The Centers for Medicare & Medicaid Services recently sent a memo to Medicare Advantage (MA) organizations and Medicare-Medicaid plans that provides additional information on the coverage criteria for basic benefits, the use of prior authorization, and review of utilization management…
On August 3, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) proposed rule for CY 2021. This proposal updates payment policies and payment rates for Part B services furnished under the MPFS, as well as makes changes to the Quality Payment Program (QPP). The rule in its entirety and the addenda, including Addendum B, which lists the proposed RVUs for each CPT code can be found here.
The proposal is currently open for comment through October 5. The rule’s provisions, if finalized, will beeff ective January 1, 2021 unless stated otherwise. The following summarizes the major policies in the proposal.
Planned 30-day Delayed Effective Date for the Final Rule (p. 801)
Normally, CMS provides a 60-day delay in the effective date of final rules after the date that they are issued. However, the Congressional Review Act allows an agency to change the effective date if there is good cause to not follow regular notice and public procedures. Since CMS is prioritizing efforts to contain and combat the COVID-19 public health emergency (PHE), the work needed to complete the PFS payment rule will not be completed in accordance with their usual schedule, which aims for a publication date of at least 60 days before the start of the applicable fiscal year, approximately November 1. The agency expects to need at least 30 additional days to complete the work on the payment rule. Therefore, the agency expects that the PFS final rule will be released December 1 and will have an effective 30 days after publication of January 1.
Conversion Factor and Specialty Impact (p. 894)
The proposed conversion factor for 2021 is $32.26, a decrease of almost $4 from the current conversion factor of $36.09. This reduction of 10.61 percent stems from adjustments that statutorily required to accommodate the new spending on the outpatient evaluation and management (E/M) changes as well as other changes in the budget neutral system. Table 90 (see Appendix A), extracted from the rule, provides a summary of the impact of the changes in the proposed rule by specialty. The changes in the rule are budgetneutral in the aggregate, which explains why the impact for all physicians is shown as zero. The proposed rule shows changes in the range of minus 11 percent to plus 17 percent with allergy and otolaryngology seeing 9 and 7 percent increases respectively. However, the ultimate impact on an individual physician’s reimbursement will depend on their case mix as the majority of services that are not E/M have decreased.
As you will see in the attached chart, the budget neutrality adjustment is resulting in significant increases to many of the specific codes billed by AAOA members.
Refinements to Values for Certain Services to Reflect Revisions to Payment for Office/Outpatient Evaluation and Management (E/M) Visits and Promote Payment Stability during the COVID-19 Pandemic (p. 144)
BACKGROUND: In the CY 2020 PFS final rule, CMS adopted the CPT Panel’s changes to the outpatient E/M family that will be effective on January 1, 2021. Providers will no longer use history and physical exam to select the appropriate visit level, and E/M visits will include a medically appropriate history and exam when it is reasonable and necessary, and clinically appropriate. Visit level selection will be based on either the level of medical decision making (MDM) as redefined by CPT or the total face-to-face and non-face-toface time spent by the reporting practitioner on the day of the visit.
Read the full summary here.
Download the AAOA Proposed 2021 MPFS Codes