Bad News and Good News: Medicare Pay Cuts for Physicians and New Code Updates

On November 2, 2023, the Centers for Medicare and Medicaid Services (CMS) issued their “Final Rule” on the 2024 physician fee schedule, including some important changes all US MIGS surgeons should know about.  

First the bad. The 2024 conversion factor for Medicare dropped from $33.89 to $32.74 per relative value unit (RVU). That’s a decrease of 3.4%. Most of us realize that the time and effort to provide care to patients has not declined in the past year at all, much less 3.4%. Last year they increased the value of office staff in the practice expense section (increasing reimbursement for nurses, medical assistants, etc.) but continued to reimburse less for physician work. There are also more covered services this year which further divides the pie. Because Medicare is required by law to be budget neutral, when they increased the RVUs of the office evaluating and management (E&M) codes, they had to decrease the overall value of the RVU. In addition, the higher RVU for stand-alone office visits was not factored into the global period. Thus, the post op visits in the global period are still valued at the previous E&M values.  While almost all the surgical societies (including ACOG) pushed for the higher values to be included in the global period office visits, their efforts were rebuffed by others in the house of medicine.

The impact of the final rule by specialty can be found here. Since our main society is OB and GYN, there is no division published on the impact specifically to GYN only providers. If you would like to advocate to your elected representatives about this topic, here is a simple, free email campaign you can utilize.

Now for the win (and the likely reason OBGYN will see an increase in total reimbursement from CMS).  We have a new current procedural terminology (CPT) code. 99459 was initially proposed and presented by ACOG to CMS and the American Medical Association CPT and Relative Value Scale (RVS) Update Committee (RUC). This code is a practice expense only code that will reimburse your private practice office for the use of a chaperone (for 4 minutes), the table and light, speculum, lubricant, and swabs during a patient E&M visit. It also includes the cost of a chaperone. The value of this code is 0.68 RVUs (not work RVUs, just practice expense RVUs, providers get paid for the E&M code) and can only be used in a non-facility setting. This code should be added to any 99202-5, 99212-5, 99242-5, 99384-99387 and 99393-7 codes. You cannot use it on post-op visits since the cost of providing those visits is already included in the global payment. Documentation must state the need for the pelvic exam AND confirm the use of a chaperone. 

Of course, the effect on the hospital employed physician who is paid by work RVUs (wRVUs), is more subtle. While the wRVUs are still the same, the hospital may decrease the dollars per work RVU because the overall reimbursement is less. OBGYNs are generally paid less per wRVU than other specialties because we see so many Medicaid pregnancies which lowers the dollars per wRVU the hospital brings in and those “savings” by the government are passed on from the hospital to the OBGYN department. Hopefully, more MIGS surgeons are forming separate divisions and asking for work RVU payments equal to our surgeon colleagues (which can sometimes be double what OBGYN departments get from the health care systems).

Feel free to reach out with any questions, concerns, or other coding and reimbursement requests.