• AAFP Advocacy Focus: Medicare Physician Fee Schedule (MPFS)

    Overview

    The Centers for Medicare & Medicaid Services (CMS) annually revises the Medicare physician fee schedule for the upcoming calendar year. The regulation governs physician payment and coverage for services under Medicare Part B and the Quality Payment Program; its annual revisions update payment policies, rates, and provisions for services based on relative value units and geographic location.

    Office/outpatient Evaluation and Management (E/M) services are a major category of Current Procedural Terminology (CPT) codes (99202 –99215) that family physicians and other clinicians use to bill for office visits. During outpatient E/M visits, physicians provide screenings and other preventive services, diagnose and manage patients’ chronic conditions, treat acute illnesses, develop care plans, coordinate care across providers and settings, and discuss patients’ preferences. The E/M patient visit is most frequently billed by family physicians and is the core of most family physician practices.

    2021 MPFS Changes

    CMS published the CY 2021 MPFS proposed rule on August 17, 2020, and it included plans to adopt increased values for outpatient E/M services originally finalized in 2019 and to implement the updated outpatient E/M coding and documentation guidelines developed by the CPT Editorial Panel.

    The changes go into effect on Jan. 1, 2021. CMS also indicated in the proposed rule that it plans to move forward with implementing an add-on code that family physicians can bill to account for the inherent complexity of primary care services. The AAFP has advocated for these E/M increases, which will help to ensure that primary care services are valued more appropriately, correcting a longstanding imbalance in the MPFS.

    However, CMS did not propose to permanently cover audio-only telehealth services, which has also been a priority for the Academy in order to improve equitable telehealth access.

    Additionally, CMS declined to automatically apply extreme and uncontrollable circumstances for the Merit-based Incentive Payment System, which would protect physician practices that are not able to report to MIPS due to the ongoing COVID-19 pandemic.

    The CY 2021 MPFS also includes a proposal to increase payment for the immunization administration base codes (90460, 90471, 90473).

    The AAFP’s comments on the 2021 proposals can be found in a September 28, 2020, letter to CMS Administrator Seema Verma. You can also find a comprehensive summary of the proposed rule here.

    The CY 2021 MPFS final rule is expected to be released around Dec. 1, 2020, at which point the Academy will analyze the finalized changes and communicate them to members before they go into effect Jan. 1.

    Why We Fight

    More than 90% of family physicians accept Medicare. The MPFS is also often the basis for payment schedules used by other payers, including TRICARE, state Medicaid plans, and many private payers. What happens with the MPFS therefore has an enormous impact on primary care. Yet the annually updated MPFS does not necessarily advance a primary care–centered health system that improves health and reduces system costs.

    In the 2020 MPFS final rule, CMS adopted policies to increase values for E/M services, introduce an add-on code to account for the inherent complexity of primary care, and adopt the updated outpatient E/M coding and documentation guidelines. The new values and guidelines go into effect Jan. 1, 2021. These changes are a direct result of years of lobbying by the AAFP and amount to an estimated 13% increase in Medicare payment for family medicine — a long-sought raise for family physicians. To the extent other payers rely on the MPFS, family physician may experience a payment increase beyond Medicare, too.

    In 2020, the Academy pushed CMS to follow through with the previously finalized changes and to resist pressure from other medical specialties to reverse course. The AAFP has told both CMS and Congress that the new E/M changes must go into effect in 2021 as planned.



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