. What this is saying is that the physician really feels like there is some sort of unmet social determinant of health and that's interfering with what I would typically do or, you know, the treatment plan or my diagnosis. The tool itself and the questions itself, they propose some and I'll show you that here in a second. They propose the name of some, but then they backed off that in the final rule and said, well, okay, you could do other tools, but make sure that it includes these four domains, the food insecurity, housing, transportation, utility difficulties. They say, you can go beyond that. They're not limiting what we do to that, but they're saying it does have to do that and what they expect in return, and this I think would speak to maybe what some of that documentation might be is, you know, they want the clinician to say, what is that risk factor? And at a minimum, make a referral to someone who can then try to address it. And, you know, having an example of how that might impact the treatment plan. Next slide. It's not changed yet, Nicole. There we go. So this is an add-on code. They did crosswalk it payment-wise to a depression screening. Keeping in mind though, that this is not a screening. This is an assessment. It will be done under the outpatient E&M, transitional care management, and or you could have the hospital discharge also count as that initiating visit. So they really want us to address, you know, what is the impact on what condition? So the lack of a constant temperature to keep their meds in is impacting their diabetes or whatever. They do want that. They're encouraging us to use the Z codes. They didn't require it, but they are strongly encouraging it. Next slide. And I think what Medicare envisioned was once we identify that, well, that kind of opens the door to these other services, this community health integration. Here too, they're saying you need that initiating visit. And once you identify that social determinant of health, well, now we need to go on to do the things that we need to do to actually address this. I think if we have nurse navigators, they may be doing some of this, you know, trying to work with the drug companies to get samples and such. Now it is a 60 minute per month minimum. So I don't know if we're really spending that much time in our cardiology practices. This might be something, you know, for part of a larger organization that becomes a centralized team or someone that you would refer that patient to who then goes to try to connect that patient to all these various resources. Well, if that's the case, it's still the physician who referred it and identified it and helped develop that treatment plan that would bill it. They do say that, you know, this is something that you could contract with someone else to do. So I think it's just kind of getting a feel for how much of our patient population are being impacted by this. What do we do now when we identify it and who is doing it? So it's just something to consider. Next slide. Very similar to this is a principal illness navigation. And, you know, Nicole and I were talking, you know, I know that we personally in my organization, we just are struggling to get chronic care management off the ground. But why aren't we looking more at principal care management? It's a little easier. And I think, you know, really taking into account this principal illness navigation and doing some sort of a compare and contrast between that and principal care management. Now, CMS says the distinction they feel like they're making is this one also is gonna take those social determinants. And the condition that would maybe qualify is the same. You can see there, they list heart failure and some of the other things. It would be monthly after you have that initiating visit. One thing that is interesting here is those of you in hospital outpatient departments for your site of service, you can't bill that the health integration or this one. I don't know why CMS chose to do that. They're saying, you know, the hospital inpatient, OBS, ED, nursing homes, you know, those don't qualify, but neither do the hospital outpatient departments, which I think is kind of strange. This one too does allow you to contract with others. It would be under general supervision and they do want those ZCOs, although they're not requiring them. Next slide. So, you know, a lot of this comes down to who can really do it. And, you know, if you're going to look into these, look at the various information in the final rule about the nature of services to be rendered. That's kind of what they default to, to say that you need to be able to render all of these types of services. And I think everyone from the social workers, community health workers, nurse navigators, I think, you know, MAs are kind of questionable. We need to look at some of this and look at the nature of it and really just see if that's gonna work for us. So it does list those anticipated activities and they'll defer to state law. And if not, it does give some minimum. And one final slide. I mentioned the ZCOs. If you've not seen it, this particular resource tool is available from CNS and it lists, you know, some of those very common social determinants in a