CMS on Tuesday released its final rule to update the Medicare Physician Fee Schedule (MPFS) for calendar year 2021, which, among other provisions, will boost payments for some physicians, reduce payments for others, and expand the list of telehealth services that Medicare covers.
The rule, which CMS administrator Seema Verma called "the most significant updates to E/M codes in 30 years," was delayed by a month as CMS focused on urgent issues related to the Covid-19 epidemic, Modern Healthcare reports. The rule takes effect on Jan. 1, meaning health care organizations have less than a month to adjust to the changes while also dealing with their own Covid-19 response efforts.
CMS said the final rule includes several "standard technical proposals involving practice expense, including the implementation of the third year of the market-based supply and equipment pricing update, and standard rate-setting refinements to update premium data involving malpractice expense and geographic practice cost indices."
As required by law, CMS finalized a budget neutrality adjustment that accounts for changes in relative value units (RVUs)—including changes in evaluation and management services and codes—that are converted into PFS payments rates. Based on the changes, CMS set the final PFS conversion factor for 2021 at $32.41, down $3.68, or 10.6%, from 2020's conversion factor of $36.09.
Jefferies analysts previously said the payment-rate adjustments would reallocate Medicare payments in a way that benefits general practitioners, family practice providers, and NPs, but that reduces payments for some specialties.
Further, CMS finalized a proposal to rebase and revise the market basket for federally qualified health centers (FQHCs) to a 2017 base year, meaning the proposed FQHC market basket update for 2021 will be 2.4%. After accounting for the 2021 multifactor productivity adjustment of 0.7%, CMS said the payment update for FQHCs is 1.7% for 2021.
E/M coding changes
CMS in the final rule said it will align "E/M visit coding and documentation policies with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits" beginning Jan. 1, 2021.
The agency finalized revaluation of several code sets that will increase the value of ED visits, end-stage renal disease capitated payment bundles, maternity care bundles, and more.
CMS also continued its efforts to simplify billing and coding requirements for office and outpatient visits by finalizing revisions recommended by the American Medical Association (AMA) and other organizations. CMS said those revisions—which would take effect Jan. 1, 2021—will save clinicians about 2.3 million hours of work each year.
CMS in a release said it is currently covering 144 services via telehealth under the federally declared public health emergency (PHE) in response to America's coronavirus epidemic, and that between mid-March and mid-October, more than 24.5 million Medicare beneficiaries received a service via telehealth.
The final rule adds more than 60 services to the list of telehealth services that Medicare will cover beyond the PHE. The agency added some of those services to the Medicare telehealth list on a Category 1 basis, because the services are similar to others already included on the list. The services that CMS added to the list on a Category 1 basis include:
- Cognitive Assessment and Care Planning Services CPT Code 99483;
- Domiciliary, Rest Home, or Custodial Care services CPT Codes 99334 and 99335;
- Group Psychotherapy CPT Code 90853;
- Home Visits, Established Patient CPT Codes 99347 and 99348;
- Prolonged Services HCPCS Code G2212;
- Psychological and Neuropsychological Testing CPT Code 96121; and
- Visit Complexity Associated with Certain Office/Outpatient E/Ms HCPCS Code G2211.
CMS also finalized the creation of a temporary third category (Category 3) of services for the Medicare telehealth services list. Category 3 will reflect services that the Trump administration added to the list under the Covid-19 PHE. Under the rule, Category 3 services will remain on the Medicare telehealth services list through the end of the year in which the PHE declaration ends. The services that CMS added to the list on a Category 3 basis include:
- Domiciliary, Rest Home, or Custodial Care services, Established patients CPT Codes 99336 and 99337;
- ED Visits, Levels 1-5 CPT Codes 99281, 99282, 99283, 99284, and 99285;
- Home Visits, Established Patient CPT Codes 99349 and 99350;
- Hospital discharge day management CPT Codes 99238 and 99239;
- Nursing facilities discharge day management CPT Codes 99315 and 99316; and
- Psychological and Neuropsychological Testing CPT Codes 96130-96133 and 96136-96139.
