CMS Releases Annual Medicare Physician Payment Rule


On August 3, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule containing potential policy changes to Medicare physician reimbursement under the Physician Fee Schedule (PFS) and other Medicare Part B issues for 2021.

The sprawling 1,353-page proposed rule covers numerous issue areas and topics. Here is an overview of the major proposals:

Telehealth Services

During the COVID-19 emergency, CMS has allowed for many services to be furnished via telehealth. This proposed rule would make permanent certain services including:

  • Group Psychotherapy (CPT code 90853)
  • Domiciliary, Rest Home, or Custodial Care Services, Established Patients (CPT codes 99334-99335)
  • Home Visits, Established Patient (CPT codes 99347- 99348)
  • Cognitive Assessment and Care Planning Services (CPT code 99483)
  • Visit Complexity Inherent to Certain Office/Outpatient E/Ms (HCPCS code GPC1X)
  • Prolonged Services (CPT code 99XXX)
  • Psychological and Neuropsychological Testing (CPT code 96121)

CMS is also proposing that the following services will be temporarily reimbursable by Medicare for the duration of the COVID-19 public health emergency:

  • Domiciliary, Rest Home, or Custodial Care Services, Established Patients (CPT codes 99336-99337)
  • Home Visits, Established Patient (CPT codes 99349-99350)
  • Emergency Department Visits, Levels 1–3 (CPT codes 99281-99283)
  • Nursing Facilities Discharge Day Management (CPT codes 99315-99316)
  • Psychological and Neuropsychological Testing (CPT codes 96130- 96133)

The full list of proposed permanent codes is available at Table 8 of the proposed rule and the temporary services list is available at Table 10. CMS is also not proposing to add certain services to the Medicare telehealth services list, but is requesting public comment on whether the agency should add them on a permanent or temporary basis, and lists these services in Table 12.

Values for Evaluation and Management (E/M)

The CY 2020 PFS rule would have implemented the RUC-recommended time for E/M codes 99202–99215. However, CMS is now proposing to adopt the actual total times, rather than the RUC-recommended times. See Table 17 for more information.

CMS is proposing to revalue services that are analogous to office/outpatient E/M visits. In the proposed rule, CMS highlights that total care management, cognitive impairment assessment and care planning, certain end-stage renal disease (ESRD), annual wellness visits and preventative physical exam services are closely tied to the office/outpatient visits codes. Therefore, CMs believes it is appropriate to adjust their values commensurate with any changes made to the values for the office/outpatient E/M visits.

A summary of CY 2020 and CY 2021 proposed work RVUs are available in Table 19 and a comparison of proposed values for physician time and clinical staff time is available in Table 20.

Relevant Proposals Regarding Scope of Practice

The proposed rule would allow nurse practitioners, clinical nurse specialists, physician assistants and certified nurse-midwives to supervise diagnostic tests permanently. Such providers still must practice in accordance within state law. This is currently a temporary policy for the COVID-19 pandemic.

Additionally, this proposed rule clarifies that physicians can review and verify documentation entered into the medical record by members of a medical team for their own services that are paid under the PFS. Furthermore, therapy students working under a physician may document in the record so long as it is reviewed and signed by the billing physician.

For the duration of the COVID-19 emergency, teaching physicians and residents have been granted various flexibilities. For example, the physician may use audio/video technology for supervision purposes, and residents may furnish certain expanded primary care services at primary care centers. CMS is considering expanding these policies through 2021 or making them permanent.

Quality Payment Program Proposals for CY 2021

CMS is proposing changes to the Quality Payment Program, including the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM). For example, CMS will continue to refine the MIPS Value Pathways (MVPs) rather than implement them in January 2021.

MVPs were proposed in last year’s PFS, in part, to simplify the MIPS program, although many commenters did not agree MVPs would ease program burden and instead would create more confusion. CMS is also proposing an APM Performance Pathway (APP) that would be similar to MVPs.

CMS is proposing to incrementally adjust the performance threshold and performance category weights to meet statutory requirements. CMS is proposing the following performance threshold and category weights for the 2021 performance period (i.e., 2023 payment year).

  • The performance threshold would be 50 points.
  • The quality performance category would be weighted at 40 percent (5 percent decrease from performance year (PY) 2020).
  • The cost performance category would be weighted at 20 percent (5 percent increase from PY 2020).
  • The promoting interoperability performance category would be weighted at 25 percent (no change from PY 2020).
  • The improvement activities performance category would be weighted at 15 percent (no change from PY 2020).

CMS also is proposing to increase the maximum number of points available for treating COVID-19 patients. Clinicians, groups, virtual groups and APM entities could earn up to 10 bonus points toward their final score for PY 2020. This would only apply to PY 2020.

Below is a list of helpful links:

Comments to the proposed rule are due by October 5, 2020. ACOFP will continue to review the proposed rule and plans on submitting comments.