All right, welcome everyone to DO Day, our virtual platform this weekend. Today we are going to talk about Medicare physician payment cuts and how the medical profession can make a difference. My name is Sean Hamm, I'm a family medicine physician here in Western North Carolina. I see patients in clinic four days a week. And then I also am the medical director of the Burke County Public Health, our local health department here in Western North Carolina. I'm currently on the AOA Board of Trustees as the new physician and practice member, and I serve as the chair of the Bureau of Emerging Leaders. Gabriel? Good morning, everyone. My name is Gabriel Miller, and I lead regulatory affairs at the AOA. So all of our federal agency engagement on a broad range of issues, and then I also lead our engagement with the American Medical Association's CPT Editorial Panel and Relative Value Scale Update Committee. And I also have no relationships to disclose, but really excited to be here and talk about Medicare physician payment with everyone. Great, yes. Gabriel and I are looking forward to having a robust discussion today, which includes a few of these learning objectives. We are going to talk about the background on Medicare payment and current challenges we're facing. We're going to talk about paving the path forward to long-term reform, and we're going to share some really exciting opportunities for physicians out there to really improve their payment and get reimbursed for the work that they are doing day in and day out. Our learning objectives today include describe the evolution of policy that has resulted in the stagnation of payment rates under the Medicare physician fee schedule. Apply background in payment policies and their impact on the landscape of physician practices in an advocacy context to pursue reform. And then lastly, identify some recent policy changes that can support improved payment for office-based physicians in light of stagnant payment rates. All right. So to get us started, we're going to talk a little bit about the background on Medicare payment, what brought us to this current moment, and just talking through a little bit of the policy history to sort of set the stage for what is it that needs to change, what are the underlying drivers of these challenges that physicians face. So to set the stage, we're going to first talk a little bit about the physician fee schedule and how payment is determined. As we all know, Medicare payment rates are determined by a formula in the physician fee schedule, and variation to any inputs within that formula are going to influence final payment rates. And there are underlying policies that sort of drive changes to these different components resulting in underpayment. So we are, and also I want to highlight, we're not going to dive into detail on each component of this formula, into details on how relative value units are calculated, things like that, because we recognize that there is a broad range of challenges within physician payment. But really, our goal is to focus on, at a high level, what are the key drivers of the challenges physicians are facing in payment. So talking a little bit about that formula, total Medicare payment for a given service is determined by multiplying the total relative value units for a service by the Medicare conversion factor. The relative value units are the basic component of the resource-based relative value scale, which is the methodology used by payers to determine physician payment. And RVUs define the value of a particular service in relation to other service within the RBRBS system. That total RVU calculation accounts for physician work, practice expense, malpractice, and then also a geographic adjustment based on the practice setting or where the practice is located. And then those total relative value units, once calculated, are multiplied by the conversion factor, which is just the standard multiplier expressed as a dollar amount, used to convert the RVUs for each service into a payment amount. In Medicare, the conversion factor is set by CMS every year in the Medicare Physician Fee Schedule rulemaking process, and it applies to all services billed. Now CMS establishes service RVUs and the conversion factor through the MPFS rulemaking process. But these values may be influenced by various statutory requirements. So CMS generally has pretty broad flexibility as it relates to determining relative value units for an individual service, using the agency's expertise essentially to determine relative values. Physician work values, for example, are based on recommendations from the AMA's Relative Value Scale Update Committee. CMS has a specific formula for calculating practice expense, but many of the inputs are set based on surveys or other data that the agency collects. So the agency has a broad range of tools at its disposal to determine those rates. And we recognize that when we talk about physician payment in totality, there are a broad range of challenges that physicians across specialties face, and that there are inequities that exist within the fee schedule itself. But our goal for our conversation today isn't to get into those minute details or into the specific challenges faced specialty by specialty that may be driven by some of those inequities, but rather recognizing that every physician across the country is grappling with reduced payment year over year, and it's largely driven by reductions to the Medicare conversion factor based on statutory requirements that are driving either a stagnant conversion factor every year or even reductions. As we've seen since 2020, the conversion factor has actually reduced year over year over the last five years. And that's really where we're going to be focusing our conversation today. So how total payment is determined for physicians participating in Medicare has evolved pretty substantially over the last decade, starting out with the repeal of the sustainable growth rate under the Medicare Access and CHIP Reauthorization Act, referred to as MACRA. However, many physicians thought that repealing the SGR would be the solution that everyone had been needing for decades, yet that did not quite pan out as everyone anticipated. And so we'll talk a little bit about that policy background here. So the SGR was implemented in the late 90s and was conceived as a way to manage spending growth within the Medicare program. It utilized an algorithm to set a growth rate for target Medicare spending based on factors such as enrollment, economic