really nice at-a-glance format. So if you've not seen this, just wanted to make you aware that CMS has a really nice resource tool available. All right. That's it for me. All right. So we'll transition over to Matt, actually. Thanks, Nicole. And good afternoon, everyone. Gonna go through some quality measures and then into the OPPS segment. So with the QPP, not a whole lot of major changes or additions, but there were some updates. There were three new measures added that were cardiovascular related. They were the episode-based heart failure cost measure added to the Advancing Care for Heart Disease MVP. There was the excessive radiation dose or inadequate image quality for diagnostic computed tomography in adults added. And then there's also the cardiovascular disease risk assessment measure specifically for pregnant and postpartum patients. They did see, we did see the deletion of the cardiac stress imaging not meeting AUC measure. This was tested in asymptomatic and low risk patients. I believe it was removed as it appears the measure has become a standard practice and essentially everyone was doing it appropriately. So been taken out. Next slide, please. With the MVP, there were six new MIPS measures added to the Heart Disease MVP for quality and two cost measures. Quality measures being the antiplatelet therapy for coronary artery disease, as well as the ACE or ARB therapy for coronary artery disease measures, the screening for social drivers of health and the patient activation measure. This is a patient reported outcome measure or a PROM measure that presents the patient with a survey given to the patient at the beginning of care. And then again, 12 months later, and the point is to track whether the patient, the level to which they feel empowered regarding their healthcare, whether they have a voice in that healthcare. There were also five new MVPs created, none of which were directly related to cardiovascular. So I'm not gonna go into the details on them. In the MIPS program, the performance threshold, the points for the performance threshold were proposed to be raised from 75 up to 82 points in response to comments, seemingly overwhelming comments from various stakeholders. This is being maintained at 75 points, you know, rather than that increase for next year. The rule continues, further refines the MVPs and continues to attempt to align the policies with the MSSP with the MIPS program. The scoring breakdown is going to remain as it was, which is 30% on quality, 30% cost, 15% improvement activities, and 25% promoting interoperability. Next slide. In the Medicare Shared Savings Program or MSSP, some updates to the MSSP include the creation of Medicare Clinical Quality Measures or CQMs for accountable care organizations participating in the Medicare Shared Savings Program as a new collection type for Shared Savings Program ACOs under the Alternative Payment Model and the Alternative Payment Pathway. Another change was the, they're removing the Shared Savings Program Certified Electronic Health Record Technology or CERT threshold requirements beginning in performance year 2025 and adding a new requirement that all MIPS eligible clinicians, qualifying APM participants or QPs and partial QPs that are participating in an ACO regardless of track are to report the MIPS Promoting Interoperability Performance Category measures and requirements for the performance years beginning on or after January 1st, 2025. This was originally scheduled to go into effect for 2024. In the final rule, it was finalized, but with a one-year delay in response to comments asking to allow more time to prepare for the transition. Next slide, please. Final OPPS highlights, we can, there you go. All right, in the Outpatient Prospective Payment System, again, not a lot of major changes in this for cardiovascular. The overall system saw a 3.1% increase in payment rates reflecting the 3.3% increase in the market basket update reduced by a productivity adjustment of 0.2%. The cardiac ablation services were not proposed for the ACC covered procedure list. In the proposed rule, they were discussed briefly in the final rule because of comments submitted, presumably by those who had requested the codes be added. And CMS commented that they believe perhaps a greater degree of transparency in education regarding the application process may be needed. They stated that a webinar has been created and going through final vetting. It should be available for public viewing in January. And as a frame of reference, only 11 of 235 codes that were applied for the CPL were accepted. So it is a pretty narrow window there, but they are putting out more education seemingly to help people submitting these applications better understand the process. No guarantee that'll change the outcome, but that was CMS's comment. In regards to the cardiac PET scans, these were reviewed for updating their APC placement. They're in new technology APCs right now. The most widely used of these codes, 7, 8, 4, 3, 1, was finalized as proposed, which was over many comments objecting to this as it will be a decrease from the 2023 payment rate down to what it was in 2022. Again, based on claims data that shifts this from one APC to the next