The 2021 Proposed Physician Fee Schedule: The Major Points

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On August 3 CMS published the proposed policy changes for the Physician Fee Schedule (PFS).  The comment period is open through October 5, 2020.  At a very high level I have provided the major points open for comment.  There are a number of significant changes.  It is critical to perform an analysis against current operations to see if a proposed rule impacting your operations – how significant is it, what operational changes are needed (if any), what are the financial impacts, and what if any education is needed to beneficiaries.  The complete rule can be found here.

2021 PFS Ratesetting – Lower Conversion Factor

First, what is a “conversion factor” and why is it important?  In short, CPT® codes have an associated Relative Value Unit (RVU) in which a fee is paid by Medicare for the specific CPT® code.  The building blocks of the total RVU calculation includes sub-values for: physician work (RVUw), practice expense (RVUpe), and malpractice (RVUmp).  The conversion factor (CF) is the number of dollars assigned to an RVU.  The conversion factor includes within its complex formula the state of the U.S. economy, number of Medicare beneficiaries, the prior year spend amount, and changes in covered services.

The bottom line for proposed for 2021:  A $3.83 decrease in the conversion factor.  The proposed rule has set the 2021 PFS conversion factor at $32.26 compared to the 2020 PFS conversion factor of $36.09

This is a significant decrease and if approved will be financially difficult for practices on top of the current financial difficulties caused by COVID-19.

Expanding Telehealth and Other Services Involving Communications Technology

CMS determines approval of telehealth based on requirements in two categories.  CMS has category 1 and category 2.

Category 1:  Services are similar to existing which are currently approved for telehealth delivery.  In deciding to approve      codes CMS looks to similarities between the requested and existing telehealth services, including interactions among beneficiaries and the practitioner at the distant site, telepresenter, and similarities in technologies used to deliver the proposed service.

    Category 2:  Services not similar to Medicare-approved telehealth services.  CMS will look to see whether the service is accurately described by the CPT® code when delivered via telehealth, and whether use of technology to deliver the service has a demonstrated clinical benefit to the patient.

Services identified in the proposed rule as Category 1 codes are:

  • Visit Complexity Associated with Certain Office/Outpatient E/Ms (GPC1X)
  • Prolonged Services (99XXX)
  • Group Psychotherapy (90853)
  • Neurobehavioral Status Exam (96121)
  • Care Planning for Patients with Cognitive Impairment (99483)
  • Domiciliary, Rest Home, or Custodial Care Services (99334, 99335)
  • Home Visits (99347, 99348)

CMS is also proposing to create a third temporary category criteria for adding telehealth services.

Category 3:  Services added to the Medicare telehealth list during the public health emergency (PHE) for the COVID-19 pandemic that will remain on the list through the calendar year in which the PHE ends.

Proposed services to be added as Category 3 are:

  • Domiciliary, Rest Home, or Custodial Care Services, Established Patient (99336, 99337)
  • Home Visits, Established Patient (99349, 99350)
  • Emergency Department Visits (99281, 99282, 99283)
  • Nursing Facilities Discharge Day Management (99315, 99316)
  • Psychological and Neuropsychological Testing (96130, 96131, 96132, 96133)

Subsequent Nursing Facility Visits – Frequency Limitation

CMS is proposing to revise the frequency limitation from one visit every 30 days to one visit every 3 days. CMS is suggesting this would enhance patient access to care by removing the frequency limitations altogether.

Furnishing of Brief Online Assessments by: PT, PT, SLP, LCSW, and others

CMS has clarified licensed clinical social workers, clinical psychologist, physical therapists, occupational therapists, and speech-language pathologists can furnish the brief online assessment and management services as well as virtual check-ins and remote evaluation services.

As a result, CMS is proposing two new HCPCS codes.  Additionally, CMS has clarified the question as to whether telehealth services can be used when such services are performed in the same institutional setting as the beneficiary utilizing telecommunications technology due to risk exposure.  CMS reiterated, telehealth rules do not apply when the beneficiary and the practitioner are in the same location even if audio/video technology assts in furnishing a service.

Remote Physiologic Monitoring (RPM) Services

CMS continues to expand services around RPM.  CMS proposes the following and also issued some clarification.

RPM proposals:

  • Permanent policy to allow consent to be obtained at the time RPM services are furnished;
  • Permanent policy to allow auxiliary personnel to furnish CPT® codes 99452 and 99454 under a physician’s supervision. CMS included contracted employees as auxiliary personnel;
  • RPM services are considered to be E/M services; and
  • Whether current RPM codes accurately and adequately describe the full range of clinical scenarios.

The proposed rule also provides several clarifications for RPM services:

  • Following the PHE for COVID-19, CMS will again require an established patient-physician relationship exists for RPM services to be furnished;
  • Medical device supplied to a patient as part of a CPT code 99454 must be a medical device defined by Section 201(h) of the Federal Food, Drug, and Cosmetic Act, and the device must be reliable and valid, and data must be electronically collected and transmitted rather than self-reported;
  • After the PHE for COVID-19, CMS will maintain the current requirement that 16 days of data each 30 days must be collected and transmitted to meet CPT® 99453 and 99454 requirements;
  • Only physicians and NPPs who are eligible to furnish E/M services may bill RPM services;
  • Practitioners may furnish RPM services to patients with acute conditions as well as patients with chronic conditions; and
  • CPT® codes 99457 and 99458 are an “interactive communication” which is defined as a conversation which occurs real-time and includes synchronous, two-way interactions which can be enhanced with video or other kinds of data described by HCPCS G2012.

Immunization Services

CMS is proposing new payment rates for the below codes to better reflect the resources involved:  90460, 90461, 90471, 90472, 90473, 90474, G0008, G0009, and G0010.

Direct Supervision by Interactive Telecommunications Technology

CMS is proposing to allow direct supervision to be provided using real-time, interactive audio and video technology, excluding telephone not inclusive of video, through December 31, 2021.

Payment for Office/Outpatient E/M and Analogous Visits

CMS is looking to align E/m visit codes.  As part of this alignment, CMS is clarifying the time for which prolonged services can be reported for Office/Outpatient E/M visits.  In addition to this change, CMS is proposing to revalue the following code sets:

  • ESRD Monthly Capitation Payment (MCP) Services
  • Transitional Care Management (TCM) Services
  • Maternity Services
  • Cognitive Impairment Assessment and Care Planning
  • Initial Preventive Physical Examination (IPPE) and Initial and Subsequent Annual Wellness (AWV) Visits
  • Emergency Department Visits
  • Therapy Evaluations
  • Psychiatric Diagnostic Evaluations and Psychotherapy Services.

Additionally, CMS is seeking comment to clarify the definition of the previously finalized add-on code GPC1X and whether CMS should refine their utilization assumptions for this code.

Professional Scope of Practice and Related Issues

CMS has several items in the proposed rule for comment.  The categories are:

  • Supervision of Diagnostic tests by Certain Nonphysician Practitioners (NPPs)
  • Pharmacists Providing Services Incident to Physicians’ Services
  • Therapy Assistants Furnishing Maintenance Therapy
  • Medical Record Documentation
  • PFS Payment for Services of Teaching Physicians (Including Primary Care Exception)