CMS under the final rule also:
- Clarified that Medicare telehealth rules don't apply to services that clinicians provide via telehealth technologies when they're in the same location as the patient, such as when a clinician uses telehealth technologies to avoid potential exposure to a patient infected with the coronavirus;
- Clarified the types of clinicians who can provide brief online assessment and management services, virtual check-ins, and remote evaluation services via Medicare telehealth; and
- Finalized a frequency limitation for subsequent nursing facility visits provided via Medicare telehealth of one visit every 14 days; and
- Finalized a proposal to extend through Dec. 31, 2021, an interim final policy adopted under the PHE declaration to federal rules that allows direct supervision to include instances when a supervising physician or practitioner is overseeing other clinicians via interactive audio/video real-time communications technologies.
In addition, CMS under the rule clarified Medicare payment policies for certain remote physiologic monitoring (RPM) services. For example, the agency clarified that:
- Auxiliary personnel, including contracted employees, may provide certain RPM services if they are under a physician's supervision;
- CMS will again require that an established patient-physician relationship already exist for RPM services to qualify for Medicare coverage once the PHE declaration ends;
- Only non-physician practitioners (NPPs) and physicians eligible to provide E/M services are eligible to bill Medicare for RPM services;
- Providers may obtain patients' consent at the time RPM services are furnished; and
- Qualifying clinicians may provide RPM services to patients with acute conditions and those with chronic conditions.
Updates related to professional scopes of practice
CMS in the rule also finalized updates and clarifications regarding professional scopes of practice and related issues. For example, CMS under the rule will permanently allow CNMs, CNSs, NPs, and PAs—in addition to physicians—to supervise the administration of diagnostic tests within their state scope of practice and applicable state laws, as long as they maintain required relationships with collaborating or supervising physicians.
CMS also extended some policies implemented under the PHE declaration that relate to services furnished by pharmacists and physical therapists, as well as certain flexibilities related to medical record reviews and verification. In addition, CMS clarified policies regarding Medicare payments for services provided by teaching physicians and resident "moonlighting" services.
CMS under the rule also will:
- Adjusted the Medicare Shared Savings Program to account for the Covid-19 epidemic, such as giving providers full credit for 2020 patient experience surveys;
- Implement Sections 2002 and 2003 of the SUPPORT Act, which require initial preventive physical examines to include screening for potential substance use disorders and mandates that clinicians electronically prescribe certain scheduled drugs in accordance with applicable electronic prescription drug monitoring programs;
- Make certain updates to Medicare's Diabetes Prevention Program Expanded Model;
- Revise data reporting periods and the agency's planned phase-in of payment reductions for clinical diagnostic laboratory tests, as called for by recent federal laws; and
- Update several policies related to Medicare payments for opioid use disorder treatment services provided by opioid treatment programs.
CMS also finalized several updates to the Quality Payment Program (QPP). For a full breakdown of CMS' QPP updates, click here.
Several provider groups have raised concerns about the conversion factor reductions, saying they could financially harm health systems and medical groups that are working to combat the new coronavirus.
Anders Gilberg, SVP of government affairs at the Medical Group Management Association, in a statement said, "The 10% decrease to the conversion factor and resulting reimbursement cuts to many specialties is deeply troubling during a time when COVID-19 cases are skyrocketing and practices are scrambling to stay financially viable. We are disappointed that CMS decided to not provide the stability that physician practices require to meet patient needs during this unprecedented public health emergency."
AMA President Susan Bailey in a statement said, "The (American Medical Association) strongly urges Congress to prevent or postpone the payment reductions resulting from Medicare's budget neutrality requirement. Physicians are already experiencing substantial economic hardships due to Covid-19, so these payment cuts could not come at a worse time."
However, in comments submitted on the proposed rule MedPAC noted that the policy change could help close the pay gap between primary care physicians and specialists (Minemyer, FierceHealthcare¸12/1; Brady, Modern Healthcare, 12/1; Brady, Modern Healthcare, 12/2; CMS release, 12/1; CMS fact sheet, 12/1).