on kind of hard, empirical numbers, payment in the APC it was in in 2023 was $2,750.50. It will drop down to $2,250.50, approximately an 18% reduction. The college, along with the American Society for Nuclear Cardiology did submit comments, and I'm sure others opposing this change. Obviously, it was overruled. And further, the ACC, at least, did also request that there be more narrow pay bands developed because above a certain dollar amount, I believe above $2,000, the pay bands jump in $500 increments, which leads to great changes year to year based on sometimes random swings in the claims year to year. So CMS recognized it and mentioned it in their response to comments that they would look at that for future rulemaking. So perhaps we can, in the future, narrow the changes to that code going forward with narrower pay bands. The other two codes in this family, 78432, was proposed to be reduced as well to a smaller degree because its baseline was below that $2,000 threshold, so it would have been a lower drop. But in response to comments, again, from the ACC and the ASNC, they did, CMS, decide to change in the final rule and keep it in its current APC so there'll be no change to that APC placement or payment rate. And the 78433 was finalized as proposed, which was to keep it in its same APC, so no change in location or reimbursement on that code. There were no cardiovascular changes on the inpatient-only list, also no cardiovascular changes on the APC covered procedure list. Supervision by NPs, PAs, CNSs of cardiac rehabilitation, intensive cardiac rehabilitation, and pulmonary rehabilitation services. These can now be furnished with those professionals supervising. This CMS finalized regulatory changes to do this that conform with the ACC-promoted Improving Access to Cardiac and Pulmonary Rehabilitation Act, which passed as part of the Bipartisan Budget Act of 2018, allowing these changes to be implemented. We'll see in the final rule of the expiration of next year, there will be the expiration of the transitional pass-through payment for coronary and for intravascular lithotripsy, or IVL. Comments were submitted requesting the CMS address what will be a gap in reimbursement here. CMS did not extend this transitional pass-through payment or assign the procedures most often performed with IVL to a higher-paying APC. As a result, payment for IVL in the outpatient setting between July 1st of 2024 through December 31st will be bundled as part of the underlying PCI service. And finally, on the enhancement and enforcement of hospital transparency requirements, this is mostly kind of a patient-affecting front, but in brief summary, CMS is attempting to improve access and usability of information to the public while also reducing burdens on hospitals, and they're attempting to do that by providing CMS-created templates and technical guidance on how the hospital should display the standard charge information. Those rules were completed, finalized as proposed. That is everything I have on the QPP and SSP and the OPPS. I'm going to turn it over to James to give some updates on what we're doing in advocacy. James. Yeah, thanks, Matt. Thanks for running through that, and Nicole and Linda for all the great information up to here. This is a little bit farther afield from the fee schedule, but some relevant advocacy topics we wanted to share with this group and really engage audience. Thanks all for joining. I was going to note, I see some folks have their hands raised. I was checking with our moderator. If you have a question, it's best to put it in the Q&A because we can't really, with this many people, interface with the raised hands. So I'm going to let you all know that. The first thing that we see here in broader advocacy work that ACC is working on just now is the PPI surveys. We've been talking about this for the last six months already, and we'll talk about it for the next four or five yet. These are really important surveys that are being administered by the AMA, the American Medical Association, and a contractor to try to update the practice costs that Medicare uses to pay physicians. And so this will inform one of the many complicated steps of the payment formula when it comes to indirect practice costs. So I just dropped into the chat the kind of overall website we have on ACC explaining this. We've been talking a lot about it in advocacy newsletters, in the Board of Governors. We did a nationwide mailing to try to get a postcard in everybody's inboxes. So if you were going to receive these, you or one of the physicians maybe in the practice would have received it. It should be coming to someone with some sort of financial responsibility for the group. But hopefully you've got these now and you've identified them, or you still can. The first wave of surveys started in July, the second in October, and they're running all the way through April. So it's not too late. Please do take a look at those if you happen to have them or know others who have, or just confused, you can reach out to me. Next item we've got here is Medicare payment reform. We talked about the conversion factor cut. That's one element, just trying to kind of emergently fill this hole. There's a specific