On July 13, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) proposed rule for CY 2024 (CMS-1784-P). This rule updates payment policies and payment rates for Part B services furnished under the MPFS, as well as makes changes to the Quality Payment Program (QPP). The rule in its entirety and the addenda, including Addendum B, which lists the proposed RVUs for each CPT® code can be found on the CMS website. Comments are due on September 11.

• Proposed CY 2024 MPFS Impacts on Urology Codes Compared with CY 2022 Rates (Facility and Non-Facility Rates)
• Proposed CY 2024 MPFS Impacts on Evaluation & Management Codes Compared with CY 2022 Rates (Facility and Non-Facility Rates)

In this proposed rule, CMS discusses several significant policy changes including paying for HCPCS G2211 for services associated with complex patient care, creating and reimbursing HCPCS codes for health-related social needs services, and continuing to pay for telehealth services at the non-facility rate if the POS code indicates the originating site is the patient’s home. The following summarizes the major policies in the proposal. Note that the page numbers listed in this document refer to the display copy of the proposed rule.

Regulatory Impact Analysis

Highlight: Conversion factor set for a decrease yet again for CY 2024

Conversion Factor for 2024
The conversion factor for 2024 is set to decrease by approximately 3.36% from $33.8872 to $32.7476. This decrease is the result of a statutory 0% update scheduled for the PFS in 2024, a negative 2.17% RVU budget neutrality adjustment, and the expiration of part of the funding patch Congress passed at the end of 2022 through the Consolidated Appropriations Act of 2023 (CCA, 2023).

Specialty Level Impact of the Proposed Changes
The impact on group practices and individual physicians varies based on practice type and the mix of patients and services provided to those patients. Note that the impact table, Table 104, which estimates specialty level impacts, includes the 2.17% cut described above and includes impacts of rate-setting changes and changes to RVUs within the budget neutral system, including the impact of updated proposals to the complexity add-on code G2211. The following table outlines estimated specialty level impacts from Table 104 (Appendix C) and includes some of the specialties with the greatest impact, both positive and negative. We have included other specialties in this table for comparison.

Specialty	Medicare Allowed Charges (millions)	Work RVU Impact	PE RVU Impact	MP RVU Impact	Overall Impact
Hematology/Oncology	$1,591	1%	0%	0%	2%
Internal Medicine	$9,618	0%	1%	0%	1%
Obstetrics/Gynecology	$558	0%	1%	0%	1%
Urology	$1,623	0%	0%	0%	1%
Infectious Disease	$573	-1%	0%	0%	-1%
Vascular Surgery	$1,009	0%	-3%	0%	-3%
Interventional Radiology	$457	-1%	-3%	0%	-4%

Table 1: CY 2024 Estimated Impact Total Allowed Charges by Specialty

Determination of Practice Expense RVUs – p. 33

Highlight: No change in the MEI methodology while CMS waits for updated practice expense data from the AMA.

Last year, CMS finalized policy to rebase and revise the Medicare Economic Index (MEI) to reflect current market conditions in providing physician services. However, after receiving comments on this issue, and considering the American Medical Association’s project of updating and collecting new data through the Physician Practice Information Survey (PPIS), CMS has again delayed implementation of the rebased MEI data.

Payment for Medicare Telehealth Services Under Section 1834(m) of the Act – p. 68

Highlight: CMS updates telehealth regulations to be consistent with Consolidated Appropriations Act, 2023 extensions and will continue to pay for telehealth services at the non-facility rate if the POS code indicates the originating site is the patient’s home.

CMS Proposal to Add New Codes to the Telehealth List
CMS proposes to add HCPCS code GXXX5 (Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment tool, 5-15 minutes) to the telehealth list. This service requires a face-to-face encounter between a clinician and beneficiary during which the practitioner uses their clinical judgement to determine whether to complete the SDOH screening with or without direct patient interaction. The service must be delivered on the same day as an E/M service, which can be delivered via telehealth.

Proposed Clarifications and Revisions to the Process for Considering Changes to the Medicare Telehealth Services
CMS clarifies the process by which services may be added to the Medicare Telehealth Services list. The determination to add a service to the list on a temporary Category 3 basis is part of the regular, not the public health emergency-related, process to allow the service to be furnished via telehealth while additional evidence is developed; this evidence is then used to make a determination about whether the service should be added to the list permanently. CMS believes the Category 1, 2, or 3 designation is causing confusion and instead proposes to consider additions to the list on either a permanent or provisional basis.

To add a service to the list, CMS requires evidence to support how the telehealth service is either clinically equivalent to a telehealth service already on the list permanently or evidence that presents studies where findings suggest a clinical benefit sufficient for the service to remain on the list provisionally to allow time for confirmative study. Proposed steps of analysis for services under consideration for addition, removal, or change in status on the Medicare telehealth list include:

1. A determination of whether the service is separately payable under the PFS.
2. A determination of whether the service is subject to the provisions of section 1834(m) of the Act: This condition is satisfied when at least some elements of the service, when delivered via telehealth, are a substitute for an in-person, face-to-face encounter, and all those face-to-face elements of the service are furnished using an interactive telecommunications system.
3. Review of the elements of the service as described by the HCPCS code and a determination of whether each of them is capable of being furnished using an interactive telecommunications system.
4. Consideration of whether the service elements of the requested service map to the service elements of a service on the list that has a permanent status described in a previous final rulemaking.
5. Consideration of whether there is evidence of clinical benefit analogous to the clinical benefit of the in-person service when the patient, who is located at a telehealth originating site, receives a service furnished by a physician or practitioner located at a distant site using an interactive telecommunications system.

CMS proposes to assign “provisional” status on the Medicare Telehealth Services List when there is enough evidence to suggest that further study may demonstrate that the service, when provided via telehealth, is of clinical benefit. Where the clinical benefit of a telehealth service is clearly analogous to that of an in-person service, CMS proposes to assign the code “permanent” status on the list even if the code’s service elements do not map to the service elements of a service that already has permanent status.

Should these proposed changes be finalized, the timeline to analyze submissions would be unchanged: CY 2025 submissions would be due by February 10, 2024. Additionally, all requests for additions, deletions, and modifications to the telehealth list would be addressed through annual notice and comment rulemaking.

Consolidation of the Categories for Services Currently on the Medicare Telehealth Services List
For services already on the Medicare Telehealth Services List, CMS is proposing that those designated as Category 1 or 2 be designated as “permanent” and those designated as temporary Category 2 or Category 3 be designated as “provisional.” The agency does not propose any specific timing for reevaluation of services on the list provisionally because evidence generation may not align with a specific timeline.