growth, and measures of physician efficiency. And it was intended to bring actual Medicare expenditures in line with the growth rate. So that spending in excess of targets would drive reductions in the Medicare conversion factor. However, there were some pretty substantial flaws within the formula and instances where the SGR resulted in rate reductions required that ended up resulting in Congress needing to intervene year over year over year to implement fixes. And this caused the target rate and actual expenditures to deviate more and more over time. Ultimately, Congress had to intervene 17 times to avert payment cuts. And by the end of that period, SGR payment reductions reached 21.2% in 2015. And so this became just an annual tradition where Congress needed to avert cuts. This system was unsustainable. And so lawmakers decided to overhaul physician payment. And that was the how the Medicare Access and CHIP Reauthorization Act became law. MACRA repealed the SGR to implement a new payment system. And it also sought to provide for incentives for high delivery of high quality care and support quality based payment by implementing the quality payment program and the merit based incentive payment system or MIPS. Now, it did away with the SGR, stabilized physician payment, and provided for a modest 0.5% annual payment adjustment for the first five years of the law's enactment to ensure a stable physician payment. And then it froze payment updates for the subsequent five years. And actually, then following that period, starting next year, actually provides for once again, a very, very modest update to physician payment. So starting moving forward, physicians participating in MIPS will receive a 0.25% annual payment adjustment. And then physicians participating in advanced alternative payment models will receive a annual 0.75% adjustment under the physician fee schedule. As I said, MACRA also consolidated existing incentive programs into the MIPS program. And established a framework for dispersing incentive payments or penalties. But as we've seen over the last several years, SGR was repealed with the intent of stabilizing physician payment, preventing funding shortfalls and continued payment cuts that require congressional intervention. But in reality, we've now entered this situation of effectively SGR 2.0, where we have rising inflation that's driving up practice costs. We have statutorily mandated payment reductions driven by a range of factors that we'll talk through in a moment. And as a result, year over year, we are needing Congress to intervene to address those payment cuts every single year. So we're effectively back at where we started. Granted, those payment cuts may not be as profound as they were under SGR at 21.2%. But at the end of the day, a payment rate, a payment cut at current rates is not sustainable for physician practices. It's not something that they can bear. And it is causing practices across the country to close their doors to sell or to not be able to see Medicare patients to the extent that physicians want to be able to care for those patients. So let's talk a little bit about these statutory requirements that are driving this reduced payment and creating this really challenging environment. So in addition to the conversion factor updates that were established under MACRA, those very modest updates that I just spoke to a moment ago, there are other policies that are compounding these challenges, interacting with that. First, are the budget neutrality requirements that are within the Social Security Act. Section 1848 of the Social Security Act requires that any adjustments to relative value units within the physician fee schedule must be made in a budget neutral manner. This means that if payment rates are increased in a particular portion of the fee schedule such that these changes will result in increases to expenditures, then the physician fee schedule of more than $20 million, there must be a corresponding decrease to payment in another part of the fee schedule to ensure that budget neutrality, to ensure that those changes and expenditures do not exceed $20 million in net. And so there are a number of ways that this is achieved. It can be through, again, like I said, modifications to RVUs within the fee schedule, but more typically what happens is CMS just reduces the conversion factor across the board to maintain relativity, appropriate relativity across all physician fee schedule services. That way, that payment reduction is applied across the schedule and the relative values are maintained constant. And so when we talk about these payment reductions year over year, it's predominantly through those reductions to the conversion factor. Another factor that in some years is driving changes to the conversion factor as well that's not highlighted on this slide, but I think does merit a very brief reference are requirements under sequestration. So there are a couple of laws that require mandatory payment cuts when federal spending reaches a certain threshold. These are known as the Budget Control Act of 2011 and PAYGO cuts. That said, pretty much every single year Congress has averted these cuts and prevented them from taking effect because the reality is that they are a very, very draconian measure to control spending that no one really supports when they are implemented. It just causes problems across federal programs. So fortunately, they haven't actually created a problem, that big of a problem to date, but it is just one more thing that's compounding these challenges and posing a threat to payment and something that has needed to be addressed in the past. So those are some of the key factors that are driving changes to the conversion factor and that payment formula we spoke about earlier. The other thing that I think is important to highlight is the MIPS program and payment under other reporting programs. So we talked a little bit about MACRA and how it implemented the MIPS program to incentivize the delivery of high-quality care, but that system is flawed as it tends to unfairly penalize many clinicians under its tournament-based model, and it also relies on measures that are often not clinically relevant for many physicians, especially specialists who may have a very limited number of measures that they're able to attest to and perform to. And so this model poses a problem for physicians across specialties, but it also poses a unique challenge for small and independent practices because largely how a physician is paid under the MIPS program