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A New Medicare Physician Fee Schedule for the New Year
Late in 2020, CMS finalized its annual Medicare Physician Fee Schedule (PFS) for 2021. Caravan sent comments on the proposed PFS in October, and the final version includes some important changes. Notably, the 2021 PFS affects ACO quality measurement, physician payment, ACO attribution, and COVID relief. There are also clinical changes affecting telehealth, care management, remote patient monitoring, and annual wellness visits.
ACOs are settling into these changes as the new year gets underway. This blog offers some explanation of the PFS provisions we get asked about most. Importantly, the year-end COVID relief law impacted some of these PFS provisions, especially related to physician pay.
MSSP Quality Change
In the proposed 2021 PFS, CMS outlined a major overhaul to ACO quality measurement. The proposal would have moved all ACOs to a new APM Performance Pathway (APP) system with a new measure set and a new reporting method. In the final rule, CMS adopted the APP system, but will allow ACOs to use the previous measure set and reporting method for the 2021 performance year, thus delaying the most disruptive changes. As expected, CMS finalized a proposal for all ACOs to receive full credit for CAHPS reporting for 2020 due to the uncertainty from the COVID-19 pandemic.
Physician Payment Changes
The 2021 PFS included a significant increase for evaluation and management (E/M) office visits and a payment add-on code for E/M billing for patients with complex conditions (G2211). This would have raised payment for office-based specialties that bill a lot of E/M services, including primary care specialties such as family medicine.
These payment increases were good news for primary care practices. However, CMS rules are subject to budget neutrality requirements and the E/M increases would have resulted in payment cuts for many procedure-based specialties, such as radiology and surgical specialties. In response to concerns from certain physician specialty groups, Congress made adjustments to mitigate payment decreases. Congress took two actions: (1) implemented a 3.75% across-the-board increase in physician payment (paid for with a $3B in additional funding) and (2) delayed the implementation of the add-on code for 3 years.
These legislative changes will reduce, but not eliminate, many of the cuts that physician specialty groups were concerned about. At the same time, primary care reimbursement is still expected to increase. For example, according to an AMA analysis, billing by family medicine physicians is expected to rise by 11%, compared to 13% estimated after the final PFS. On the other hand, radiology billing was expected to decrease by 10%, and that decrease is now down to 4%.
New Primary Care Service Codes for ACO Assignment
After advocacy from ACOs and others, CMS added 11 primary codes to the list used for ACO beneficiary assignment. Two of these, principal care management and non-complex chronic care management, were just added to the PFS last year. Several of the others are similar to codes already used for beneficiary assignment.
The newly added codes that can be used for ACO assignment are:
- 99421, 99422, and 99423 (online digital evaluation and management, also known as “e-visits”)
• 99483 (assessment of and care planning for patients with cognitive impairment)
• 99491 (chronic care management)
• G2058/99439 (non-complex chronic care management)
• G2064 and G2065 (principal care management)
• G2214 (psychiatric collaborative care model)
• G2010 and G2012 (remote evaluation of patient video/images and virtual check-ins)
Extreme and Uncontrollable Circumstances Policy for Quality Reporting
In providing relief to ACOs for quality reporting during the COVID-19 PHE, CMS considered altering the MSSP 2020 Extreme and Uncontrollable Circumstances policy to award ACOs the higher of their 2019 or 2020 quality scores, so long as the ACO fully reports quality in PY 2020. However, CMS did not finalize this policy, and instead will award ACOs either their own quality score or the mean score across all ACOs for 2020, whichever is higher.
Limited Expansion of Telehealth Services
Telehealth has been a lifeline for many patients during the COVID-19 pandemic, especially those in rural areas. The 2021 PFS adds to the list of available codes that can be billed through telehealth. Note that CMS does not have authority to pay for most telehealth/virtual care services in non-rural areas or in patient homes beyond PHE.
9 codes are added permanently and can be used after the COVID-19 PHE ends.
• 90853 (Group psychotherapy)
• 99334–99335 (Domiciliary, rest home, or custodial care services, established patients)
• 99347–99348 (Home visits, established patient)
• 99483 (Cognitive assessment and care planning services)
• G2211 (Visit complexity inherent to certain office/outpatient E/M, this add-on code is delayed for 3 years by the relief law)
• G2212 (Prolonged services)
• 96121 (Psychological and neuropsychological testing)
CMS has temporarily added 60 codes until end of year that the PHE ends. CMS is evaluating the clinical effectiveness of these codes when delivered via telehealth and will consider adding them permanently at a later time. This list includes codes for psychological and neuropsychological testing, emergency department visits, and certain PT/OT services. There are approximately 30 codes that CMS is not proposing to extend at all after the COVID-19 PHE ends.
Clinical Service Changes
There are several important changes to clinical services, including care management services. Principal care management (PCM) codes for managing care for patients with one serious chronic condition were new in last year’s PFS. These codes are now available at Rural Health Clinics and Federally Qualified Health Centers. Additionally, transitional care mganagement (TCM) can now be billed concurrently with certain ESRD codes and with basic care management when reasonable and appropriate.
The initial preventive physical examination (IPPE) (“Welcome to Medicare Physical”) and annual wellness visit (AWV) now require a review of current opioid prescriptions and screening for substance use disorder. Auxiliary personnel, including contracted employees, may furnish Remote Patient Monitoring services under the general supervision of the billing physician or practitioner.
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