Implementation of Provisions of the CAA, 2023
The CAA, 2023 extended certain telehealth policies through December 31, 2024. CMS seeks to update its regulations to reflect this extension for the following flexibilities: (1) in-person requirements for mental health telehealth; 92) originating site requirements; (3) the expansion of telehealth practitioners to include occupational therapists, physical therapists, speech-language pathologists, and audiologists as well as marriage and family therapists and mental health counselors as of January 1, 2024; and (4) audio-only services.

In the CY 2023 final rule, CMS established POS 10 for telehealth provided in the patient’s home. The agency proposes that claims billed with POS 10 will be paid at the non-facility rate beginning in CY 2024 in recognition that practitioners will need to maintain an in-person practice setting in addition to providing telehealth services. Claims billed with POS 02 (Telehealth Provided Other than in Patient’s Home) will continue to be paid at the facility rate beginning on January 1, 2024. CMS believes, for these non-home originating sites, such as physician’s offices and hospitals, the facility rate more accurately reflects the PE of these telehealth services. Through this policy, the agency seeks to protect access to mental health and other telehealth services by aligning with the telehealth-related flexibilities that were extended via the CAA, 2023.

Other Non-Face-to-Face Services Involving Communications Technology under the PFS
Direct Supervision
CMS is concerned about the abrupt expiration of its policy to allow direct supervision via a virtual presence at the end of 2023 since practitioners have established new practice patterns during the public health emergency. Therefore, the agency proposes to continue to define direct supervision to permit the presence and “immediate availability” of the supervising practitioner through real-time audio and visual interactive telecommunications through December 31, 2024, to align with the extension of other telehealth flexibilities through that date. During this time, CMS will collect more data to inform a more permanent approach to direct supervision. The agency is soliciting comment on whether the definition of direct supervision to permit virtual presence should be extended beyond December 31, 2024 and would like input on patient safety or quality concerns stemming from virtual direct supervision; if this flexibility would be more appropriate for certain types of services or when certain types of personnel are performing the supervised service; and potential program integrity concerns.

Supervision of Residents in Teaching Settings
In the CY 2021 final rule, CMS included a policy to allow teaching physicians to supervise residents virtually for services delivered in residency training sites that are located outside of an Office of Management and Budget-defined metropolitan statistical area (MSA) after the end of the public health emergency and now seeks to align this policy with other telehealth policies. The agency proposes to allow the teaching physician to have a virtual presence in all teaching settings when the services is furnished virtually through December 31, 2024. The virtual presence policy would continue to require real-time observation by the teaching physician and would exclude audio-only technology. The documentation would have to include whether the physician was physically present or present virtually at the time of the telehealth service.

CMS is exercising enforcement discretion to allow teaching physicians in all residency training sites to be present virtually for services furnished involving residents through December 31, 2023.

The agency seeks comment on how telehealth services can be furnished in all residency training sites beyond December 31, 2024, including what other clinical treatment situations are appropriate to permit the virtual presence of the teaching physician.

Clarifications for Remote Monitoring Services
Under current policy, remote physiologic monitoring (RPM) services may only be delivered to established patients after the end of the public health emergency. Patients who received initial remote monitoring services during the public health emergency are now considered established patients for the purpose of this policy.

The agency is not extending its interim policy to permit billing for remote monitoring codes when less than 16 days of data are collected within a given 30-day period. This 16-day monitoring requirement was reinstated when the public health emergency expired and applies to RPM and remote therapeutic monitoring (RTM) services. This requirement applies to the following codes:

• 98976 (Remote therapeutic monitoring (eg, therapy adherence, therapy response);
  device(s) supply with scheduled (eg, daily) recording(s) and/or programmed alert(s)
  transmission to monitor respiratory system, each 30 days);
• 98977 (Remote therapeutic monitoring (eg, therapy adherence, therapy response);
  device(s) supply with scheduled (eg, daily) recording(s) and/or programmed alert(s)
  transmission to monitor musculoskeletal system, each 30 days);
• 98978 (Remote therapeutic monitoring (eg, therapy adherence, therapy response);
  device(s) supply with scheduled (eg, daily) recording(s) and/or programmed alert(s)
  transmission to monitor cognitive behavioral therapy, each 30 days);
• 98980 (Remote therapeutic monitoring treatment management services, physician or
  other qualified health care professional time in a calendar month requiring at least one
  interactive communication with the patient or caregiver during the calendar month; first 20 minutes); and
• 98981 (Remote therapeutic monitoring treatment management services, physician or
  other qualified health care professional time in a calendar month requiring at least one
  interactive communication with the patient or caregiver during the calendar month; each
  additional 20 minutes (List separately in addition to code for primary procedure)).

Use of RPM, RTM, in conjunction with other services
Either RPM or RTM, but not both, may be billed concurrently with the following care management services: Chronic Care Management (CCM), Transitional Care Management (TCM), Behavioral Health Integration (BHI), Principal Care Management (PCM), and Chronic Pain Management (CPM). CMS intends to provide maximum flexibility for practitioners to select the appropriate mix of care management services without creating program integrity concerns.

Other Clarifications for Appropriate Billing
CMS has received inquiries regarding the use of remote monitoring during surgical global periods and proposes to clarify that RPM or RTM services may be furnished and paid separately from the global period if the requirements for the global and remote monitoring service are both met.

Telephone Evaluation and Management Services
Since the start of the public health emergency, CMS has separately paid for CPT codes 99441 through 99443 and 98966 and 98968, which describe E/M and assessment and management services delivered via telephone. The agency proposes to continue to assign an active payment status for these services through CY 2024 to align with the telehealth flexibilities extended through 2024.

Telehealth Originating Site Facility Fee Payment Amount Update
For CY 2024, CMS proposes that the payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is $29.92.

Valuation of Specific Codes – p. 177

Highlight: In this year’s proposed rule, CMS has accepted over 90% of the RUC’s recommendations.

Cystourethroscopy – p. 186
The AUA was instrumental in valuing new and revised CPT codes, through the AMA RUC survey process, used to report services for cystourethroscopy and bladder dysfunction. CMS proposes to accept the RUC-recommended work RVU of 3.10 for new CPT code 5X000 (Cystourethroscopy, with mechanical urethral dilation and urethral therapeutic drug delivery by drug coated balloon catheter for urethral stricture or stenosis, male, including fluoroscopy, when performed). The code will be available for use January 1, 2024.