and how they perform also relates to how they are able to report under the program because physicians have flexibility to select measures that are most relevant to them and physicians will choose to report the measures where they know that they are able to monitor their performance and perform better. Granted, we know that all physicians are committed to quality improvement and that they participate in a broad range of programs to continuously drive high-value care to improve the quality of the care they're providing to their patients, but the way the MIPS program is designed often doesn't actually result in that, especially when you have large hospitals and health systems that are working to optimize reporting to improve that payment, and this is why we've seen this discrepancy where small and independent practices systematically perform worse than hospital and health system-based physicians, even though generally based on comparable measures, these physicians perform comparably when it comes to patient outcomes. But the reality is it's just that reporting that is the factor and the reason that the payment rates differ for those physicians and that some get an upward adjustment and some get a negative adjustment. And the other challenge is that because of the tournament model, bonuses to some physicians are funded through the penalties paid by other physicians, which makes this system challenging, and while in a world where physician payment was adequate, updated every single year, this would pose less of a challenge, not that the tournament model is the way for physician reform, and we actually at AOA have had a lot of discussions around MIPS reform and what an ideal model could look like, but when physician payment is stagnant or declining, costs are increasing, those small and independent practices who are systematically disadvantaged and faced with penalties, this just creates an unbearable burden for them to sustain their practices. Yeah, Gabriel, if I could, I would add something to that, just as an example, here in Western North Carolina with UNC Health Blue Ridge, my employer, across the street, we have multiple small private family medicine practices, and I often wonder how are they even able to do this or participate in something like this if they don't have the resources like I do in my practice, even though I'm a small practice, I'm employed and we have a wonderful opportunity to tap into the resources that UNC Health throughout North Carolina can offer through our management contract to be able to do that reporting you were suggesting and do the administrative burden that's needed in order to participate. I just often wonder what my colleagues across the street are doing to be able to participate in something like this if they don't have the resources like I do. Yeah, I appreciate you sharing that example, and I also really like the call out there about the administrative burden that this program creates, because that's just one more cost that these practices are saddled with when you reference the technical infrastructure, the staff, and this is just so difficult for small and independent practices to be able to afford that infrastructure to perform as well. And building on that, kind of compounding this challenge is there was for a period of time a pool of bonus payments, MACRA set aside $500 million for exceptional performers under MIPS to ensure that physicians that performed well could get enhanced payment, and that pool of funding has expired, so all bonus payments now come exclusively from that pool of funds that's funded by penalties. Got it, yep. And bonus payments against alternative payment models, so those physicians who don't participate in MIPS and choose to participate in a model that's testing innovative value-based designs, historically, those physicians would have been eligible for a bonus payment that was intended to incentivize their shift towards these new models of care. However, those bonuses have expired, and those incentives now no longer exist, and so we have these compounding challenges that are starting to really build up and are fortunately starting to generate a lot more discussion on Capitol Hill around comprehensive reform and what that could look like, but it's really, really important that physicians keep pushing and keep advocating to drive home how important this is and the impact it's having on their patients, and I think, and so we're going to shift the conversation a little bit to talk a little bit about that and the impact that this inadequate payment is having on practices and having on patients. So the cost of practicing medicine is increasing, and Medicare payment is just not keeping pace, as we all know. In March of 2023, the Medicare Payment Advisory Commission recommended that Congress make updates to physician payment in light of the rapid rise in practice costs, and it's actually expected that they're going to make a similar recommendation again in their upcoming report. At the time of this recording, it has not been released yet, but will be released in the coming days, and the reason for this is that the cost of operating practice is becoming unsustainable relative to what is being paid under the Medicare system, and I think this visual on the left really clearly highlights that discrepancy. You see that top line and the chart there reflects growth in the Medicare Economic Index, which is the measure of inflation in health care, and the line towards the bottom with the triangle markers reflects physician updates year over year, so increases in payment. And you'll see that they're pretty much stagnant year over year. And while costs have increased 30% since 2010, physician payment has only increased 6%. Now, when you adjust that number to reflect payment updates since 2020, payment has actually declined. And when we look back to 2001, so we take a longer window, this picture gets even more dramatic with physician payment having declined on net accounting for inflation by 26%, which paints a pretty dark picture. And it raises the question, how can this be sustained? CMS projects that MEI is going to increase a further 3.5% this year. And it's important to highlight that within every other payment system in the Medicare program, those facilities, institutions, providers, they all receive a payment update year over year based on inflation. It's just the Medicare physician fee schedule that does not because of those changes that were implemented under MACRA. So if you've attended DO Day in the past few