bill listed there. That one addresses trying to get an inflation-adjusted annual update. Another bill that's under consideration is a discussion draft that would raise the budget neutrality threshold. Right now it's just at $20 million, which maybe in 1987 was a lot of money, but it's really easy to hit that now. And then all of this is in the context of ongoing congressional dysfunction and difficulties with appropriations. The thing that is hard right now is with the way that the continuing resolutions are playing out to fund the government. There isn't an obvious legislative vehicle to do the sort of annual fix that we're trying to get right now. So we could see this go into January with some retroactive fix. It's really hard to say. I wish we could be more specific and optimistic right now. Other things that have been important recently or that are still on the horizon, transitional coverage of emerging technology is meant to be an innovative program from CMS to get coverage more quickly for breakthrough devices after the FDA approves them. It's not instant coverage because at least the ACC has viewed that as a little bit challenging in certain mechanical ways, but it should be more rapid than maybe some things that have happened in the past with that. There's a new, or not a new, but an updated national coverage determination for carotid artery stenting. If any of you are in practices with physicians that do that work, indications now reflect ACC guidelines. We were really happy to see that. It's been a long time since that policy was updated. Still an interesting time as there are providers that still don't think that technology is proven. So I'm not a clinician. We just try to work with what the guidelines say on our team. You know, we continue to expect a CMMI model on the cardiovascular front in the future. Our payer team is always in discussions with the agency on that. Matt did a lot of work last year on a proposal from the FTC regarding restricted covenants. I know that's a topic of interest to a lot of folks, some who really, really despise them and a smaller group that see them as an important tool for their practices. ACC tried to speak to both elements of that, but we'll see what, if anything, the FTC does down the way on that. We're working right now to respond to a proposed rule about the disincentives for information blocking as they affect facilities and clinicians and practices. So our team has reviewed that and working with our advocacy committee to put some thoughts down. You can, I don't know if we've got a resource on that offhand, but we can follow up or maybe there's something on acc.org. I think it's on the, I forget if it's an HHS site or an ONC rule, Office of National Coordinator. There might be a little more information there. Apologize for not having that at the ready. And that's it. We're always working on a wider variety of things because cardiology is a big specialty and there's a lot of different government agencies that interface with it and Congress, obviously. So I'll stop there and turn it back over to Nicole and Linda. I think if you, behind these slides, you've got space for Q&A and also some references to other summaries of some different topics. Yes, and James, this is the slide where we have the ACC Physician Fee Schedule Calculator from the final rule. So there's a link here where you can go and put in your volumes and get some calculations done. So this is where you can download this information from. And then as a reminder, I know we're getting a few coding questions on this particular web where we're focusing on the rules. We are gonna be starting our bootcamp on December 12th where we are going to, the first session is going into the CPT coding changes. Then we'll have a webinar on ASC coding and peripherals. And our one on Monday will be one with Linda and I going over complex E&M coding. So we're gonna cover a varying amount of things with high-level E&M services, critical care, and some prolonged services and other things there. So keep your detailed coding questions for those sessions if you didn't get an answer. I saw, and Matt may have answered this when I have, for some reason, I'm not able to see. Matt, I know they asked about if there was a CT PET payment reduction on the physician side for that CPT code as well. I don't believe there was, but I just wanted to confirm that. Yeah, I did write back that I don't believe I saw any change to that either, just the APC placement within the OPPS system. So, and we certainly didn't have the value come up at the RUC or anything, so. Okay, and then I know there's a code around the G2066 in regards to the technical portion. That is for our 30-day monitoring codes for the ICMs and the loop recorders. So they were asking if other CPT codes could be billed with that. When you look at how you're billing the G2066 now, it would fall into the same as using the global code versus how you're doing it now. So that one's a little harder to answer, but the G2066 was associated with ICMs and loop recorders only for 30-day monitor. Yeah, Nicole, could I build on that a little bit? Yes, absolutely. This is a complicated chunk here, and I wasn't thinking through anticipating questions of