Neurostimulator Services – p. 190
CMS proposes to accept the RUC recommended work RVUs for neurostimulator services associated with bladder dysfunction. Those services are described by CPT codes 64590 (Insertion or replacement of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, requiring pocket creation and connection between electrode array and pulse generator or receiver) and 64595 (Revision or removal of peripheral, sacral, or gastric neurostimulator pulse generator or receiver, with detachable connection to electrode array) and will have work RVUs of 5.10 for 64590 and 3.79 for 65495.

Additionally, CMS has requested clarification regarding the practice expense values for code 64590. The agency believes that the RUC has mistakenly proposed incorrect times for two equipment pieces used in the provision of this service. The proposed 56 minutes of equipment time for EQ114 (electrosurgical generator) instead of 48 minutes, which would match the clinical labor time. Also, the agency believes that the RUC intended to propose 84 minutes of equipment time for EQ209 (programmer, neurostimulator (w- printer)) to match the equipment time used in for a power table at the follow-up visit.

Pelvic Exam – p. 213
At the September 2022 AMA CPT Editorial Panel Meeting, the Panel approved a new code to capture the practice expense of providing a clinical staff chaperone during a pelvic examination. The new CPT code 9X036 is a practice expense-only code, and therefore has no work associated with the service. As such, the code is valued with a PE RVU of 0.68 which captures four minutes of clinical staff time when chaperoning a pelvic exam. The code may be reported with evaluation and management services in the non-facility/office setting.

Payment for Caregiver Training Services (CTS) – p. 218
In recent years, CMS has been exploring policies to increase the support and training needed when caring for patients that have certain illnesses and diseases. New this year, and to align with a White House executive order to increase access to high quality care and increase support for caregivers, CMS proposes to make payment for CTS by establishing an active payment status for CPT® codes 96202 (Multiple-family group behavior management/modification training for parent(s)/guardian(s)/caregiver(s) of patients with a mental or physical health diagnosis, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of parent(s)/guardian(s)/caregiver(s); initial 60 minutes) and 96203 (each additional 15 minutes).

Additionally, the agency proposes payment for new codes 9X015 (Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face; initial 30 minutes), 9X016 (each additional 15 minutes), and 9X017 Group caregiver training in strategies and techniques to facilitate the patient's functional performance in the home or community (eg, activities of daily living [ADLs], instrumental ADLs [IADLs], transfers, mobility, communication, swallowing, feeding, problem solving, safety practices) (without the patient present), face-to-face with multiple sets of caregivers).

In the rule, the agency includes a definition of caregiver to include “a family member, friend, or neighbor who provides unpaid assistance to a person with a chronic illness or disabling condition.” CMS has also broadly defined the types of clinical scenarios where CTS may be beneficial including stroke, traumatic brain injury (TBI), various forms of dementia, autism spectrum disorders, individuals with other intellectual or cognitive disabilities, physical mobility limitations, or necessary use of assisted devices or mobility aids. If finalized, payment for these services will go into effect January 1, 2024.

Evaluation and Management (E/M) Visits – p. 240

Highlight: CMS revises utilization assumptions for O/O E/M visit complexity add-on code reduces negative impact on conversion factor and seeks comments on how to properly value E/M and other services.

Office/Outpatient (O/O) E/M Visit Complexity Add-on Implementation
For CY 2021, CMS had finalized the O/O E/M visit complexity add-on code G2211 to describe intensity and complexity inherent to O/O E/M visits for 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, or complex condition. The agency planned for the add-on code to be reported with all O/O E/M service levels. However, Congress delayed the code’s implementation until January 1, 2024.

Since the delay of the code’s implementation, CMS has received feedback from stakeholders about when it would be appropriate to report G2211 and the redistributive impact of its implementation. The agency proposes to assign the add-on code the “active” status indicator effective January 1, 2024, as well as several policy refinements. First, CMS proposes that G2211 would not be payable when the O/O E/M visit is reported with payment modifier -25, meaning that the add-on code cannot be billed when an O/O E/M service is billed on the same day as a procedure or other service by the same practitioner.

Additionally, CMS revised its utilization assumptions and does not believe that it would be appropriate to bill G2211 when the care delivered during the O/O E/M visit is provided by a practitioner whose relationship with the patient is “of a discrete, routine, or time-limited nature; such as, but not limited to, a mole removal or referral to a physician for removal of a mole; for treatment of a simple virus; for counseling related to seasonal allergies, initial onset gastroesophageal reflux disease; treatment for a fracture; and where comorbidities are either not present or not addressed, and/or when the billing practitioner has not taken responsibility for ongoing medical care for that particular patient with consistency and continuity over time, or does not plan to take responsibility for subsequent ongoing medical care for that particular patient with consistency or continuity over time.” The agency excluded claims from practitioners participating in CMS capitated models; for established patient visits performed by specialties that are unlikely to have a longitudinal care relationship with a beneficiary; and for services delivered as consults or to provide a second opinion. CMS expects the code will be billed with 38 percent of all office visit E/M services in the first several years of use, and after education and update for the code over several years, the estimation of billing jumps to 54 percent of all office visit E/M services. CMS seeks comment on these utilization assumptions.

Request for Comment About Evaluating E/M Services More Regularly and Comprehensively
CMS is seeking comment about the range of approaches that the agency could take to improve the accuracy of valuing services and is particularly interested in how E/M services might be evaluated with greater specificity, more regularly and comprehensively. Feedback is requested on the following questions:

• Do the existing E/M HCPCS codes accurately define the full range of E/M services with appropriate gradations for intensity of services?
• Are the methods used by the RUC and CMS appropriate to accurately value E/M and other HCPCS codes?
• Are the current non-E/M HCPCS codes accurately defined?
• Are the methods used by the RUC and CMS appropriate to accurately value the non-E/M services?
• What are the consequences if services described by HCPCS codes are not accurately defined?
• What are the consequences if services described by HCPCS codes are not accurately valued?
• Should CMS consider valuation changes to other codes like the approach in section II.J.5 (Adjustments to Payment for Timed Behavioral Health Services on p. 293) of this rule?
  • CMS is particularly interested in approaches to ensure that the relative values of these services accurately reflect the resources required to deliver them, especially since systemic undervaluation could serve as an economic deterrent to their delivery and be a contributing factor to the workforce shortage.

CMS requests specific recommendations on ways to improve data collection and to make better evidence-based and more accurate payments for E/M and other services. The agency seeks to make more timely improvements to its methodologies to reflect changes in the beneficiary population, treatment guidelines, and new technologies that represent standards of care. Additionally, CMS seeks recommendations that would ensure data collection from, and documentation requirements for these services impose as little burden as possible on physician practices. The agency is interested in comments on whether the AMA RUC is the entity best positioned to provide recommendations on resource inputs for work and PE, as well as how to establish values for E/M and other physician services; or if another independent entity would better serve CMS and interested parties in providing these recommendations.

