Medicare Physician Fee Schedule 2021
After the release of the Final Rule December 2, 2020, physicians across the country were feeling the pinch of a 10% reduction in the MPFS. The Consolidated Appropriations Act, finally signed into law on December 27th, modified the Final Rule terms by revising the conversion factor to $34.8931 reflecting a 3.75% increase across the board for CY 2021. The legislation also suspended the 2% payment sequestration through March 21, 2021 and reinstated the 1.0 floor work geographic price cost index through 2023. The AMA lobbied against the implementation of the complexity code (G2211) due to its ambiguous and controversial definition, the Act will delay its use now to 2024. You can find the AMA specialty analysis here: https://www.ama-assn.org/system/files/2021-01/2020-combined-impact-table.pdf.
Highlights of the Final Rule
IPPE and AWE Changes
As part of Medicare’s commitment to identify, prevent, and treat some of the 10.3 million people across the US that are currently part of the opioid epidemic the IPPE and AWV visits will contain new language to help identify these at risk patients. The revision to Section 2002 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) Act Requirements enforced this change for 2021.
The IPPE and AWV reimbursement will increase along with the opioid screening being added to the documentation criteria. Note that some of the other language will also be revised to better define the purpose of the screening area. For 2021, CMS will be adding a new section to screen for potential substance abuse disorder (SUD) within the criteria. Providers will need to:
- Review any current opioid prescriptions
- Evaluate the potential risk factors for a SUD disorder
- Evaluate the individual’s severity of pain and current treatment plan
- Discuss through counseling non-opioid prescription options
- Create referral to a specialist if appropriate
Although we are waiting for the MLN guidance to publish, it is recommend this area of screening is included with the 2021 IPPE and AWV initial visit documentation to comply with the MPFS final rule.
Longer Virtual Check-in’s
Public comment, as part of the CMS draft rule, was very favorable to the G2012, quick check-in, lasting 5-10 minutes, as it provided a means for the provider to quickly resolve a new complaint or determine if the patient needed a more time intense visit. Providers felt this was a valuable service but often assessments surpassed the maximum time. CMS created HPCPS code G2252, also defined as a brief communication technology-based service, but with an extended time requirement of 11-20 minutes of medical discussion. The work value of the code is .97 and has the same requirements of the patient not being seen the past 7 days or next 24 hours. This code is temporary through 2021. Note, when the health emergency (PHE) ends and the telephones codes expire for Medicare payment (codes 99441-99443), providers will use G2012 and G2252 as the replacements.
New Virtual Check-in’s for LCSW’s, PT’s, OT’s, SLP’s, and Clinical Psychologists
Due to many non-physician qualified healthcare professionals being restricted to providing most of their services via telehealth, CMS developed two new HCPCS codes to address similar circumstances as the G2012 (virtual check-in) and G2010 (store and forward) available to physicians. The two new G codes can be used by licensed clinical social workers, clinical psychologists, occupational, speech, and physical therapists. Note the final rule excluded both audiologists and medical nutritionists from billing these services.
• G2250 (Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment).
• G2251 (Brief communication technology-based service, (e.g. virtual check-in), by a qualified health care professional who cannot 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 a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion)
Direct Supervision
As part of the PHE coverage, CMS implemented a rule to allow physicians to provide direct supervision via telehealth for required visual supervision using real time audio-video. This rule will expire at the end of the year following the Covid-19 pandemic.
PHE Supplies
It is not a surprise that office and hospital resources have increased significantly between PPE and testing supplies. The AMA lobbied to create RVU’s for an add-on code to be used with regular E/M services. Code 99072, defined as additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a PHE as defined by law, due to respiratory-transmitted infectious disease, was shot down with CMS stating, we believe that use of these additional forms of PPE would be inherent to the furnishing of separately paid services under these practitioner/patient interactions, and therefore will not be adding payment for 2021.
Skilled Nursing Telehealth
The final rule making for skilled nursing visits was huge disappointment for seniors needing regular access to providers via telehealth. During the PHE, limitations are removed from the use of subsequent codes 99307-99310, and provided a new layer of access to prevent our most vulnerable from being sent to the emergency room. The draft rule comment fell short of articulating the need for these codes to be more available for providers to oversee acute problems that often times increase the overall cost of care. CMS ruled that a 14 day visit was enough for oversight of these patients. Several pieces of legislation, house and senate sponsored, could change or modify this rule. These bills likewise address the originating site rules currently waived during the PHE. GCS is watching these events closely and will update if provisions make it through Congress.
Telehealth Services Added
As part of an ongoing effort for CMS to add similar face-to-face services to the approved telehealth list, they expanded the category 1&2 lists and added a category 3 for services through the PHE. Category 1&2 will include the following permanent codes:
Group Psychotherapy (CPT 90853)
Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT 99334-99335)
Home Visits, Established Patient (CPT 99347- 99348)
Cognitive Assessment and Care Planning Services (CPT 99483)
Prolonged Services (HCPCS G2212)
Psychological and Neuropsychological Testing (CPT 96121)
Category 3 codes have expanded from the original proposed rule list. These codes will expire at the end of the year following the Covid-19 pandemic.
Domiciliary, Rest Home, or Custodial Care Services, Established Patients (CPT 99336, 99337)
Home Visits, Established Patient (CPT 99349, 99350)
Emergency Department Visits, Levels 1-5 (CPT 99281-99385)
Nursing Facilities Discharge Day Management (CPT 99315, 99316)
Psychological and Neuropsychological Testing (CPT 96130-96133, 96136-96139)
Psychological and Neuropsychological Testing (CPT 96130-96133; CPT 96136-96139)
Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161-97168; CPT 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507)
Hospital Discharge Day Management (CPT 99238-99239)
Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT 99469, 99472, 99476)
Continuing Neonatal Intensive Care Services (CPT 99478-99480)
Critical Care Services (CPT 99291-99292)
End-Stage Renal Disease Monthly Capitation Payment codes (CPT 90952, 90953, 90956, 90959, 90962)
Subsequent Observation and Observation Discharge Day Management (CPT 99217, 99224-99226)
2021 Evaluation & Management Webinars
The much anticipated rule change is currently in effect for CPT codes 99202-99205 and 99211-99215. Although the medical decision making tables mirror several of the 1995 guidelines, there are an abundance of changes that will impact the requirement of documentation and coding. GCS has prepared education and if you are interested in scheduling a live webinar to review these changes, you can email us at info@gillcompliance.com. Group rates available and all sessions include and on-demand link and a 15 minute post webinar Q&A. Our most popular sessions include:
- Navigating the 2021 E/M Guidelines
- Understanding the 2021 CMS Final Rule for Physician Services
- Telehealth Services for Clinic & Hospital Settings