years, you've probably seen this visual that's up on the screen here that really highlights what I just described, that every payment system has an annual adjustment to account for inflation, whether it be payment for hospice care, ambulatory surgical centers, hospital inpatient services, hospital outpatient services. Last year, under each of those payment systems, CMS estimated that the cost of those services would increase about 2.9%. They increased the payment for those services accordingly. Yet, we look at the physician fee schedule. Inflation in 2023 was, or excuse me, last year was, sorry, the number here needs to be corrected. But last year was a decline of 2.8% for inflation. Excuse me, increase in cost of 2.8%, excuse me, based on inflation, reduction payment of 2.8%. So as we can see, there's a huge discrepancy here. You have an increase in the cost of delivering care, and then at the same time, a payment cut that went into effect at the end of 2024 and into 2025. So this is a huge discrepancy across sites of care. And one of the things that I think is really important to highlight here is that this not only isn't making it difficult for practices to keep their doors open, but it's also creating an incentive for hospitals, health systems, larger groups to actually acquire physician practices. And it's driving consolidation because these other sites of care can command higher rates. They have different mechanisms of billing under their respective payment systems. For example, hospitals can bill a facility fee for their services when services are rendered in a hospital outpatient department. So if they're able to acquire a medical group practice and incorporate those physicians into their outpatient departments, they can charge higher fees. This is creating misaligned incentives within our health care payment system and driving consolidation. And a stable payment environment for hospitals paired with incentives to shift volume to that setting, like I just described, is really what's encouraging those acquisitions. And this is creating challenges for both physicians and payments and both physicians and patients. And so as practices struggle to keep doors open, larger enterprises are motivated to consolidate, to increase their market share, and maximize revenue or profits. And this visual on the right-hand side here reflects that consolidation. An increasing share of hospitals are affiliated with health systems. And also an increasing share of physicians are affiliated with hospitals or health systems as well, generally reflecting this trend of consolidation across settings across the country. And so on the left-hand side here, showing the consolidation of hospitals with larger health systems. In 2005, about half of all hospitals were health system affiliated. In 2022, that number increased to 68%. In 2025, that number is now a little bit higher, actually. And same goes for this number on physician practice consolidation. In 2012, only 29% of physicians were associated with a hospital or health system. In 2022, that number increased to 41%. That number is actually substantially higher in 2025. And another thing that this number for the physician number does not account for is physicians that are part of a private equity-owned large group practice, which is also another growing trend, another form of consolidation that's taking place. And I think what's really important to highlight around consolidation and the corporatization of medicine is that this consolidation reduces market competition, which allows these enterprises to have greater leverage in price setting and in negotiating with insurers as they increase their market share, which means they're able to command higher prices and higher rates and make competition with smaller businesses, smaller practices very, very difficult for those smaller entities. And hospital acquisitions of physician offices have also led to an increase in Medicare spending. I believe that number is about that consolidation has driven an increase in spending of about 14% per beneficiary. And so markets across the country are becoming increasingly concentrated or dominated by a limited number of enterprises. And not only does that increase costs for the patient, but it also has an impact on physicians' experience delivering care and their satisfaction and their level of burnout because these employers will often impose very high productivity targets. They may engage in contracting practices that are unfair and may harm career mobility or just engage in staffing practices that may impact physician satisfaction or workload and happiness in delivering care. And these are all issues that the AOA is working on at the federal level. But I think it's also important to communicate to lawmakers that as small practices struggle and close their doors, this is what happens, right? And so it creates new challenges that we need to work to address. Yeah, Gabriel, I appreciate that you mentioned this pressure to perform like you were mentioning. Thinking back on connecting with my friends from residency, I'm very thankful that I work with a small community hospital system that owns itself and is not part of a larger system, even though we have a management agreement with UNC Health, of course, a much larger health system, but we still own ourselves and we still care for our local community the way we always have for many, many years. But I hear from my friends from residency that have employment contracts with gigantic health systems and their level of enjoyment with their work and their burnout, this feeling of burnout is very real. And I think it stems a lot from this performance piece that you just talked about. See more patients, don't wanna have any of your feedback, we don't need to change anything, just see more, more, more, more, more. And that really does, maybe would you agree an unintended consequence of what this consolidation has done? Oh yeah, absolutely. I mean, I don't think lawmakers, when they wrote MACRA in 2015, anticipated that it would result in the environment that we've found ourselves in today. So absolutely an unintended consequence, but I think it's really essential that we communicate to lawmakers, hey, this is a direct result of the implementation of this policy and what the law currently is and it needs to be changed. And so I think on that note, I think that's a perfect segue into talking about how do we actually drive change? And so the AOA is really, of course, this is a huge priority in our policy team and across