Split/Shared Visits
A split/shared visit is an E/M service performed by a physician and a NPP in the same group practice in the facility setting where the “incident to” policy does not apply. CMS has proposed, and delayed multiple times, that the “substantive portion,” which determines who bills the service—the physician or the NPP—would be defined by which practitioner provides more than half the service by time. In this proposed rule, the agency intends to maintain the current definition of “substantive portion,” which allows for the use of either one of the three components—history, exam or medical-decision making—or more than half of the total time spent to determine the provider that will bill for the visit. CMS will continue to analyze and collect information from interested parties.

Services Addressing Health-Related Social Needs (Community Health Integration Services, Social Determinants of Health Risk Assessment, and Principal Illness Navigation Services)

Highlight: The agency proposes to pay for new services to provide greater access to care that includes payment for community health workers services.

Community Health Integration Services – p. 236
The agency has taken steps to recognize the valuable services that community health workers (CHWs) provide when assisting Medicare beneficiaries with services not typically reimbursed on the MPFS. Therefore, CMS is proposing the creation of two new HCPCS codes to describe services performed by “certified or trained auxiliary personnel, which may include a CHW, incident to the professional services and under the general supervision of the billing practitioner.”

The services described by the new codes are expected to be provided monthly after an E/M visit (CHI initiating visit) in which the provider identifies the need for CHI based on the presence of certain social determinants of health (SDOH) factors. The framework for the provision of these services is similar to that for care management services. The first visit, the CHI initiating visit would “serve as the pre-requisite for billing CHI services by the billing practitioner” whereby they would identify and assess the SDOH needs of the patient that limit the practitioners ability to diagnose and treat the patient’s medical condition. Any of the follow-up CHI performed by the CHW or other authorized personnel would be billed incident the professional services of the practitioner who billed the initiating visit. For a proposed descriptor of the codes, see page 241 of the proposed rule.

Social Determinants of Health (SDOH) – Establishment of a HCPCS G Code – p. 251
One of the pillars of the Biden administration has been the development of policies and regulations that address health equity and fair access to government funded programs. In keeping with this, the agency proposes the development of HCPCS code GXXX5 - Administration of a standardized, evidence-based Social Determinants of Health Risk Assessment, 5-15 minutes, not more often than every 6 months. The agency has proposed a total RVU of 0.57 when performed in the non-facility setting.

The code was developed to account for time and other resources required when providers are assessing their patient’s SDOH as those factors usually affect the outcome of treatment. CMS has stated that the performance of the SDOH risk assessment must be provided on the same date as an E/M service. The required elements of the assessment must include “administration of a standardized, evidence-based SDOH risk assessment tool that has been evaluated and validated through research, and includes the domains of food insecurity, housing insecurity, transportation needs, and utility difficulties.”

The service must be documented in the medical record and accompanied by ICD-10-CM codes Z codes (Z55-Z65) which are codes used to indicate SDOH data. Finally, the agency proposes adding this service to the Medicare Telehealth Services List to allow greater access. The agency is seeking comment on this service, how it may be provided and where. Additionally, CMS proposes to add the SDOH Risk Assessment be added as an optional, additional element of the annual wellness visit with an additional payment.

Principal Illness Navigation – p. 256
Included in this rule and conforming with other proposals that expand care for many different types of populations, CMS has proposed to create HCPCS codes and payment to describe services associated with the care of patients with a “serious, high-risk disease expected to last at least 3 months, that places the patient at significant risk of hospitalization or nursing home placement, acute exacerbation/decompensation, functional decline, or death.”

The new services, Principal Illness Navigation (PIN), are like CHI services, but the patient may not necessarily have SDOH that affect their care and as such may involve “service elements to describe identifying or referring the patient to appropriate supportive services, providing information/resources to consider participation in clinical research/clinical trials, and inclusion of lived experience or training in the specific condition being addressed.”

The services will be billed incident to physician services and provided under general supervision. The code descriptions are found on page 264 of the proposed rule. The service described by code GXXX3 is billed 60 minutes per calendar month, and the second code, GXXX4 is billed each additional 30 minutes per calendar month. CMS has proposed work RVUs of 1.00 for GXXX3 and 0.70 for GXXX4.

Drugs and Biological Products Paid Under Medicare Part B – p. 351

Highlight: Policies related to the Inflation Reduction Act are codified. CMS is seeking comments non-chemotherapeutic complex drug administration payments.

Provisions from the Inflation Reduction Act Relating to Drugs and Biologicals Payable Under Medicare Part B
The Inflation Reduction Act (IRA) included several provisions that impact payment limits or beneficiary out-of-pocket costs for certain drugs payable under Part B. The agency is proposing to codify these provisions in regulation. Two provisions that affect payment limits for biosimilar biological products (“biosimilars”) are as follows:

• Section 11402 amends the payment limit for new biosimilars furnished on or after July 1, 2024, during the initial period when ASP data is not available
• Section 11403 revises the payment limit for certain biosimilars with an average sales price (ASP) that is not more than the ASP of the reference biological for a period of 5 years (CMS implemented this section with program instructions)

Two provisions make statutory changes that affect beneficiary out-of-pocket costs for certain Part B drugs are as follows:

• Section 11101 of the IRA requires that beneficiary coinsurance for a Part B rebatable drug be based on the inflation-adjusted payment amount if the Medicare payment amount for a calendar quarter exceeds the inflation-adjusted payment amount, starting on April 1, 2023 (CMS issued initial guidance to implement this provision)
• Section 11407 of the IRA provides that for insulin furnished through an item of durable medical equipment (DME) on or after July 1, 2023, the deductible is waived, and the coinsurance is limited to $35 for a month’s supply of insulin furnished through a covered DME (CMS implemented this section with program instructions)

Payment for Drugs Under Medicare Part B During an Initial Period
Section 11402 of the IRA required that for new biosimilars furnished on or after July 1, 2024, during the initial period when ASP data is not available, the payment limit for the biosimilar will be the lesser of: 1) an amount not to exceed 103 percent of the Wholesale Acquisition Cost (WAC) of the biosimilar or the Medicare Part B drug payment methodology, or 2) 106 percent of the lesser of the WAC or ASP of the reference biological, or in the case of a selected drug during a price applicability period, 106 percent of the maximum fair price of the reference biological. CMS is proposing to codify these changes in regulation.

