CMS Showing Favoritism, Insurers Hiding Intent and 2026 IPPS TEAM Preview

Many of you may be aware last year the Centers for Medicare & Medicaid Services (CMS) added HCPCS code G2211 that physicians can use in addition to their office or other outpatient visit code that CMS labels as a code to compensate for the inherent complexity of the longitudinal care of patients but really was designed to allow doctors to earn a little more money in the face of continuing payment cuts.

Well, that movement goes on in the 2025 physician fee schedule proposed rule where CMS has proposed adding a code for use by infectious disease doctors to describe intensity and complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease. CMS does note that the COVID-19 pandemic has, as they state, “ignited a hypervigilance for infectious diseases.”

Now this is great; ID doctors absolutely deserve this boost in payment, but so does every other doctor who cares for hospitalized patients. Pulmonary physicians are exposed to airborne infectious diseases all day long. Do they not also deserve to have an add-on code? The ED doctor is encountering the patient with an infectious disease even before the diagnosis is made; do they not deserve an add-on code?

Now how did this code come about? Well, according to social media, this was an intensive lobbying effort by the Infectious Disease Society of America. They spoke to CMS and Congress and advocated for their physician members. That’s awesome but CMS really needs to take a wider look when they add payment specific to one specialty to ensure they are not playing favorites.

In other news, I am going to call this section “the words they use to hide their evil.” Credit to Dr Al Gore, physician advisor from Santa Rosa, California who shared online this quote from Humana- “The company saw ‘higher-than-anticipated’ inpatient admissions in the quarter and we continue to assess the durability of the higher admissions, including clinical appropriateness and potential mitigation activities.”

Potential mitigation activities? Why don’t they just come out and say they are going to start being more aggressive with auditing and denying of claims.

Then credit to Brian Murphy, the past head of ACDIS, now branding director at Norwood, who posted a Cigna policy update. In this update, Cigna noted that they stop paying for serum folic acid levels “when billed with a diagnosis that is considered not medically useful.” “Medically useful”? Why would they not use the common terminology “medically necessary”? Perhaps because usefulness allows them to deny payment without having to justify it.

Finally, the 2025 IPPS final rule was released, and it is 2,987 pages. CMS is finalizing their TEAM model, Transforming Episode Accountability Model, a bundled payment program for coronary artery bypass graft surgery, lower extremity joint replacement, major bowel procedure, surgical hip/femur fracture treatment, and spinal fusion covering all services from hospitalization to 30 days after discharge.

Don’t panic yet – this program won’t start until 2026, so we all have time to understand it. There are 188 metropolitan areas that will be included in this program. If you want to know if you are included, go to page 1885 of this display version of the rule- https://public-inspection.federalregister.gov/2024-17021.pdf. CMS does try to explain their rationale, but the math is, as usual, incomprehensible. It is interesting to note that Spearfish, South Dakota is included, where there is one hospital with under 30 beds but the Chicago metropolitan area, with many hospitals including several academic medical centers, is not included.

Now all is not lost for those areas not selected; CMS will allow hospitals to opt in but only if they are participating in or have participated in either CJR or BPCI in the past.

I promise to provide more information as I read the 731 pages describing this new model, but I can report that CMS will waive the 3-day SNF rule but only if the chosen SNF has three or more stars and will once again forbid steering of patients to partner providers, requiring full patient choice.

Programming note:

Listen to Dr. Ronald Hirsch on Monitor Mondays when he makes his Monday rounds, 10 Eastern and sponsored by R1-RCM.