The Centers for Medicare & Medicaid Services (CMS) regularly updates policies that directly impact your practice revenue. Here's a breakdown of the most significant recent changes and what they mean for your practice.
1. Medicare Physician Fee Schedule Changes
CMS has updated the conversion factor for the Medicare Physician Fee Schedule:
- Conversion factor decreased by approximately 3.4% from the previous year
- E/M visit codes (99202-99215) saw modest increases
- Telehealth services temporarily expanded through the end of the year
- Behavioral health integration payment increased
What This Means for Your Practice
If you're heavily Medicare-dependent, expect a slight revenue decrease. Offset this by:
- Increasing telehealth volume (lower overhead)
- Optimizing coding to capture all billable services
- Adding behavioral health integration codes if applicable
2. Quality Payment Program (QPP) Updates
The Merit-based Incentive Payment System (MIPS) has new requirements:
MIPS Performance Categories
| Category | Weight | Key Changes |
|---|---|---|
| Quality | 30% | New measures added, some retired |
| Cost | 30% | Increased from 25% — measure your total cost of care |
| Promoting Interoperability | 25% | New API requirements |
| Improvement Activities | 15% | Simplified activity list |
What to Do
- Check your measures — ensure you're reporting on current measures
- Focus on cost — this category now represents 30% of your score
- Use certified EHR — your EHR must support the new API requirements
- Document improvement activities — keep records of what you've done
3. Telehealth Policy Extensions
CMS extended several telehealth flexibilities:
- Mental health telehealth — no geographic restrictions (permanent)
- Audio-only telehealth — allowed for mental health services
- Home as originating site — extended through the year
- Expanded telehealth list — additional services added
Billing Telehealth Correctly
Use these CPT codes for telehealth:
| Code | Description | Notes |
|---|---|---|
| 99202-99215 | Office/outpatient E/M | Use modifier 95 for synchronous video |
| G2010 | Remote evaluation | Store-and-forward |
| G2012 | Virtual check-in | 5-10 min, not from a visit |
| 99421-99423 | Online digital E/M | Asynchronous messaging |
4. Remote Patient Monitoring (RPM) Expansion
RPM reimbursement continues to grow:
- CPT 99453 — Initial setup and patient education
- CPT 99454 — Device supply and daily data collection
- CPT 99457 — RPM management (first 20 min/month)
- CPT 99458 — Additional 20 min/month
Revenue Potential
For a practice with 50 RPM patients:
- 99453 (one-time): ~$120 × 50 = $6,000
- 99454 (monthly): ~$65 × 50 × 12 = $39,000
- 99457 (monthly): ~$55 × 50 × 12 = $33,000
- Total annual RPM revenue: ~$78,000
5. Prior Authorization Changes
CMS implemented new prior authorization requirements:
- New service categories — additional services require prior auth
- Electronic prior auth — encouraged via X12 278 transactions
- Decision timeframes — 7 calendar days for standard, 72 hours for expedited
- Transparency — must provide reason for denial
What to Do
- Check your EHR — does it support electronic prior auth?
- Train staff — which services now require prior auth?
- Track turnaround — monitor how long payers take to respond
- Appeal denials — CMS requires specific denial reasons
6. Price Transparency Requirements
Hospitals and practices must now:
- Post machine-readable files — all standard charges
- Post 300 shoppable services — consumer-friendly pricing
- Include payer-specific rates — not just chargemaster
- Update annually — or face penalties
For Small Practices
While the hospital rule doesn't directly apply to small practices, patients will increasingly ask for price estimates. Be prepared to provide:
- Good faith estimates — for self-pay patients
- Cost ranges — for common procedures
- Insurance-specific estimates — based on patient's plan
7. Health Equity Initiatives
CMS is prioritizing health equity:
- Social determinants of health (SDOH) screening
- Health-related social needs (HRSN) codes
- Health equity adjustment in MIPS
- Z-codes for SDOH documentation
New ICD-10 Z-Codes for SDOH
| Code | Description |
|---|---|
| Z55 | Problems related to education |
| Z56 | Problems related to employment |
| Z57 | Occupational exposure to risk |
| Z59 | Problems related to housing and economic circumstances |
| Z60 | Problems related to social environment |
Documenting these codes can improve your MIPS score and help justify additional services.
Conclusion
CMS policy changes are constant. The practices that thrive are the ones that:
- Stay informed — review CMS updates quarterly
- Use technology — let your EHR handle coding and reporting
- Train staff — ensure everyone knows the current rules
- Track metrics — monitor reimbursement rates and denial patterns
- Adapt quickly — implement changes before deadlines
Neuraline EHR stays current with CMS requirements, including MIPS reporting, telehealth billing, and prior authorization. See how it works.