Inflation-adjusted Beneficiary Coinsurance and Medicare Payment for Medicare Part B Rebatable Drugs
Section 11101 of the IRA requires the payment of rebates into the Supplementary Medical Insurance Trust Fund for Part B rebatable drugs if the payment limit amount exceeds the inflation-adjusted payment amount. CMS previously issued final guidance for computing the inflation-adjusted beneficiary coinsurance. Additional information on implementation of this section can be found on the CMS website.

For Part B rebatable drugs furnished on or after April 1, 2023, in quarters where the amount specified in the statute exceeds the inflation-adjusted payment amount, the coinsurance will be 20 percent of the inflation-adjusted payment amount for that quarter. The agency is proposing to codify the coinsurance amount for Part B rebatable drugs.

The section also requires that if the inflation-adjusted payment amount of a Part B rebatable drug exceeds the payment amount described in the statute, then the Part B payment will equal the difference between the payment amount and the inflation-adjusted coinsurance amount. CMS is proposing to codify the Medicare payment for Part B rebatable drugs.

Limitations on Monthly Coinsurance and Adjustments to Supplier Payment Under Medicare Part B for Insulin Furnished through Durable Medical Equipment
Drugs furnished through a covered item of DME are covered under Part B. Insulin that is administered through a covered DME, such as a durable insulin pump, is covered under this benefit. Section 11407 of the IRA made three changes to beneficiary payment for insulin furnished through covered DME. The bill waived the Part B deductible for insulin furnished through covered DME on or after July 1, 2023. It established a $35 limit on the beneficiary coinsurance amount for a month’s supply of insulin furnished on or after July 1, 2023, and required the Secretary to increase to the Part B payment to above 80 percent in cases where the coinsurance amount for insulin equals less than 20 percent of the payment amount to pay for the full difference between the payment amount and coinsurance; this ensures that the supplier is not responsible for the reduction in the beneficiary coinsurance amount.

CMS implemented these provisions through program instruction, which can be found in the CMS Manual System. The agency is proposing to codify the provisions from the program instruction in regulation. This includes the following provisions:

• The $35 coinsurance limit applies to the duration of the calendar month in which the date of service occurs, which is the date that the beneficiary receives the insulin, or it is shipped.
• When a 3-month supply is billed for insulin, then a coinsurance limit of $105 applies for the 3-calendar month period.
• MACs will ensure that the coinsurance does not exceed $35 for a 1-month supply or $105 for a 3-month supply for claims billing insulin administered through covered DME.

Request for Information: Drugs and Biologicals which are not Usually Self-Administered by the Patient, and Complex Drug Administration Coding
Medicare is allowed to pay for services and supplies, including drugs and biologicals, that are not usually self-administered by the patient and that are furnished as “incident to” a physician’s professional service. CMS has provided definitions and guidance to the MACs about determining if a drug is usually self-administered and publishing this information on their websites as the self-administered drug (SAD) list. Stakeholders have requested that CMS update and clarify the SAD list guidance. Stakeholders have also raised concerns that non-chemotherapeutic complex drug administration payments are inadequate and do not reflect the resources used to furnish infusion services.

CMS is requesting comments on these two issues, particularly on whether the agency should revise policy guidelines to better reflect how these specific infusion services are furnished and should be billed.

Requiring Manufacturers of Certain Single-Dose Container or Single-Use Package Drugs to Provide Refunds with Respect to Discarded Amounts
Section 90004 of the Infrastructure Investment and Jobs Act (“the Infrastructure Act”) added a new requirement for manufacturers to provide a refund to CMS for certain discarded amounts from a refundable single-dose container or single-use package drug, referred to as a “refundable drug.” The refundable amount is the amount of discarded drug that exceeds an applicable percentage of total charges for the drug in each calendar quarter; the applicable percentage is required to be at least 10 percent.

CMS previously finalized several policies to implement this new requirement in the CY 2023 MPFS final rule. The agency proposes several more policies in this rule:

• The date of the initial report to manufacturers;
• The date for subsequent reports to manufacturers;
• The method for calculating refunds for discarded amounts in lagged claims data;
• The method for calculating refunds when there are multiple manufacturers for a refundable drug;
• Increased applicable percentages for certain drugs with unique circumstances; and
• A future application process for manufacturers to apply for an increased applicable percentage for a drug

Modifications Related to Medicare Coverage for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTPs) – p. 500

Highlight: Agency sees value in providing telehealth opioid treatment services.

During the COVID-19 public health emergency (PHE), CMS allowed opioid treatment programs to deliver periodic assessments using audio-only communications, if audio-visual communication was not available. In this rule, CMS proposes to allow OTPs to use, and hence billing of audio-only periodic assessments until the end of 2024. The agency sees this as a means to promote beneficiary access to these valuable services while maintaining care due to the end of the COVID-19 PHE. The agency notes in the rule that use of audio-only services must meet SAMHSA and DEA requirements at the time the service is provided.

Medicare Part B Payment for Preventive Vaccine Administration Services – p. 757

Highlight: Vaccine payment rates stay the course

The agency did not propose any changes to payment rates for the administration of preventive vaccines. Nor were there any policy updates as to how CMS would develop those rates. As finalized in 2023, the agency will continue to update payment rates for preventative vaccines using the percentage increase in the Medicare Economic Index. Those base payments will then be adjusted by a geographic locality adjustment to account for differences in costs across the US.

Updates to the Quality Payment Program (QPP) – p. 946

CMS continues to move the QPP forward, including focusing more on measurement efforts and refining how clinicians would be able to participate in a more meaningful way, to achieve continuous improvement in the quality of health care services provided to Medicare beneficiaries and other patients through the QPP’s Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs) for the CY 2024 performance period/2026 MIPS payment year.

Transforming the QPP – p. 959

This proposed rule aims to advance CMS’ National Quality Strategy Goals by increasing alignment across value-based programs, advancing health equity, and accelerating interoperability. As such, CMS is requesting comments on how they can modify policies under the QPP to foster clinicians’ continuous performance improvement and positively impact care outcomes for Medicare beneficiaries. CMS requests feedback on the following questions:

• What potential policies in the MIPS program would provide opportunities for clinicians to continuously improve care?
• Should we consider, in future rulemaking, changes in policies to assess performance to ensure ongoing opportunities for continuous performance improvement?
• Should we consider, for example, increasing the reporting requirements or requiring that specific measures be reported once MVPs are mandatory?
• Should we consider creating additional incentives to join APMs to foster continuous improvement, and if so, what should these incentives be?
• What changes to policies should CMS consider assessing continuous performance improvement and clinicians interested in transitioning from MIPS to APMs?
• We acknowledge the potential increase in burden associated with increasing measure reporting or performance standards. How should we balance consideration of reporting burden with creating continuous opportunities for performance improvement?
• While we are aware of potential benefits of establishing more rigorous policies, requirements, and performance standards, such as developing an approach for some clinicians to demonstrate improvement, we are also mindful that this will result in an increasing challenge for some clinicians to meet the performance threshold. Are there ways to mitigate any unintended consequences of implementing such policies, requirements, and performance standards?

