Summary of the 2021 Proposed Physician Fee Schedule Rule
- The rule was released August 3rd, and confirms CMS’s support of the AMA revised definitions of E/M codes 99202—99215, with increased RVUs and payment for these services
- Changes to payments in the fee schedule must be budget neutral; the increases in payments for codes 99202—99215 results in a significant decrease in to the overall conversion factor, setting up disagreement between specialties who perform procedures and those that perform mostly E/M services
- CMS is seeking comments regarding the definition of an add-on code GPC1X (placeholder code) to be added to E/M services for increase complexity
- CMS is thinking ahead about telehealth after the public health emergency (PHE) ends
- CMS notes that the final rule will be released by Dec. 1st, not Nov. 1st this year
The conversion factor decreases significantly from the current $36.09 to $32.26. The law requires budget neutrality in the physician fee schedule. That means, when new services are added or the fees for certain services increase, fees in other areas must decrease.
The increase in fees for 99202—99215 and decrease in the overall conversion factor means that some specialties will see an increase in their revenue in 2021, and some others will see a significant decrease. To see CMS’s estimate of the effect of these proposed changes download Table 90, page 898 and 899 of the proposed rule.
E/M services account for 40% of all allowed charges paid under Part B. The office and/other outpatient codes 99201—99215 account for 20% of allowed charges. The AMA is making substantial revisions to codes 99202—99215, the first ones in over two decades. In 2021, a clinician may select the level of service for these codes based on medical decision making or time. The definition of MDM is revised. If using time, the clinician will include total time for the day, including pre-time, visit time, and post-visit time. The codes now have a time range. CodingIntel members, you can read in detail about the upcoming changes here.
CMS is re-valuing certain services that include office and outpatient services, including monthly capitation for end staged renal disease, transitional care management and the maternity package. The maternity package is, in my opinion, valued too low and paid significantly too little, so this is welcome news.
Rules for all other E/M services that are based on history, exam and MDM remain unchanged in 2021.
Add-on code GPC1X
CMS will develop an add-on code for use with E/M services associated with primary care and some non-procedural specialty services. They discussed their intent to do this in 2021 in last year’s rule. They are actively seeking comments about how to define this add-on code and when it can be used.
For 2021, CPT is developing a new prolonged services code that may be added on to codes 99215 and 99205 only, when an additional 15 minutes of time is spent in either face-to-face or non-face-to-face services. Unfortunately, the time thresholds to use this code in the AMA’s 2021 draft guidelines (released last year) and the time thresholds in the CMS 2021 proposed rule are not the same. There will undoubtedly be many comments about this, but we will have to wait until the final rule is released to see if the time differences are resolved. CPT has not released the new prolonged services code yet, but is using placeholder code 99XXX now.
Members can watch the on-demand webinar to learn more about coding for prolonged services.
CMS responded to the PHE by removing restrictions on telehealth services, including geographic location of the patient and site of service restrictions. They substantially increased what services could be provided via telehealth, added physical therapists, occupation therapists and speech language pathologists to the list of providers who may provide telehealth, and temporarily added services that could be provided via audio/telephone only.
In the proposed rule, they are proposing to add nine services to the telehealth list permanently, and thirteen services temporarily. They are not proposing to include office visits in the list of services that can be provided via telehealth after the end of the public health emergency. They propose to stop paying for telephone codes 99441—99443 and 98966—98968 after the PHE ends. However, they are soliciting comments on adding additional virtual HCPCS services for services that take longer than G2012. (Tammy, should we link to our articles?)
Communication technology-based services (CTBS)
CMS is proposing to allow licensed clinical social workers, licensed psychologists, PTs, OTs and SLPs to use HCPCS codes G2061—G2063. These codes are for on-line messaging and management by clinicians who do not have E/M services in their scope of practice. They are also proposing to add to additional CTBS HCPCS codes for practitioners who cannot bill E/M services that correspond roughly to G2012 and G2010.
Remote physiological monitoring
CMS notes that they receive many questions about the correct use of codes 99453, 99454, 99091, 99457 and 99458. They are proposing some clarifications, including that codes 99453 and 99454 describes the work of non-practitioners, and these non-practitioners can be contracted, not employees, under physician/non-physician practitioner supervision. These two codes may only be reported once in a 30-day period, no matter how many devices are used. The data must be digitally, automatically uploaded, not patient recorded or self-reported. That is an important clarification.
