CMS Releases Proposed 2021 Medicare Physician Fee Schedule and Hospital Outpatient Rules

The Centers for Medicare and Medicaid Services (CMS) on Aug. 3 released the proposed 2021 Medicare Physician Fee Schedule, addressing Medicare payment and quality provisions for physicians in 2021. Under the proposal, physicians will see a reduced conversion factor from $36.09 to $32.26, effective Jan. 1, 2021. 

This reduction mostly stems from adjustments that must be made to accommodate new spending resulting from implementation of changes to evaluation and management (E/M) payments in the budget neutral system. CMS estimates that the physician rule will increase payments to cardiologists by one percent from 2020 to 2021 through updates to work, practice expense and malpractice RVUs, depending on the mix of services provided in a practice. 

The Physician Fee Schedule was released in tandem with the proposed 2021 Hospital Outpatient Prospective Payment System rule. The outpatient rule indicates a 2.6 percent payment update for hospitals and other proposals. Highlights from OPPS rule can be found here.  

Physician Fee Schedule Highlights:

  • After proposing and revising changes to E/M documentation and payment in 2019 and 2020, the proposed 2021 rule includes final policies and rates for these services. Among the changes:
    • Walking back a 2019 plan to pay a blended rate for level 2-4 visits, CMS will implement revised E/M code definitions developed by the AMA CPT Editorial Panel starting Jan. 1, 2021. Members from across the House of Medicine worked together on the revised definitions in order to address concerns about documentation burden in a manner that was less disruptive and correctly discerned differences in levels of E/M services.
    • The proposal to adopt revised coding definitions is paired with a decision to pay for each level of service rather than use a blended rate.
    • CMS proposes to adopt revised and increased work RVUs for E/M services based on recommendations from the AMA Relative Value Scale Update Committee (RUC). 
    • Revaluing other services analogous to office E/M services, such as transitional care management, maternity care, and end stage renal disease. 
  • Following on the heels of a presidential executive order focused on “Improving Rural Health and Telehealth Access,” the proposed rule includes a number of important telehealth policy proposals, including expansion of the list of telehealth services that will remain permanent beyond the COVID-19 public health emergency. It also proposes Category I and Category III codes, some of which will remain on the list through the calendar year in which the PHE ends. The Agency is seeking comments regarding the services included in both lists. Regarding audio-only telephone E/M services, CMS is specifically seeking comments on whether to “develop coding and payment for a service similar to the virtual check-in but for a longer unit of time and subsequently with a higher value.” The ACC Advocacy team details specific highlights here. 
  • CMS proposes no changes regarding implementation of the Appropriate Use Criteria (AUC) Mandate when ordering advanced imaging services (i.e., SPECT/PET MPI, CT and MR). Requirements were previously summarized in this MLN Matters article
  • The proposed rule includes updates to work and/or practice expense (PE) values for codes describing E/M, intracardiac echocardiography, electrocardiography, EP infusion stimulation, transthoracic echocardiography, VAD interrogation, venography, and extracorporeal counterpulsation. More detail will be available after CMS posts supporting data tables. Additionally, the rule includes proposed work and/or PE values for new/revised codes describing extended external ECG monitoring, atrial septostomy, nuclear physicist dose consultation, and percutaneous ventricular assist device services.
  • The rule addresses professional scope of practice and related issues, including supervision of diagnostic tests by certain NPPs; pharmacists providing services incidents to physician’s services; therapy assistants furnishing maintenance therapy; modifications to medical record documentation; and updates to payment for services of teaching physicians.
  • As clinicians across the country continue to respond to COVID-19, CMS notes it is limiting the number of significant changes to the Quality Payment Program in 2021, including a delayed implementation timeline for the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) until the 2022 performance period, and introducing the Alternative Payment Model (APM) Performance Pathway (APP) to align with the MVP framework. Additionally, as part of APP implement, the CMS Web Interface would be sunset as a collection type beginning in the 2021 performance period. Get a detailed breakdown on all QPP policies and changes here.
  • The rule includes revisions reflecting the current payment methodology finalized in the 2020 PFS and the addition of two new HCPCS codes, G2064 and G2065, to the general care management HCPCS code, G0511, for Principle Care Management Services furnished in Rural Health Clinic (RHC) and Federally Qualified Health Clinics (FQHC). Additionally, the rule creates new E/M CPT and HCPCS codes based on the methodology used to assign beneficiaries to ACOs to reflect services for cognitive impairment and chronic management.
  • After creating a process to remove outdated NCDs in 2013, CMS proposes to apply those criteria within physician fee schedule rulemaking to remove nine NCDs.

ACC staff are reviewing the proposed rules to identify additional topics of interest to members. More information will be forthcoming in the Advocate newsletter and on ACC.org in the coming weeks. CMS fact sheets are available here and here. The College will submit written comments at the end of the summer. Download a PDF of the detailed highlights from both rules.

Not long before the final rules are released in the fall, experts will discuss federal legislative and regulatory topics at ACC’s 2020 Virtual Legislative Conference October 4-6. Don’t miss this opportunity to learn about hot button issues facing cardiologists and to ensure the voice of cardiology is heard on Capitol Hill. Learn more here.

Keywords: ACC Advocacy, Relative Value Scales, Centers for Medicare and Medicaid Services (U.S.), Medicare, Healthcare Common Procedure Coding System


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