Header: For physicians managing inpatient care, CMS and AMA’s CPT system offer a range of codes covering initial, mid-stay, and discharge day encounters, each with multiple levels of time and intensity to capture the scope of patient care. Now, CMS has introduced an add-on code specifically aimed at compensating the added complexity of treating infectious disease patients in these settings.
For more information and links, click here:
https://www.discoveriesinhealthpolicy.com/2024/11/cms-releases-final-pfs-and-opps-rules.html
For the CY2025 PFS rule see here. In the inspection copy version, see pp. 301-316.
IDSA flags the new code as a big win - here. See also their 2024 comment letter. And see the Congressional letter of support, which notes that 80% of US counties lack even one ID specialist and last year, only half of infectious disease fellowship slots were filled.
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In final rulemaking for CY2025, CMS creates a new G-code code, valued at about 1 RVU (circa $30), that reflects the adding complexity of managing an infectious disease patient. The code is G0454 and defined as follows:
Visit complexity inherent to hospital inpatient or observation care associated with a confirmed or suspected infectious disease by an infectious diseases consultant, including disease transmission risk assessment and mitigation, public health investigation, analysis, and testing, and complex antimicrobial therapy counseling and treatment. (add-on code, list separately in addition to hospital inpatient or observation evaluation and management visit, initial, same day discharge, or subsequent).
This is an add-on code, billed together with the underlying encounter code the provider would otherwise bill (and still bills).
The code seems to be triggered if the patient (1) is an inpatient (or inpatient observation), (2) the patient has confirmed or suspected infectous disease, and (3) the billing provider is "an infectious disease consultant." This includes infectious disease specialty physcians, but also e.g. a nurse practitioner with infectious disease specialization.
If the consultation is made remotely, bill the appropriate electronic records review consultation code, but do NOT add G0545.
Justification for the novel code includes special public health concerns (including data research and time) related to being an infectious disease physician caring for an infectious disease patient:
- Disease transmission rusk assessment and mitigation
- Such as consulting with infectoius prevention staff and managing prevention protocols;
- Public health investigation and analysis
- Such as in-depth chart review farther back in time communicating with microbiology lab, state health, CDC;
- Complex antimicrobial therapy counseling and treatment
- Such as counseling regarding antimicrobial stewardship, resistance, emergence of variants, new strains, public health concerns, etc.
AI Corner
Here is a Chat GPT generated news article.
CMS Finalizes New Add-On Code for
Infectious Disease Hospital Visits: HCPCS Code G0545
The Centers for Medicare & Medicaid Services (CMS) recently announced a significant policy update impacting hospital inpatient and observation care for infectious diseases. Under the new rule finalized for Calendar Year (CY) 2025, CMS introduced HCPCS code G0545—a complexity add-on code to enhance payments for infectious disease specialists providing complex care during hospital stays.
Addressing Complexity in Infectious Disease Care
The decision to create HCPCS code G0545 acknowledges the unique challenges posed by infectious disease cases in hospital settings. Infectious disease cases often involve intricate decision-making and risk management, including infection control, collaboration with public health agencies, and personalized antimicrobial therapy management. According to CMS, infectious diseases require extensive medical review because resistance patterns and public health risks continually evolve, posing unique challenges for patient management and community safety.
Key Components of HCPCS Code G0545
HCPCS code G0545 allows infectious disease specialists to report additional complexity beyond standard Evaluation and Management (E/M) hospital codes. This add-on code covers three main areas:
- Disease Transmission Risk Assessment and Mitigation – Includes specialized infection control measures, counseling for patients and caregivers, and care coordination to reduce transmission risks.
- Public Health Investigation, Analysis, and Testing – Encompasses thorough patient history reviews, specialized diagnostic evaluations, and coordination with public health authorities for contact tracing and diagnostic testing.
- Complex Antimicrobial Therapy Counseling and Treatment – Involves advising patients and families on antimicrobial stewardship, managing resistance concerns, and selecting appropriate therapies based on population health considerations.
Implications for Infectious Disease Specialists and the Healthcare System
The final rule emphasizes that G0545 may be billed only by infectious disease professionals trained to manage the unique challenges inherent in infectious disease cases. CMS has set a work Relative Value Unit (RVU) of 0.89 for G0545, reflecting the time and decision-making intensity involved, estimated at 30 minutes per encounter, though not time-based for billing. This new code is seen as a response to growing concerns that current E/M codes fail to account for the expertise required in managing infectious diseases, particularly in light of increased vigilance following the COVID-19 pandemic.
Responses to Public Comments and Future Directions
The proposal for HCPCS code G0545 received broad support, with many stakeholders welcoming its focus on complexity. Some commenters requested it be converted to a standalone code for use without a face-to-face visit, but CMS decided to keep it as an add-on code. Additionally, CMS clarified that practitioners, including nurse practitioners and physician assistants with infectious disease expertise, can bill for G0545 under the appropriate conditions. CMS also affirmed that no new documentation requirements would accompany this add-on code, maintaining that the medical record should reflect the complexity inherent in infectious disease cases.
The implementation of HCPCS code G0545 marks a key step toward improving reimbursement for specialized care in infectious disease cases and reflects CMS’s ongoing efforts to adapt Medicare payment policies to the complexities of modern medical practice.
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I understand there was a complaint from someone that CMS violates longstanding policy by creating a specialty specific code (re read the PDF if needed).
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Yes, there was indeed a complaint from several commenters regarding CMS’s decision to create a specialty-specific code for infectious disease care, specifically HCPCS code G0545. These commenters argued that CMS's approach departs from longstanding policy, as CPT codes have traditionally been non-specialty-specific to ensure fairness across medical disciplines. The concern is that such specialty-focused codes, like G0545, may inadvertently favor one specialty’s expertise over others, potentially creating imbalances in physician payment.
The commenters suggested that instead of focusing solely on infectious disease specialists, CMS should consider a more generalized code for complex inpatient care that any specialty could use. They pointed out that many specialties also provide critical, complex E/M services in inpatient settings, and these services are similarly undervalued under the current Physician Fee Schedule (PFS). The commenters also expressed willingness to collaborate with CMS and other stakeholders to address broader issues with the undervaluation of E/M services across specialties.
In response, CMS maintained that infectious diseases require unique attention due to their inherent risks and public health implications. CMS argued that infectious disease cases, by nature, demand specialized infection control, complex diagnostic coordination, and nuanced antimicrobial stewardship, which are not fully accounted for in general E/M codes. Thus, CMS finalized HCPCS code G0545, reaffirming its belief that the complexities of infectious disease care justify a distinct coding approach.