all segments of our policy team, congressional, regulatory, grassroots. We are working hard to drive home the importance of this reform and work with lawmakers to develop a long-term solution. And so we'll talk first a little bit about what the AOA is doing, but then I'd love to hand it over to Dr. Hamm to talk about what is it that physicians can do to communicate the importance of this reform and how can you work with your lawmakers to make a difference? And so first off on the regulatory side, as we've indicated over the course of this conversation, there are some ways that the agencies can try to mitigate the impact of some of these challenges, but they're largely driven by statutes. And so AOA has worked with CMS to use its regulatory authority to enhance payment and make improvements to the MIPS program. We've advocated for policies that support payment for primary care, system payment for telehealth and parity between in-person services and telehealth services, advocating for payment for those longitudinal care relationships, some of those that we'll talk about later in today's presentation. We've also advocated for simplification of the MIPS program and scoring improvements to ensure that small and independent practices are not disadvantaged, whether it be ensuring that the performance threshold is not raised at a point where small and independent practices are struggling to return to performing in the program after challenges faced during the COVID-19 public health emergency, and then immediately after that in the year following, struggling to perform due to the change healthcare cyber attack that completely disrupted practice operations and payment to those practices. So making sure that CMS is mindful of the current practice environment and not making MIPS so much of a burden to those practices that they then suffer penalties, as well as modifications to scoring, whether that be changes to the cost performance category scoring that was implemented this past year, or whether that be changes to specific, the scoring for specific quality measures. This is something that we are actively working on, but that's only one piece of the puzzle because at the end of the day, Congress needs to act to ensure comprehensive reform. The underlying law that CMS has to operate within is what needs to change. CMS's authority is significantly limited. And so they are not able to upwardly adjust payment year to year, and they're not able to make significant overhauls to the MIPS program. So what does comprehensive reform look like from a legislative standpoint? It means implementing an annual inflationary adjustment to payment and eliminating statutorily mandated cuts so that physicians have stable payment and year over year, they know that payment will keep pace with the cost of practicing medicine. It means implementing reform of budget neutrality requirements so that number one, CMS has greater flexibility as it calculates budget neutrality, but then number two, when CMS might make mistakes, such as overestimating what it expects to spend when it adopts a new service for payment or revalue services, if they overestimate costs, making sure that physicians are made whole for that over-calculation. And then overhauling the MIPS program to modify how payment adjustments are determined, support quality improvement and adjusting scoring so that we don't have this model where certain physicians benefit at the expense of other physicians. And we are actually incentivizing high quality care and rewarding the things that matter and not creating unnecessary burden. So that is what we are working to communicate to lawmakers, but it's really important that physicians actually tell their stories to lawmakers and tell them, here's what my practice looks like. And here's how each of these issues have posed a challenge to me or impacted my delivery of care to patients. And so Dr. Him, I'd love to hand it over to you to talk about some of your experience. Absolutely. Thanks, Gabriel. So one of the things I love the most about DOJ that the AOA offers is a platform for us to play a critical role in advancing these reforms and enacting this kind of comprehensive reform is really a long-term effort that will require us being a unified voice in advocacy across the physician community and the voices of physicians on the ground in the way that we play an essential role there. So physicians not only need to reach out to their lawmakers to ask for these changes, but they need to build a relationship with lawmakers to put a face to the impact that inaction really has. And building relationships with lawmakers can help generate support for reform and provide a human story behind these complex issues. And some steps that physicians can take really include engaging our member of Congress by writing to their office, setting up meetings at their local district offices, or participating in our AOA advocacy alerts. When meeting or communicating with our representatives, I think it's really important to contextualize the issues and communicate the impact that inaction will have and how reforms will make a difference. Some examples include discussing the impact of inadequate payment on the sustainability of practices and how it may contribute to provider consolidation like Gabriel was talking about. The impact payment may have on decisions around where to practice or how to specialize and implications for patient access. And the impact payment reform can have on promoting high value care and providing services to patients where it's most needed. And finally, participating in events like DO Day and meet with lawmakers in person. I know I'm very much looking forward to that myself and finding other opportunities to continue building and maintaining relationships with our lawmakers. It may be helpful to include an anecdote while you're in person with them on how to frame these issues and conversations. And that brings up a really important point for me. In my particular case in the North Carolina 14th District, I have a brand new Congressman. Congressman Tim Moore used to be the Speaker of the House for the State North Carolina Congress. And now he is on the federal level. He is someone that I'm really looking forward to talking to when I get to DO Day on the Hill in person to really engage about these issues and tell him, listen, this is what's going on in Western North Carolina. I know that you know very well the inner workings of what's going on, especially in Western North Carolina with our recent impact