On December 1, 2020, the Centers for Medicare & Medicaid Services (CMS) issued their final updates on policy changes for the 2021 Medicare Physician Fee Schedule (MPFS), cementing the reimbursement changes related to evaluation and management services effective January 1st.

Highlights of the final rule include:

Fee Schedule

In earlier rulemaking cycles, CMS announced the intent to adopt recommendations by the American Medical Association (AMA) for both updated documentation requirements and increased Relative Value Units (RVUs) for office & outpatient Evaluation and Management (E/M) codes.  Due to the Congressionally mandated budget neutrality of the fee schedule and the high rate of utilization of office & outpatient E/M codes (20% overall), adopting these recommendations results in a reduction to reimbursement for specialties that do not normally bill these codes.

CMS did not eliminate or delay the implementation of these updates effective 1/1/21.

  • Final 2021 Conversion Factor (CF) is set at $32.40 – this is a slight increase to the proposed rule’s conversion factor of $32.26 but is a 10% (-$3.69) reduction to the current conversion factor $36.09.
    • Final Anesthesia CF for 2021 is set at $20.05, a -$1.96 change from the current conversion factor $22.01.
  • The final estimate of total impact to specialties remains similar (within 1%) to the estimates provided in the proposed rule

Specialty

Final Impact

Proposed Impact
Radiology -10% -11%
Interventional Radiology -8% -9%
Radiation Oncology -5% -6%
Nuclear Medicine -8% -8%
Pathology -9% -9%
Anesthesiology -8% -8%
Nurse Anes / Anes Assistants -10% -11%
Dermatology -1% -2%

The full impact table is available HERE

 

Supervision of Diagnostic Tests by Certain Nonphysician Practitioners

CMS has finalized the permanent adoption of the waiver granted on May 1st of the Public Health Emergency (PHE) which allows Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs), Physician Assistants (PAs) and Certified Nurse-Midwives (CNMs) to supervise the performance of diagnostic tests in addition to physicians.  CMS has added Certified Registered Nurse Anesthetists (CRNAs) to this list in the final rule.

Effective January 1, 2021, NPs, CNSs, PAs CNMs, and CRNAs are allowed, under the Medicare Part B program, to supervise the performance of diagnostic tests within their state scope of practice and applicable state law, provided they maintain the required statutory relationships with supervising or collaborating physicians.

Telehealth

As a result of the rapid utilization of telehealth services during the COVID-19 PHE, CMS is finalizing many of their proposals which will help maintain the expanded access to these services outside of emergency waiver authority.

Modifications to the Telehealth List

CMS is permanently adding several CPTs to their list of services that are reimbursable if conducted via telehealth – these primarily include CPTs related to behavioral and home health but also include the two new E/M add-on codes for prolonged services (G2212) and medical complexity (G2211).

CMS has also finalized the “Category 3” criteria to add codes to the CMS list of telehealth codes on a temporary basis.  This means that CMS can now add CPT codes to the telehealth list outside of rulemaking.  During the PHE, CMS has been able to modify the telehealth list under waiver authority so the finalization of the new “category 3” criteria make this flexibility permanent. In the final rule, CMS is adding a number of CPTs to the telehealth list under the new criteria.  Note that the category 3 for the telehealth list is separate from ‘category III’ CPT codes which are used for tracking purposes.

           Direct Supervision Conducted Via Telehealth

Direct supervision furnished via telehealth has been finalized to continue for the remainder of the PHE or December 31, 2021 – whichever date comes sooner.  As a reminder, telehealth supervision must be conducted via a platform utilizing both audio and video.

Audio Only Telehealth Reimbursement

While CMS did not propose that they would continue to pay for ‘audio-only’ telehealth codes after the end of the PHE, they instead asked for comments on whether they should adopt new coding and payments for services similar to virtual-check ins ( virtual-check in codes cover a ‘brief communication’ between patients and providers to assess if a patient needs to be seen in person).

In the final rule, CMS is establishing payment on an interim final basis for a new HCPCS G-code (G2252) describing 11-20 minutes of medical discussion to determine the necessity of an in-person visit. This code will be “cross-walked” to the value of CPT 99442.

G2252

 

Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.)

 

Quality Payment Program (QPP)

2021 Performance Threshold and Category Weights for the Merit-Based Incentive Program (MIPS)

  • Penalty threshold will remain at 60 pts – CMS had previously proposed to lower this to 50 points as potential flexibility due to COVID-19 but has opted to maintain the penalty threshold finalized in the 2020 MPFS.
  • Exceptional performer threshold will remain at 85 pts – CMS had not proposed a change to this threshold.
    • As a reminder, the 2022 performance period (2024 payment year) will be the final year of the additional positive adjustment for exceptional performance.
  • Category Weights
    • Quality – 40%
      • Decrease of -5% from 2020
    • Cost – 20%
      • Increase of +5% from 2020
    • Improvement Activities – 15%
    • Promoting Interoperability – 25%

Note: CMS is required to have cost and quality equally weighted (30%) by the 2022 performance year.

 

MIPS Value Pathways (MVPs) and Alternative Payment Pathway (APP)

CMS finalized their proposals relating to the implementation of MIPS Value Pathways and Alternative Payment Pathways, the future framework of QPP participation.  Both frameworks provide MIPS participants with a smaller, standardized set of measures across all performance categories which reduces reporting burdens of the program.

CMS expects that MVPs will be available to report beginning 2022 and finalized their process for working with stakeholders on the creation and adoption of MVP framework.  CMS will approve MVPs through rulemaking and has set the stage for MVPs to be included in the 2022 proposed rule.

The Alternative Payment Pathway, the Alternative Payment Model (APM) version of an MVP, has been finalized to be available to report in 2021.  Reporting the APP is optional for MIPS APMs except for Medicare Shared Savings Program Accountable Care Organizations (ACOs), who will be required to report the APP following the removal of the CMS Web Interface reporting option in 2022.

2020 Performance Year Flexibilities

  • Complex Patient Bonus – CMS will increase the maximum allowable points for the complex patient bonus from 5 to 10 points for the 2020 performance year only. The complex patient bonus provides bonus points towards the final MIPS score based on beneficiary ICD-10 diagnosis code data, which is calculated by CMS after the submission window. CMS expects that expanding the complex patient bonus will increase 2020 MIPs scores by an average of 3 pts.
  • Extreme and Uncontrollable COVID-19 Hardship – APM Entities may now apply for the ‘extreme and uncontrollable circumstances’ hardship application for the 2020 performance year. Individuals, groups, virtual groups, and APM Entities who’ve experienced difficulties collecting or submitting MIPs data can apply to have any or all MIPS performance categories reweighted.  If the hardship is approved for all categories, participants will receive a neutral score and not be penalized in 2022.  Independent of the final rule, CMS extended the deadline to submit applications until February 1st, 2021.

 

CMS Final Rule Resources

  • The 2021 Final Rule will be published to the Federal Registrar on December 28th. – CLICK HERE
  • Fee Schedule Supporting Documents – CLICK HERE
  • CMS Fact Sheet – CLICK HERE

 

As always, ADVOCATE will continue to keep you informed on the issues impacting medical groups as they develop.

Kayley Jaquet

Manager, Regulatory Affairs