All five codes listed above must be ordered only by physicians and non-physician practitioners who are eligible to bill E/M services.
CMS is proposing to make permanent the provision that consent can be obtained at the time the RPM service is obtained.
Join us on August 27th to hear details about these proposals.
Information about the Proposed Rule is updated each year when it is released. Previous years are archived below for reference.
2020 Proposed Rule
- CMS rescinds bundled payments for 2021 and accepts CPT® revisions for new and established patients
- Proposes new HCPCS codes for care management
- Outlines proposals to further ease burden of documentation
E/M changes for 2021
The biggest news in the 2020 proposed physician fee schedule has an effective date in 2021. Last year, CMS said that it would implement a single payment and RVU value for codes 99202—99204 and another for codes 99212—99214.
Then, CPT® released revisions to the new and established patient rules effective in 2021. CMS is accepting those changes and is not going to implement the plan for a single fee/RVU value for those code ranges.
In addition, beginning in 2021, neither history nor exam will be a key component for codes 99202—99215. 99201 will be deleted in 2021. Code selection will be based on either time, with new rules related to counting time for these services, or a re-defined medical decision making. If you attended July’s webinar, you heard the details.
CMS proposing new care management codes
CMS is proposing to add new HCPCS codes to replace the current chronic care management codes, 99490, 99487 and 99489. This would most likely be for only one year, because CMS anticipates that the CPT® editorial panel will work on these codes for the future.
CMS does not come out and say that they expect CPT® to develop CPT® codes to replace the HCPCS codes, but reading between the lines, that is the implication. CMS is proposing two codes to replace 99490. CMS is proposing that one code would be equivalent to 99490, the first 20 minutes in a calendar month, but they would add a second code for each additional 20 minute increments of clinical staff time.
They’re seeking comments on whether to limit the number of additional increments of the add-on code that would be allowed.
They are proposing replacing 99487 and 99489 with HCPCS codes that would have the same time increments, and which would slightly decrease the difficulty of reporting complex chronic care management. It would no longer require a substantial care plan change in order to bill it.
Principal care management
CMS is also proposing to add an additional two HCPCS codes for principal care management. The first is defined as:
“Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.”
That code may be used by a physician, nurse practitioner, or a physician assistant.
There is an additional proposed code for use by clinical staff members.
“Comprehensive care management for a single high-risk disease services, e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.”
A patient would be eligible for principal care management (PCM) if they have only one chronic condition that is expected to last between three months and a year or until the death of the patient. It would be a condition that had led to a recent hospitalization and/or places the patient at significant risk of death, acute exacerbation/decompensation or functional decline.
CMS is not proposing any restrictions on specialties they could bill PCM, but expects that this code would be billed by specialists, when there is a single condition of such complexity that it cannot be managed in a primary care setting.
Transitional care management (TCM) changes
CMS is proposing to increase work RVUs for TCM. In addition, they note that there are currently 57 services that may not be billed during the TCM period, per CPT®. Many of these are noncovered, bundled, or invalid for Medicare purposes, but not all.
CMS is proposing to allow 14 CPT® or HCPCS to be billed within the TCM period, that are now prohibited by CPT® from being reported together, codes which may not be billed currently with TCM to be billed with TCM.
Supervision of physician assistants
Although the billing rules under Medicare for nurse practitioners, certified nurse midwives, and physician assistants are the same, the supervision rules are different for physician assistants. CMS is proposing to change that. They’re proposing that supervision requirements would be met when a PA is performing services in their state scope of practice and provided with medical direction and appropriate supervision as required by the state in which the physician assistant is practicing.
Medical record documentation
CMS notes that they have received questions from stakeholders about whether PA and NP students are covered in the definition of a student under the teaching physician roles. They note that currently and NP or PA preceptor may not use the note of an NP/PA student, in the same way a physician can use a medical student note. They are asking for comments about whether this should apply.
CMS also wants to continue lessening the documentation burden on clinicians. Read this next quotation carefully.
“Therefore, we propose to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team. This principle would apply across the spectrum of all Medicare-covered services paid under the PFS.”
This seems like a radical change to me, and I present it without comment.
2019 Proposed Physician Fee Schedule Rule
Just a reminder that all of the new HCPCS and CPT® codes discussed in the rule are “dummy” codes, placeholders for the codes to be released.
In this post: podiatry, brief virtual check-in, inter-professional consultations, and more
Count your pennies
The conversion factor was changed from $35.9996 to $36.0463.