from Hurricane Helene. But how does that translate to his work at the federal level? How can he take our stories and the impact that the Medicare payment system is having on us and be our voice and be our advocate in Congress and help make sustainable reforms happen? I really am looking forward to that conversation when I get to D.C. Gabriel, should we share with some of the participants today on some opportunities to improve payment for comprehensive care? That sounds great. So, one of the things that Gabriel and I talked about was how can we share some tips and tricks for our folks that are engaged today and things we've learned along the way, some new things that are coming about. And so, on the next slide, we're going to talk a little bit about some codes that you really need to know about. So, for those of you that don't know or haven't been updated on this yet, CMS now allows payment for the G22-1 code with preventative services. You may have known that G22 was available. Of course, that allows us to communicate to Medicare that we have a longstanding relationship with a patient. But what we want to highlight today is that there's been a change in that we can provide additional preventative services on the same day as G22-11. So, in calendar year 2024, CMS finalized the implementation of the office and outpatient E&M visit complexity add-on code G22-11. And initially, CMS billing rules stated it would not allow payment when G22-11 is billed with an E&M appended with a modifier 25. For instance, if I saw a patient for their chronic conditions and then they needed me to do a Shingrix vaccine and I told the insurance, I told the billers and coders that we needed to add a 25 modifier to indicate that I had done that vaccine, a preventative service, right? I would not previously be able to put a G22-11 code on that visit to indicate that long-term relationship. And now that has changed. So, the descriptor here for G22-11 is medical care services that serve as the continuing focal point for all needed healthcare services and or with medical care services and or with medical care services that are part of ongoing care related to a patient's single, serious, or complex condition. That's what G22 in essence is about. And let's talk a little bit about that continuing focal point. So, continuing focal point for all needed healthcare services, that's primary care. That's what I do every day, family medicine. And that describes a relationship between the patient and the practitioner when the practitioner is the continuing focal point for all healthcare services that the patient needs. And some people have asked, what does ongoing care mean? Ongoing care describes a longitudinal relationship between the practitioner and the patient which is not limited to primary care. So in my case that applies primary care but it actually is not limited to primary care which is a very important point. So recognizing that providing longitudinal primary care necessarily entails providing preventative services and many visits including E&M visits, CMS modified their billing rules to allow G2211 to be billed when a Medicare preventative service including vaccines and annual wellness visits are provided with an E&M visit. And really physicians should use this code broadly to support payment for E&M services. I know personally it was quite confusing when this first started we we weren't sure could we use this code could we not use this code would it would our claim be denied if it wasn't used in the right context because we weren't aware of it and how it should be used properly but I think now with the new update that CMS has provided with the billing rules it's it's gotten much better. It really is intended to to be used across specialties that are providing longitudinal care and is not limited specifically to primary care. CMS has provided guidance on how the relationship between the patient and practitioner should be taken into account for billing purposes. So for instance primary care physicians we a patient may see a PCP for sinus congestion physician and we suggest conservative treatment or or antibiotics for a sinus infection and then the physician must decide on the course of action and best way to communicate recommendations to the patient. How the recommendations are communicated is really important as it affects the patient's outcomes for this visit and can help build an effective trusting relationship of course. So G22 is actually billable in that case. We may we may think it's not because it's such a specific maybe acute visit but if we can show that we have a trusting longitudinal relationship we should really give ourselves credit for that and G22 G2211 should be billed and it relates to that cognitive load of building longitudinal relationship with the patient. So we switch gears out of my my usual day and go to maybe an infectious disease specialist. An example there would be maybe a patient with HIV has an office visit with a physician and the patient shares they've missed several doses of HIV medication in the last month because this physician is part of their ongoing care and has earned their trust over time. The physician advises that it's important not to miss doses of HIV medication while making the patient feel safe and comfortable sharing that information and sharing information like this is is very important in the future. Again G2211 is actually billable in this case and the physician is part of that ongoing care for a single serious condition or a complex condition and patient sharing this detail is central to medical decision-making and that's rooted in that that patient-physician relationship and we really wanted to highlight that today on our presentation that there might be a misunderstanding that G2211 only applies to primary care or intuitively applies to primary care but in fact all of our osteopathic physicians across the profession really need to take this into consideration. Yeah absolutely and just to jump in and build off of what you said really what it comes down to as you said on the last slide is that relationship. It's really the relationship with the patient that serves as the basis for building the code not necessarily the service itself being rendered at that particular encounter and so we talked a little bit about some examples of when to build the code but I'm like thinking to myself you know maybe it's helpful to think about when would it be inappropriate to build the code. So if you're a primary care physician and you see a patient who just comes