Key points of CMS’ Medicare Physician Fee Schedule proposed rule for 2021

By AOA Staff


On Aug. 3, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule and supporting fact sheet that announces and solicits public comments on proposed policy changes for Medicare payments under the Physician Fee Schedule (PFS), and other Medicare Part B issues, on or after Jan. 1, 2021.

It is worth noting that the proposed PFS rule would make permanent certain telehealth and workforce flexibilities provided during the COVID-19 public health emergency (PHE). This includes the expansion of payment for services furnished by allied health professionals both in person and through telehealth.

In addition, CMS is proposing several changes to the Quality Payment Program (QPP), including delaying the implementation of the Merit-Based Incentive Payment System (MIPS) Value Pathway framework. In the rule, CMS introduces a new Alternative Payment Model (APM) Performance Pathway to provide data reporting consistency for participants in MIPS APMs.

Conversion Factor

The proposed CY 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09.

Office/Outpatient Evaluation and Management (E/M) Visits

Rather than implement in CY 2021 the RUC-recommended total times finalized in the CY 2020 final rule for CPT codes 99202 through 99215, CMS is now proposing to adopt the actual total times (defined as the sum of the component times). See Table 17 for the proposed time changes.

Increased Work RVUs for Transitional Care Management and Behavioral Health Services

For CY 2021, CMS is proposing to increase the work RVUs associated with transitional care management (TCM) codes 99495 and 99496 to commensurate with the new valuations for the level 4 (CPT code 99214) and level 5 (CPT code 99215) office/outpatient E/M visits for established patients, and several behavioral health codes. See Table 17 in the proposed rule for the full list of codes.

Permanent and Temporary Telehealth Services

In response to the PHE for the COVID-19 pandemic, CMS undertook emergency rulemaking to add a number of services to the Medicare telehealth services list on an interim final basis. CMS is proposing to permanently add several of those services to the Medicare telehealth services list on a Category 1 and Category 3 basis for CY 2021. See Table 8 for the full list of proposed telehealth codes.

Telephone E/M Services

Instead of continuing to recognize audio-only (telephone) E/M codes (99441, 99442 and 99443) for payment under the PFS after the conclusion of the PHE, CMS is soliciting comment on whether to develop coding and payment for a service similar to the virtual check-in but for a longer time with a higher value. CMS also is seeking input on work and practice expenses associated with telephone services and whether a provisional policy should remain in effect until a year after the end of the PHE or if it should be PFS payment policy permanently.

Supervision of Diagnostic tests by Certain Nonphysician Practitioners (NPPs)

In the rule, CMS proposes to make permanent following the COVID-19 PHE, the interim policy to allow 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, in accordance with scope of practice and applicable state law, provided they maintain the required statutory relationships with supervising or collaborating physicians.

Medicare Shared Savings Program

CMS is proposing changes to the Medicare Shared Savings Program quality performance standard and quality reporting requirements for performance years beginning on Jan. 1, 2021 to align with Meaningful Measures, reduce reporting burden and focus on patient outcomes. In addition, CMS proposes to update the definition of primary care services to reflect services for cognitive impairment and chronic care management. Other proposed changes would include new E/M and care management CPT and HCPCS codes in the methodology used to assign beneficiaries to ACOs, exclude certain services furnished in skilled nursing facilities from the assignment methodology when provided in federally quality health care and rural health care facilities, and modify the definition of primary care services to exclude advance care planning when billed in an inpatient care setting.

Removal of Outdated National Coverage Determinations (NCDs)

CMS is seeking stakeholder feedback on the removal of nine outdated or obsolete National Coverage Determinations (NCDs). Removing outdated NCDs means Medicare Administrative Contractors (MACs) no longer are required to follow those outdated coverage policies when it comes to covering services for beneficiaries. As a result, the MACs would be allowed to determine coverage for beneficiaries in their geographic areas based on more recent evidence and information.

Merit-Based Incentive Payment System (MIPS)

CMS is proposing to reduce the MIPS performance threshold for the 2023 payment year, and include a total of 206 quality measures starting in performance year 2021. The Cost performance category will make up 20 percent of a MIPS eligible clinician’s final score for the 2023 MIPS payment year and 30% for the 2024 MIPS payment year as required by statute. Given the recent rise in volume of telehealth services, CMS is proposing to include telehealth services in the Quality and Cost measurement performance categories.

MIPS Value Pathways

CMS is proposing to update the guiding principles, development criteria and process for the MIPS Value Pathways (MVPs) to guide implementation beginning with the 2022 MIPS performance period/2024 MIPS payment year.

Alternative Payment Models (APMs)

Starting January 1, 2021, CMS is proposing to introduce a new APM Performance Pathway (APP) to align with the MVP concept. The APP would be a voluntary pathway for reporting and scoring under MIPS that would allow APM participants to report a single quality measure set with broad applicability, receive an Improvement Activities credit, and have the Cost performance category reweighted.

CMS also proposes to eliminate the APM scoring standard for the 2021 performance year beginning Jan. 1, 2021 to allow APM participants to participate in MIPS as individuals, groups, virtual groups, or APM entities, and report through any MIPS reporting and scoring pathway.

Due to COVID-19, CMS is waiving the 60-day delay in the effective date of the final rule, and replacing it with a 30-day delay. For additional information on the proposed rule, view the CMS fact sheet. CMS will accept comments on the proposed rule until Oct. 5, 2020.

AOA staff will continue to review the proposed rule and prepare comments.