MVP Development, Maintenance, and Scoring – p. 966

In the CY 2023 PFS final rule, CMS finalized modifications to the MVP development process to include feedback from the public before the notice and comment rulemaking process. CMS aims to gradually develop new MVPs that are relevant and meaningful for all clinicians who participate in MIPS.

In this proposed rule, CMS is proposing the following five new MVPs:

1. Focusing on Women’s Health;
2. Prevention and Treatment of Infectious Disease Including Hepatitis C and HIV;
3. Quality Care in Mental Health and Substance Use Disorder;
4. Quality Care for Ear, Nose, and Throat (ENT); and
5. Rehabilitative Support for Musculoskeletal Care

See Appendix 3: MVP Inventory (p. 1979) for details on the new MVPs.

In the CY 2022 and 2023 PFS final rules, CMS finalized a total of 12 MVPs that are available for reporting beginning with the CY 2023 performance period/2025 MIPS payment year. In this proposed rule, CMS is proposing modifications to these 12 MVPs to reflect the removal of certain improvement activities and the addition of other relevant existing quality measures.

1. Advancing Rheumatology Patient Care;
2. Coordinating Stroke Care to Promote Prevention and Cultivate Positive Outcomes;
3. Advancing Care for Heart Disease;
4. Optimizing Chronic Disease Management;
5. Adopting Best Practices and Promoting Patient Safety within Emergency Medicine;
6. Improving Care for Lower Extremity Joint Repair; and
7. Patient Safety and Support of Positive Experiences with Anesthesia
8. Advancing Cancer Care;
9. Optimal Care for Kidney Health;
10. Optimal Care for Neurological Conditions;
11. Supportive Care for Cognitive-Based Neurological Conditions; and
12. Promoting Wellness.

Additionally, through the MVP maintenance process, CMS is proposing to consolidate the previously finalized Promoting Wellness and Optimizing Chronic Disease Management MVPs into a single consolidated primary care MVP titled Value in Primary Care MVP, which aligns with the Adult Universal Core Set, as described in a journal article, “Aligning Quality Measures across CMS- The Universal Foundation.”¹

See Appendix 3: MVP Inventory (p. 1979) for the proposed modifications to the established MVPs.

MIPS Performance Category Measures and Activities – p. 952

There are three MIPS reporting options currently available: Traditional MIPS; MIPS Value Pathways (MVPs); and Alternative Payment Model (APM) Performance Pathway (APP). Under Traditional MIPS and MVPs, performance is measured across four areas – quality, improvement activities, Promoting Interoperability, and cost. Alternatively, under APPs, performance is measured across three areas - quality, improvement activities, and Promoting Interoperability.

Quality Performance Category
CMS proposes the following modifications to the quality performance category:

• To expand the definition of the collection type to include Medicare Clinical Quality Measures for Accountable Care Organizations Participating in the Medicare Shared Savings Program (Medicare CQMs).
• To establish the quality performance category data submission criteria for eCQMs that requires the utilization of CEHRT.
• To establish the data submission criteria for Medicare CQMs.
• To require the administration of the Consumer Assessment of Healthcare Providers and Systems (CAHPS) for MIPS Survey in the Spanish translation.
• To maintain the data completeness criteria threshold to at least 75 percent for the CY 2026 performance period/2028 MIPS payment year and increase the data completeness criteria threshold to at least 80 percent for the CY 2027 performance period/2029 MIPS payment year.
  • To establish the data completeness criteria for Medicare CQMs.

CMS is also proposing the addition of fourteen quality measures, including 1 composite measure and 7 high priority measures, of which 4 are patient-reported outcome measures. (See Appendix A below) This would result in a total of 200 quality measures for the 2024 performance period.

Cost Performance Category
There are currently a total of 25 cost measures available: Total per Cost Capita (TPCC) measure; Medicare Spending per Beneficiary (MSBP) Clinician Measure; and 23 episode-based cost measures. In addition to the existing measures, CMS is proposing to add 5 new episode-based cost measures beginning with the CY 2024 performance period. The measures are:

• An acute inpatient medical condition measure (Psychoses and Related Conditions)
• Three chronic condition measures (Depression, Heart Failure, and Low Back Pain)
• A measure focusing on care provided in the emergency department setting (Emergency Medicine).

CMS is also proposing to remove the acute inpatient medical condition measure – Simple Pneumonia with Hospitalization – beginning with the CY 2024 performance period/2026 MIPS payment year. Due to coding changes, the measure no longer assesses the cost of pneumonia-related care as originally intended.

Additionally, CMS is proposing to calculate improvement scoring for the cost performance category at the category level without using statistical significance beginning with the CY 2023 performance period/2025 MIPS payment year. This updated methodology would ensure mathematical and operational feasibility to allow for improvement to be scored in the cost performance category starting with the 2023 performance period/2025 MIPS payment year. This update would also align with CMS’ methodology for scoring improvement in the quality performance category.

Improvement Activities Performance Category
CMS is proposing to add five new improvement activities. These proposals include an MVP-specific improvement activity titled “Practice-Wide Quality Improvement in MIPS Value Pathways.” This improvement activity would allow clinicians to receive full credit in this performance category for adopting a formal model for quality improvement related to a minimum of three of the measures reported as part of a specific MVP. CMS is also proposing to modify one existing improvement activity and remove three existing improvement activities. If these proposals are finalized, there would be a total of 106 improvement activities in the MIPS inventory. A list of the proposed changes are listed below and included in Appendix 2 (p. 1968) of the proposed rule.

