CMS Proposes the 2024 Fee Schedule: G2211 Arrives, the Conversion Factor Falls

CMS published the calendar year 2024 Medicare Physician Fee Schedule proposed rule yesterday, July 13, 2023. The two items that matter most to the practices we work with sit on opposite sides of the ledger. The conversion factor would fall from $33.89 to $32.75, a cut of roughly 3.3%. And the visit complexity add-on code G2211, which has been sitting under a congressional payment moratorium since 2021, would finally be payable starting January 1, 2024.

The rule is a proposal. Comments are open for 60 days and close on September 11, 2023. The final rule usually lands in early November. But the shape of 2024 Medicare payment is now visible, and there is work a practice can do this summer rather than in December.

Key takeaways

• The proposed 2024 conversion factor is $32.75, about 3.3% below 2023, and the cut flows into every commercial and Medicare Advantage contract that floats with the current Medicare schedule.
• G2211 would become payable with office and outpatient E/M visits on January 1, 2024, but not when the visit carries modifier 25.
• CMS proposes raising the MIPS performance threshold from 75 to 82 points, which would push many small groups from neutral to penalty territory.
• Fee schedules and system changes wait for the final rule; provider education on G2211 should start now.

What CMS proposed

The conversion factor drop comes from two directions at once. The 2.5% payment bump Congress added for 2023 shrinks to 1.25% for 2024, and the budget neutrality adjustment for G2211 and other changes pushes the factor down further. CMS does not control the first part; Congress does. The second part is a direct consequence of paying for G2211 within a fixed pool. When CMS adds payment for one service, it has to take it from the conversion factor that prices every other service, and that is what practices are looking at here.

What G2211 is and who can bill it

G2211 is an add-on to an office or outpatient evaluation and management visit (CPT 99202 to 99215). It is meant to recognize the extra work of being the continuing focal point for a patient's care, or of managing a single serious or complex condition over time. It is not tied to a specialty. A primary care physician managing a patient's diabetes, hypertension and depression across years is the obvious case. A rheumatologist who is the ongoing manager of a patient's lupus is another.

What it is not: a code for every visit. A dermatologist removing a lesion for a patient they will not see again does not have the longitudinal relationship the code describes. CMS has been explicit that the relationship, not the visit, is what qualifies. Practices that add G2211 to every 99213 will be easy to spot in claims data.

Two practical points from the proposed rule. First, the add-on has a small payment; the dollar amount will only be certain when the final rule sets the RVUs and the conversion factor. Second, CMS proposes not to pay G2211 when the E/M visit is reported with modifier 25, meaning a visit on the same day as a minor procedure. We expect this restriction to be the most argued-over detail in the comment period, because it removes the add-on from exactly the visits where a primary care physician manages chronic conditions and also freezes a wart or gives a joint injection.

Who feels the conversion factor cut

Everyone paid under the fee schedule, but not equally. Practices heavy in office E/M visits with established patients will recover some of the cut through G2211 if they bill it correctly. Procedure-heavy specialties that rarely qualify for the add-on absorb the cut with nothing to offset it. Most Medicare Advantage contracts and many commercial contracts key their rates to the Medicare fee schedule, so the cut propagates beyond traditional Medicare, sometimes with a lag of a year.

A rough example. A three-physician internal medicine practice with $1.4 million in Medicare and Medicare-linked allowed amounts would see about $46,000 less at the proposed conversion factor if nothing else changed. If the same practice bills G2211 appropriately on a meaningful share of established patient visits, some of that comes back. How much depends on the final RVU and the practice's actual visit mix, and we would not build a budget on it yet.

The contract language is the part to check now. A commercial agreement that pays "105% of the Medicare Physician Fee Schedule in effect on the date of service" moves with the conversion factor on January 1. One that pays "105% of the 2022 Medicare Physician Fee Schedule" does not. Practices often do not know which they have until the first remittance of the year looks wrong. Read the rate exhibit this summer, while there is time to raise it with the payer.

The MIPS threshold proposal

The Quality Payment Program section proposes raising the MIPS performance threshold from 75 to 82 points for the 2024 performance year, with the payment adjustment landing in 2026. Under MIPS, a final score at the threshold means a neutral adjustment; below it means a cut of up to 9% on Medicare Part B payments two years later. A seven-point jump sounds small, but many small groups finish in the high 70s, and the proposal would move them from neutral to penalty without any change in what they do.

CMS also proposes five new MIPS Value Pathways, or MVPs, bringing the total to 16, and continues to signal that traditional MIPS reporting will be retired eventually in favor of MVPs. Nothing is mandatory yet. But a practice that finished at 78 points for 2022 should read this section carefully and decide whether to comment.

Other items worth a glance

The rule extends the current split or shared visit flexibility through 2024, so a physician and a non-physician practitioner in a facility setting can continue to define the substantive portion by history, exam, medical decision making or time. It proposes payment for caregiver training services, new codes for community health integration and principal illness navigation, and it continues most telehealth flexibilities that Congress extended through the end of 2024. It also proposes to pay for social determinants of health risk assessments as part of an E/M visit or annual wellness visit.

Honestly, most small practices should read the G2211 section and the MIPS threshold proposal and skip the rest until the final rule.

What changes in the practice's workflow

If the rule is finalized close to what was proposed, three things need to be true by the first week of January 2024.

1. Providers know what G2211 means and when it applies to their patients, and the documentation shows the longitudinal relationship or the complex condition being managed. A template line is not enough; the note has to say it.
2. The practice management system has G2211 loaded as a billable HCPCS code, with a rule that flags it when it appears with a modifier 25 visit so the biller can review rather than auto-submit.
3. The 2024 fee schedule is loaded with the final conversion factor, and payer contracts that reference the Medicare rate are checked to see whether they update on January 1 or on a later anniversary date.

There is also a patient-facing piece that practices tend to forget. G2211 carries the usual Part B coinsurance, so traditional Medicare patients without supplemental coverage will see a new line on their summary notice and a few extra dollars on their statement. The front desk will be asked what it is. A one-sentence answer, prepared in advance, avoids a lot of awkward phone calls in February.

Questions we hear

Will Congress stop the cut again?

It did for 2021, 2022 and 2023, each time partially and each time late. We would plan for the cut and treat any relief as an upside. Budgeting for a rescue that arrives in late December, if at all, is how practices end up short in the first quarter.

Can we bill G2211 with a new patient visit?

The proposed rule allows it with 99202 to 99205 as well as established visits, provided the visit begins the kind of ongoing relationship the code describes. A one-time consult does not qualify. Document the intent to serve as the continuing focal point of care.

Should we wait for the final rule to change anything?

Yes for fee schedules and system configuration. No for provider education. The concept behind G2211 will not change between now and November, and providers need more than one meeting to get comfortable with it. If your billing team is thin, this is also a reasonable moment to review whether outsourced billing with fee schedule maintenance built in makes sense before the January changeover.

What to do this month

1. Read the CMS fact sheet for the proposed rule. It is a few pages and covers everything above.
2. Pull your 2022 Medicare E/M volume by code and by provider. Estimate how many established patient visits would plausibly qualify for G2211, and how many of those carry modifier 25.
3. Find the rate exhibit in each commercial and Medicare Advantage contract and mark whether the Medicare reference floats or is fixed to a year.
4. Decide whether to comment before September 11. Specialty societies will file detailed comments; a short letter from a practice describing a real patient panel carries a different weight.
5. Schedule a 30-minute provider meeting for early November, after the final rule, so the G2211 conversation happens once with final numbers.