to your office because their their PCP was unavailable on a given day and they come in with the flu and you test them for the flu you treat that patient because that's a time limited relationship for a single time limited condition that would not be a circumstance where G2211 could be billed and I think that applies to other you know specialty care as well you know if a patient goes into a dermatologist for a specific issue that they're having that G2211 may not be billable but if the patient has a longitudinal relationship with that dermatologist and that is something that is documented then G2211 could be billable for many of that dermatologist's encounters so it just depends on the nature of the relationship more than anything. Absolutely, thank you. So I think another really exciting new opportunity for physicians and our practitioners out there is the fact that CMS has recently created some new advanced primary care management g-codes. This is really kind of hot off the press really important that everyone is aware of this. CMS describes these codes as intended to recognize resource costs associated with maintaining certain practice capabilities and activities to support a team-based approach to care that enable whole person care and coordination across the health care system. Today we wanted to share what those codes were in front of you here you see on the left the g-codes and in the middle you see the the service that is provided a level one level two level three advanced primary care management the associated RVUs and the total non-facility payment that's associated with those codes. For that first level of care I think it's important to highlight that advanced primary care management services for patients with one or fewer chronic conditions that's that translates to a level one visit and additional g-code. At the next level you've got patients with two or more chronic conditions level two and then lastly you've got advanced primary care management services that are furnished to patients with two or more chronic conditions and also who are qualified medicare beneficiaries that's a level three and you can you can see that there's quite a bit of RVU work RVU associated with that additional work that you're putting into the management of that patient from a primary care standpoint and again those codes are stratified into three level based patient characteristics that are broadly indicative of patient complexity and the consequent resource intensity involved in the provision of these services. An example from boots on the ground here in family medicine I would say that I would likely use on most days I would use the G0557 level two advanced primary care management code because in a rural family medicine environment like I'm in patients are quite complex very rarely do they come in with a single concern in and out and on their way on their way you know in their daily lives most of the time they come in and and they have multiple concerns that really do significantly take up time that's way beyond the 15 minute visit and and so I really appreciate that CMS is is recognizing that that us rural family physicians are taking care of some really complex folks and they need that extra time and that translates to extra work RVUs for us. Anything to add there Gabriel? No not that I can think of. All right so the the APCM codes are actually modeled after chronic care management with some key differences so to bill APCM practices must have certain characteristics and capabilities that CMS defines as inherent to and necessarily present when a practitioner is providing covered services using an advanced primary care delivery model so those key differences I think it's really important here compared to chronic care management is codes are not time-based and although at it although at least one service element must be furnished in a given month where billed and then practices must possess certain practice level capabilities described below doesn't mean you have to have all of them but you at least have to have certain certain capabilities like those below in order to bill for these APCM codes. Many virtual care and consultative services are consultative services are considered part of the bundle and duplicative of advanced primary care management so be aware of that and payment rates certainly differ substantially so what are some of those capabilities that we need to have in our in our practice of course we need to make sure that we have patient consent we have to show initiating the visit we have to have 24-7 access to care and care continuity jumping around here we've got to have management of care transitions so that transitional care management from hospital admission discharge into the office to follow up with patients on hospital follow-up visits we've got to have advanced enhanced communication opportunities specifically one that I want to highlight today is patient population level management and and the and performance measurement so so population level management for me that that highlights something that I'm really excited about here at UNC Health Blue Ridge we participate in what's called the primary care improvement collaborative with UNC Health and that is a population health effort across the entire state and all of our entities to really work on quality measures and and improving quality the delivered delivery of quality care to our patients but we have this reporting system integrated into our practices that allows us to do population level management not just individualized care with one patient at a time and and the other piece of that is that we also participate with MSSP and ACO REACH and that is a key core piece of being able to apply the apply these advanced primary care management codes so in my particular case we we will be able to implement these these codes effectively because we do have these service elements and practice level capabilities so so when deciding whether to bill a PCM it's important to consider what services may be considered duplicative and may not be billed and the particular documentation requirements that are necessary and I'd love to build off of that last point you made around the technical capabilities because I think what your what your system is doing is really great and really it's so important for being able to deliver this comprehensive care across your patient population that said I think it's really really important to keep in mind all of these requirements when billing a PCM because these are there are a lot of