New Improvement Activities Proposed for the CY 2024 Performance Period/2026 MIPS Payment Year and Future Years

• Improving Practice Capacity for Human Immunodeficiency Virus (HIV) Prevention Services
• Practice-Wide Quality Improvement in MIPS Value Pathways
• Use of Decision Support to Improve Adherence to Cervical Cancer Screening and Management Guidelines (submitted by CDC)
• Behavioral/Mental Health and Substance Use Screening & Referral for Pregnant and Postpartum Women
• Behavioral/Mental Health and Substance Use Screening & Referral for Older Adults

Changes to Previously Adopted Improvement Activities for the CY 2024 Performance Period/2026 MIPS Payment Year and for Future Years

• Use of Decision Support and Standardized Treatment Protocols

Improvement Activities Proposed for Removal for the CY 2024 Performance Period/2026 MIPS Payment Year and Future Years

• Implementation of co-location PCP and MH services
• Obtain or Renew an Approved Waiver for Provision of Buprenorphine as Medication-Assisted Treatment [MAT] for Opioid Use Disorder
• Consulting Appropriate Use Criteria (AUC) Using Clinical Decision Support when Ordering Advanced Diagnostic Imaging

Promoting Interoperability Performance Category
CMS is proposing the following changes to the Promoting Interoperability performance category:

• Lengthen the performance period for this category from 90 days to 180 days;
• Modify one of the exclusions for the Query of Prescription Drug Monitoring Program (PDMP) measure;
• Provide a technical update to the e-Prescribing measure’s description to ensure it clearly reflects our previously finalized policy; and
• Modify the Safety Assurance Factors for Electronic Health Record Resilience (SAFER) Guide measure to require MIPS eligible clinicians to affirmatively attest to completion of the self-assessment of their implementation of safety practices.

CMS is also proposing to update the CEHRT definition to align with the Office of the National Coordinator for Health IT (ONC)’s regulations. In a recent proposed rule, ONC signaled a move away from the “edition” construct for certification criteria. Instead, all certification criteria will be maintained and updated in statute. CMS is proposing to align with this new definition for QPP and the Medicare Promoting Interoperability Program. Additionally, CMS is proposing to remove the CEHRT threshold requirements for Shared Savings Program ACOs.

MIPS Final Scoring Methodology – p. 954

For the CY 2024 performance period/2026 MIPS payment year, the scoring weights are as follows:

• 30 percent for the quality performance category;
• 30 percent for the cost performance category;
• 15 percent for the improvement activities performance category; and
• 25 percent for the Promoting Interoperability performance category.

To avoid a negative adjustment and be eligible for a positive payment adjustment, a provider’s MIPS total score must reach a performance threshold of 82 points for the 2024 MIPS performance period/2026 MIPS payment year, which is the mean of final scores from the 2017 – 2019 MIPS performance periods/2019 – 2021 MIPS payment years.

Public Reporting on Compare Tools – p. 956

CMS proposes to modify existing policy about identifying telehealth services furnished to inform the public reporting of telehealth indicators on individual clinician profile pages. Instead of using specific Place of Service (POS) and claims modifier codes such as POS code 02, 10, or modifier 95, to identify telehealth services through annual rulemaking, CMS would use the most recent POS and claims modifier codes available as of the time the information is refreshed on clinician profile pages. CMS believes this proposal would give them more flexibility to ensure the accuracy of the telehealth indicator and reduce regulatory burden.

Request for Information: Publicly Reporting Cost Measures – Page 1133
In this proposed rule, CMS signaled its intent to begin publicly reporting cost measures, beginning with the CY 2024 performance period/2026 MIPS payment year, and included an RFI seeking comment on several aspects of how to best establish publicly reporting cost measures.

• How can we present MIPS cost measures information in a way that reflects meaningful outcomes to patients and their caregivers and the value of care, rather than cost alone?
• What are the considerations for publicly reporting the total episodic cost, component level costs, or both? Do the component costs provide adequate context for patients and their caregivers to make informed healthcare decision?
• What other specific information about MIPS cost measures, including the context of quality measures and MVPs, should we consider including on the Compare tool?
• What are the considerations for publicly reporting the national average cost, ratio of cost to the national average cost, and/or the dollar cost per episode as possible benchmarks for comparison discussed above in this section? What other benchmarks or comparator approaches should we consider?
• Are there any considerations for evaluating cost measures for public reporting beginning with cost measure data from CY 2024 performance period/2026 MIPS payment year in the CY 2026? What other factors, such as those related to health equity, should be taken into consideration?
• We request comment on additional information that we may not have considered or discussed above about publicly reporting MIPS cost measures, as well as any unintended impacts and/or positive outcomes that could result from making this information publicly available on the Compare tool.

Major APM Provisions – p. 957

CMS aims to develop, propose, and implement policies that encourage broad clinician participation in Advanced APMs. As such, CMS proposes several policies that the agency believes will provide a more accurate measure of the actual engagement of individual clinicians participating in Advanced APMs.

Advanced APMs
CMS current regulations state that 75% of eligible clinicians in each participating APM Entity (for example, an ACO) must be required under the terms of the APM to use CEHRT for the APM to be an Advanced APM. CMS proposes to remove the numerical 75% threshold and specify that, to be an Advanced APM, the APM must require the use of certified EHR technology.

APM Incentive
CMS is proposing to calculate the qualifying APM participant (QP) determinations at the individual eligible clinician level only, instead of the APM Entity level. Consistent with the Consolidated Appropriations Act, 2023, the QP and Partial QP threshold percentages for the Medicare Option and All-Payer Option will remain unchanged in 2023/2025, as per last year's values. Under current statute, the QP threshold percentages will increase beginning with the 2024 performance year/2026 payment year.

Under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), clinicians participating in advanced APMs were to receive a 5% incentive payment until the 2022 performance year /2024 payment year. The Consolidated Appropriations Act, 2023, extended the APM Incentive Payment for one year allowing eligible clinicians to receive a 3.5% incentive payment in the 2023 performance year/2025 payment year. After the 2023 performance year/2025 payment year, the APM Incentive Payment will end. As directed under MACRA, beginning for the 2024 performance year /2026 payment year, QPs will receive a higher MPFS update of 0.75% compared to non-QPs, who will receive a 0.25% MPFS update, which will result in a differentially higher PFS payment rate for eligible clinicians who are QPs. Eligible clinicians who are QPs for a year will continue to be excluded from MIPS reporting and payment adjustments for the year.