CMS is proposing two new codes to report Podiatry E/M services
- one for new patients
- one for established patients
The new patient visit would pay about $102 in the office and $73 in a facility setting. The established visit would pay $67 in the office and $45 in a facility setting. Podiatrists would use these codes in place of 99201—99215 codes.
Inherent complexity codes
- one for primary care
- one for certain specialist
GPC1X: Visit complexity inherent to evaluation and management associated with primary medical care services that serve as the continuing focal point for all needed health care services (Add-on code, list separately in addition to an evaluation and management visit).
The wRVU for this service is .07. This code has differential payment based on setting, with a payment of about $5.40 in a non-facility, office setting and $3,96 in a facility setting.
GCG0X: Visit complexity inherent to evaluation and management associated with endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology, otolaryngology or interventional pain management-centered care (Add-on code, list separately in addition to an evaluation and management visit).
This add-on code has wRVUs of .25 and a payment of about $13.70, in a facility or non- facility setting.
New prolonged services code, 30 minutes
GPRO1: Prolonged evaluation and management or psychotherapy service(s) (beyond the typical service time of the primary procedure) in the office or other outpatient setting requiring direct pateint contact beyond the usual service; 30 minutes (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service)
This code has wRVUs of 1.17. Payment in a non-facility would be about $67.40 and in a facility $63.80.
CMS heard that using the CPT® codes for prolonged services was difficult, because the prolonged time was 60 minutes. The time for this service is 30 additional minutes.
In order to bill it, the provider would need to meet the threshold of the base code and half of the prolonged code.
New CCM code (Chronic care management)
CPT® has developed a new code for 30 minutes in a calendar month of chronic care management performed by the physician or non-physician practitioner, not staff.
It has a work RVU of 1.22 and pays about $74.25. There is no differentiation between the facility and non-facility rate. The dummy code CMS used in the rule is 994X7, and we’ll see the CPT® code when the AMA releases the CPT® books.
There are existing CPT® codes for inter-professional consults, based on time, that had a status indicator of bundled. That is, CMS did not pay them. These codes, 99446—99449 have been in the CPT® book since 2013.
CMS is proposing to change the status indicator form bundled to active, making them paid services. Since these are existing CPT® codes, you can read about them in your current book.
99446 Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional, 5-10 minutes
99447 11-20 minutes
99448 21-30 minutes
99449 over 31 minutes
CPT® has developed two additional codes in this series. (Below, are the dummy codes, new CPT® codes in your 2019 book when in arrives).
994X0 Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes
994X6 Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 or more minutes of medical consultative time
Here are two quotes from the rule about the purpose of these services and CMS’s concerns:
“…specialty expertise to assist with the diagnosis and/or management of the patient’s problem without the need for the patient’s face-to-face contact with the consulting physician or other qualified healthcare professional…”
“We note there are program integrity concerns.”
The rule continues that we can’t bill for “professional courtesy or continuing education,” and that these services would require verbal consent from the beneficiary in advance of the service.
Acute stroke telehealth services
The Bipartisan Budget Act of 2018 required CMS to pay for acute stroke telehealth services. CMS is proposing to develop a modifier to report these services. The rule removes the restriction on geographic location for these services only.
Brief virtual check-in
There was a disturbance in the force. You felt it, didn’t you? CMS is proposing to pay for – well—here’s the (dummy HCPCS) code, read it for yourself.
GVCI1: 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; 5-10 minutes of medical discussion.
The non-facility payment would be about $15.40 and the facility payment would be $13.37. Not a lot of money, but isn’t there an expression about getting your nose under the tent?
This would only be allowed for established patients, and only providers with E/M services in their scope of practice could bill it. CMS is seeking comments about requiring verbal consent to bill and frequency limitations.
Here’s a picture of the tick | Remote Services
Haven’t you always wanted to send a picture of that rash or the tick to your provider? Or, have I been reading the rule for too long? Well, now we can do it.
CMS is going to pay your provider almost $13 to look at your picture and reply back to you “verbally.” There is a whopping .18 wRVU for this service, an office payment of about $12.97 and facility payment of $10.09.
GRAS1: Remote pre-recorded service via recorded video and/or images submitted by the patient (e.g, store and forward), including interpretation with verbal follow-up with the patient within 24 business hours, 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.
There’s more to the rule, but these are some of the most interesting parts for medical practices.
Learn more about these and other important proposed changes by watching the on-demand webinar.