requirements that practices will need to keep in mind and as Dr. Ham said in a given month you don't need to do all of the service elements in order to bill and get paid you just have to do one of them so you don't if you only do some community-based care coordination in a given month you know but you don't do other services that's perfectly fine you can still build a code comprehensive care management developing care plans you don't have to do every single component of this in a given month however you do have to be technically capable of every single one of these at a given time which I think is really really important you have to always you have to have the technical capacity for that population level management you have to be that in that that performance measurement you have to meet that performance measurement requirement participating in one of those pathways that Dr. Ham outlined and then last I also want to highlight that when it comes to the duplicative services it's important to consider what services those are that are not not billable so as Dr. Ham referenced chronic care management and primary excuse me and principal care management in addition to those CMS considers certain community excuse me communication-based technology services are also considered duplicative so services like virtual check-ins as well as other asynchronous services that are separately billable as well as other care management services generally those are considered duplicative of APCM so when you're determining whether to bill APCM just making sure that you're not billing both of those within a given month. Excellent okay a few other very exciting codes that we want to share with you today are some of the counseling and screening services that can be separately billed enabling payment for the time we spend with our patients. I know going through the day seeing patients all of these codes are not necessarily in the back of our mind as we are providing care but they need to be they really do because we we put a lot of work and effort into providing quality patient-centered care and we should be getting the credit we deserve for doing that work and so on the left you'll see some examples of services that are separately billable from an E&M which include screening so if we perform an alcohol misuse screening such as the CAGE screening don't forget to use G0442 to let insurance know that we are we are engaging that conversation with our patients. Annual depression screening PHQ-9 I would venture to say most practices are are doing this screening during their visit at one point or another let's get credit for that G0444 and then substance use disorder screening I know there's a huge push especially in rural rural communities to screen our patients for substance use disorder and and when we do that when we engage in that that really what could be a very difficult conversation we should get credit for having that conversation and and and and communicating that we did make that effort. On the right you'll see some counseling some counseling codes so if we counsel patients on alcohol misuse or we spend that extra five six minutes talking about obesity counseling smoking cessation I know that most most of us primary care docs spend at least a couple minutes talking to our patients about please quit smoking it's only the benefit of your health let's make sure that they understand that we we are in fact doing that work and we need to code for that. Same goes for sexually transmitted disease counseling and cardiovascular risk counseling here's all the codes that we need to keep in mind when when we're doing those screening and counseling efforts. In 2025 CMS also established an opportunity for payment for administering an evidence-based atherosclerotic cardiovascular disease or ASCVD risk assessment that is G0537 and engaging in risk management for patients at intermediate to high risk for cardiovascular disease that's G0538. One one thing that I wanted to share today too was remembering all these codes can be very challenging so one of the one of the recommendations I would make is take this information sit down with your electronic medical record and and create some quick buttons what whatever your electronic medical record system is wherever your CPT code section is on your billing and coding component of your EMR go ahead and create some quick buttons with all of these different codes that way when you're at the end of the visit and you're wrapping things up and you're putting your E&M code in there and you're indicating that you did some separately billable things with the 25 modifier you'll have those codes right there ready to go. Yes I talked about I did an alcohol misuse screening and I spent time counseling the patient on alcohol misuse I need to make sure that I communicate that I spent that time by using these codes. I spent that time reviewing that depression screening and engaging in a meaningful conversation to help that patient if they're at risk for depression. So I think that that's super important to be able to to take the thought process out of it and be able to have those codes readily available for you to click at the end of your visit to be efficient and and use your time wisely to get the credit you deserve for spending that time doing a very patient-centered visit with your patients. Thanks Dr. Hammond. I think that's a really great note to end our conversation on just highlighting all of these chances these opportunities for physicians to really optimize their visits and get credit for like you said for the work that they're doing to deliver high quality care. I know we had previously talked about having some discussion at the end of our presentation but we are actually at time and so I just want to thank everyone for joining us today. We'd love to hear any feedback that you have on this discussion and I'd love to Dr. Hammond hand it over to you in case you have any final parting thoughts. Thanks Gabriel. I really appreciate you including me in this discussion and I look forward to being a resource during DO-DAY and at the end of our presentation any conversation or questions that may come up during the during the presentation I'll be available to answer any questions at that time. Well thank you all and enjoy your DO-DAY 2025.

Medicare payment cuts

physician payment reform

Medicare payment structure

conversion factor reductions

MIPS program flaws

congressional intervention

medical field consolidation

payment enhancements

CMS codes optimization

EMR integration