Appendix A

New Quality Measures Proposed for the CY 2024 Performance Period/2026 MIPS Payment Year and Future Payment Years

• Excessive Radiation Dose or Inadequate Image Quality for Diagnostic Computed Tomography (CT) in Adults (Clinician Level)
• Ambulatory Palliative Care Patients’ Experience of Feeling Heard and Understood
• Cardiovascular Disease (CVD) Risk Assessment Measure - Proportion of Pregnant/Postpartum Patients that Receive CVD Risk Assessment with a Standardized Instrument
• First Year Standardized Waitlist Ratio (FYSWR)
• Percentage of Prevalent Patients Waitlisted (PPPW) and Percentage of Prevalent Patients Waitlisted in Active Status (aPPPW)
• Preventive Care and Wellness (composite)
• Connection to Community Service Provider
• Appropriate Screening and Plan of Care for Elevated Intraocular Pressure Following Intravitreal or Periocular Steroid Therapy
• Acute Posterior Vitreous Detachment Appropriate Examination and Follow-up
• Acute Posterior Vitreous Detachment and Acute Vitreous Hemorrhage Appropriate Examination and Follow-up
• Improvement or Maintenance of Functioning for Individuals with a Mental and/or Substance Use Disorder
• Gains in Patient Activation Measure (PAM®) Scores at 12 Months
• Initiation, Review, And/Or Update to Suicide Safety Plan for Individuals with Suicidal Thoughts, Behavior, Or Suicide Risk
• Reduction in Suicidal Ideation or Behavior Symptoms

Appendix B

Proposed Changes to Specialty Measure Sets for CY 2024 Performance Period/2026 MIPS Payment Year and Future Payment Years

Urology - Measures Proposed for Addition
Measure Title and Description	Measure Type	Measure Steward
Connection to Community Service Provider: Percent of patients 18 years or older who screen positive for one or more of the following health-related social needs (HRSNs): food insecurity, housing instability, transportation needs, utility help needs, or interpersonal safety; and had contact with a Community Service Provider (CSP) for at least 1 of their HRSNs within 60 days after screening.	Process	OCHIN
Gains in Patient Activation Measure (PAM®) Scores at 12 Months: The Patient Activation Measure® (PAM®) is a 10–or 13– item questionnaire that assesses an individual´s knowledge, skills and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale that converts to one of four levels of activation, from low (1) to high (4). The PAM® performance measure (PAM®-PM) is the change in score on the PAM® from baseline to follow-up measurement.	Patient-Reported Outcome-Based Performance Measure	Insignia Health, LLC, a wholly owned subsidiary of Phreesia

Urology - Measures Proposed for Removal
Measure Title and Description	Measure Type	Measure Steward
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan: Percentage of patients aged 18 years and older with a BMI documented during the current encounter or within the previous twelve months AND who had a follow-up plan documented if the most recent BMI was outside of normal parameters.	Process	Centers for Medicare & Medicaid Services

Appendix C

(A) Specialty	(B) Allowed Charges (mil)	(C) Impact of Work RVU Changes	(D) Impact of PE RVU Changes	(E) Impact of MP RVU Changes	(F) Combined Impact
Allergy/Immunology	$216	0%	-1%	0%	-1%
Anesthesiology	$1,647	-2%	-1%	0%	-2%
Audiologist	$69	-1%	-1%	0%	-2%
Cardiac Surgery	$174	-1%	-1%	0%	-2%
Cardiology	$5,989	0%	0%	0%	0%
Chiropractic	$644	-1%	-1%	0%	-2%
Clinical Psychologist	$711	1%	0%	0%	2%
Clinical Social Worker	$795	2%	0%	0%	2%
Colon and Rectal Surgery	$147	-1%	-1%	0%	-2%
Critical Care	$331	-1%	0%	0%	-1%
Dermatology	$3,713	0%	0%	0%	-1%
Diagnostic Testing Facility	$828	0%	-2%	0%	-2%
Emergency Medicine	$2,460	-2%	-1%	0%	-2%
Endocrinology	$507	1%	1%	0%	3%
Family Practice	$5,504	2%	2%	0%	3%
Gastroenterology	$1,474	0%	0%	0%	0%
General Practice	$361	1%	1%	0%	2%
General Surgery	$1,614	-1%	-1%	0%	-1%
Geriatrics	$180	0%	1%	0%	1%
Hand Surgery	$251	-1%	0%	0%	-1%
Hematology/Oncology	$1,591	1%	0%	0%	2%
Independent Laboratory	$546	-1%	-1%	0%	-1%
Infectious Disease	$573	-1%	0%	0%	-1%
Internal Medicine	$9,618	0%	1%	0%	1%
Interventional Pain Mgmt	$849	0%	0%	0%	0%
Interventional Radiology	$457	-1%	-3%	0%	-4%
Multispecialty Clinic/Other Phys	$146	0%	0%	0%	0%
Nephrology	$1,803	-1%	0%	0%	-1%
Neurology	$1,323	0%	0%	0%	1%
Neurosurgery	$694	-1%	0%	0%	-1%
Nuclear Medicine	$51	-1%	-2%	0%	-3%
Nurse Anes/Anes Asst	$1,081	-2%	0%	0%	-2%
Nurse Practitioner	$6,260	1%	1%	0%	2%
Obstetrics/Gynecology	$558	0%	1%	0%	1%
Ophthalmology	$4,647	0%	0%	0%	-1%
Optometry	$1,292	-1%	-1%	0%	-2%
Oral/Maxillofacial Surgery	$62	-1%	-1%	0%	-2%
Orthopedic Surgery	$3,358	-1%	0%	0%	-1%
Other	$55	0%	-1%	0%	0%
Otolaryngology	$1,112	0%	0%	0%	0%
Pathology	$1,136	-1%	-1%	0%	-2%
Pediatrics	$55	0%	1%	0%	1%
Physical Medicine	$1,087	0%	0%	0%	-1%
Physical/Occupational Therapy	$5,257	-1%	-2%	0%	-2%
Physician Assistant	$3,366	1%	1%	0%	2%
Plastic Surgery	$300	-1%	-1%	0%	-1%
Podiatry	$1,890	0%	0%	0%	0%
Portable X-ray Supplier	$75	0%	0%	0%	-1%
Psychiatry	$897	1%	1%	0%	2%
Pulmonary Disease	$1,290	0%	0%	0%	0%
Radiation Oncology and Radiation Therapy Centers	$1,552	0%	-2%	0%	-2%
Radiology	$4,517	-1%	-2%	0%	-3%
Rheumatology	$509	1%	1%	0%	2%
Thoracic Surgery	$292	-1%	-1%	0%	-2%
Urology	$1,623	0%	0%	0%	1%
Vascular Surgery	$1,009	0%	-3%	0%	-3%
TOTAL	$88,549	0%	0%	0%	0%

*Column F may not equal the sum of columns C, D and E due to rounding.

Table 104: CY 2024 PFS Estimated Impact on Total Allowed Charges by Specialty

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