mixing 9.5 and or 9.6, 9.7 and 9.8. So I apologize, Robin. I don't know that I can answer that one just now. I was looking in the background at the MUEs and NCCI edits, and I don't see anything there that would prohibit what you're describing, but maybe we need to dig into that more deeply. An element that in conversations I've had with different vendors and clinicians is also, it could also be the case that depending what sort of service arrangement you have with a vendor, you're still just billing the 9.7 or 9.8-26 because it may be the case that the vendors, if the vendor previously billed the G2066, it's going to now likely be the case, and you'll want to confirm this with them, but what I think would likely be the case that they'll, so let's say it's the 9.7 code, you would maybe bill the 9.7-26 for the professional, and if the vendor has been billing the code directly, they would bill the 9.7-TC. So you may not want to jump straight to billing the global because that could create some paperwork headaches on the back end. Absolutely. All right. I think I have enough of those. Thank you very much. Yeah. Yeah, the mixing the 30 and the 90 days. Yeah, that's the other piece, and then they're, you know, they're obviously I know there's issues with billing two technicals on the same day when you're billing for ICM when devices have multiple capabilities. So it's not going to change the methodology of billing those services. So you want to know how you're billing them now, and if your vendor was billing the technical, if you were billing the technical, and if you're doing ICM interpretations on the same day as a pacemaker or a ICD implant, what were you doing previously with the G code? I don't believe that's going to change any of those principles, but we shall see because I don't think we'll know some of those things until mid-January. Yeah, I was just on the CCI sort of site and I wasn't seeing anything interesting there. One thing I might do just here at the end, if I can, Nicole. Deborah on our team put together a new code for 24 now that we had some guidance on some specific elements from the fee schedule rule. So maybe it's a little warmup for your MedAxium webinars next week. What's some whistles out there? Yes, yes. So we'll be going over the new codes. There's not really a lot out there. There's some, but there's some that I think, obviously coronary lithotripsy on the professional side, physicians will be happy. We don't have the T code to contend with. So a couple of other things in the congenital space and a few others. So definitely be diving deep into those coding weeds for that one. Linda, anything else that you want to share from questions you may have answered or anything? I don't think so. I think I'm pretty excited about the boot camps coming up, both the 2024 and the complex E&M. I'm working on that slide deck now. So if you've got those difficult, complex E&M scenarios and questions, there was one that was asked about split shared. And would the physician have to completely write the assessment and plan or would they need to be the first one to write the assessment and plan? And, you know, a lot of those things, I know we're waiting on a legal to interpret some of that too. Because Nicole showed you, you know, really when it says when the physician accepts that inherent risk, okay, well, they kind of do that when they co-sign. So, you know, I think when it comes to level of service, it really could be one sentence that documents the acute complicated condition that give you your nature of presenting illness. And then maybe that last one of their own parental control still, or, you know, you're going to be monitoring for toxicity doing labs in a couple of days. Now you could, in theory, in one sentence, support two out of three on that medical decision-making. So I think, you know, those of us with larger organizations, you know, reach out to your compliance folks and see how they're interpreting it. And I think we'll see more being released publicly and maybe more from Medicare as well. But yeah, we'll talk about what we can do. We'll try to get specific and get into the weeds during that complex E&M session. We'll also talk about prolonged services. That too has a change. If you've not noticed in 24, AMA removed the time ranges from the outpatient E&Ms, which then changes how you would implement prolonged. So we'll talk about that. And if you have other things that are on your mind, you want to hear about those perplexing things that keep you up at night, send an email. Send us an email. We'll be happy to look at it and figure out where that best fits. All right. Well, sounds great. I appreciate all of you who joined us for the webinar today. And we're going to go ahead and end. If we didn't get to your question, we will send out the Q&A or it'll be available to you. And this has also been recorded and is able to be listened to as well. So Linda, Matt, James, thank you very much. And I hope you have a good afternoon.

2024 final Medicare physician fee schedule

hospital payment rules

cardiology

reimbursement impacts

appropriate use criteria program

Telehealth services

distant site practitioners

billing telehealth services

direct supervision