• Medicare 2021 E/M Payment Boost Intact, Academy Reports

    AAFP Publishes Initial Summary of Medicare Physician Fee Schedule

    August 27, 2020, 1:15 pm News Staff -- An AAFP summary for members of the proposed 2021 Medicare physician fee schedule released by CMS on Aug. 3 confirms expected good news for primary care: The increase in total allowed charges for family physicians announced last year is still set to begin in 2021 -- and is now 13% rather than the previously mooted 12%.

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    Comments on the MPFS are due to CMS by Oct. 5. The agency has indicated that it may finalize the MPFS later than usual this year because of the pandemic, though it says the changes will still take effect on Jan. 1, 2021.

    Ahead of the Academy's detailed formal response to the fee schedule, the member summary provides an overview of its potential impacts.


    As codified in the 2020 MPFS, the Academy writes, "CMS will be largely aligning its evaluation and management visit coding and documentation policies with changes laid out by the Current Procedural Terminology Editorial Panel for office/outpatient E/M visits, beginning Jan. 1, 2021."

    Specifically, the 2021 fee schedule "proposes a refinement to clarify the times for which prolonged office and outpatient E/M visits can be reported, and proposes to revise the times used for rate setting for this code set."

    "Additionally, CMS proposes to follow through with its plans to increase the relative value units for office and outpatient E/M visits in 2021 and to create and pay for a new code that family physicians may list separately in addition to an E/M visit, to be compensated for '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.'"

    Story Highlights

    About other RVU changes, the summary notes that the fee schedule proposes to "revalue multiple code sets that include, rely upon or are analogous to office/outpatient E/M visits." These revalued code sets include transitional care management services, maternity services, cognitive impairment assessment and care planning, the "welcome to Medicare" visit (along with initial and subsequent annual wellness visits) and ER visits.

    CMS also cites a federally mandated "budget neutrality adjustment" as the cause of a proposed 2021 conversion factor of $32.26, down $3.83 from 2020 -- a reduction of more than 10%.


    The proposed rule would halt payment for audio-only E/M visits after the public health emergency ends. "CMS is seeking comment on whether they should develop coding and payment for a service similar to the virtual check-in, but for longer time and with higher value," the summary says.

    Meanwhile, the MPFS proposes to add permanently to the Medicare telehealth list

    • visit complexity (GPC1X),
    • group psychotherapy (90853),
    • neurobehavioral status exam (96121),
    • prolonged office or outpatient E/M service (99XXX),
    • assessment of and care planning for a patient with cognitive impairment (99483),
    • domiciliary or rest home visit for E/M of established patient (99334, 99335), and
    • home visit for E/M of established patient (99347, 99348).

    Temporary telehealth services added during the public health emergency that would remain on the list until the end of the calendar year in which the emergency ends include

    • domiciliary or rest home visit for E/M of established patient (99336, 99337),
    • home visit for E/M of established patient (99349, 99350),
    • ER visits (99281, 99282, 99283),
    • nursing facilities discharge day management (99315, 99316), and
    • psychological and neurological testing (96130, 96131, 96132, 96133).

    The agency's pandemic-revised definition of "direct supervision" -- which now includes the virtual presence of the supervising physician using real-time, interactive audio/video technology -- likewise would be extended only until the end of the calendar year in which the public health emergency ends.

    Among the changes to remote physiologic monitoring services included in the fee schedule, CMS proposes to resume requiring that an established patient-physician relationship exist for such services to be furnished.

    Quality Payment Program

    For the Merit-based Incentive Payment System, CMS proposes

    • increasing the performance threshold to 50 points and retaining the exceptional performer threshold of 85 points;
    • reducing the weight of the quality performance category to 40% and increasing the weight of the cost performance category to 20% (with the improvement activities and promoting interoperability performance category weights unchanged at 15% and 25%, respectively, and the quality and cost categories equally weighted at 30% beginning with the 2022 performance year); and
    • postponing the implementation of MIPS Value Pathways until performance year 2022 while refining the MVP's guiding principles (a move detailed in the summary).

    For the 2021 performance year, CMS is allowing eligible clinicians to apply for an extreme and uncontrollable circumstances exception. Groups, virtual groups and alternative payment model entities can also apply for an exception. Because of the pandemic, CMS is proposing to increase the complex patient bonus to 10 points.

    The MPFS also proposes to end the APM Scoring Standard and implement the Alternative Payment Model Performance Pathway. The performance pathway may be reported by individual eligible clinicians, group TINs and APM Entities; the pathway would include a fixed set of quality measures.

    The summary adds: "For AAPM participants, CMS is proposing to modify the qualified participant threshold score calculation. CMS is also proposing a targeted review option for QPs and partial QPs for eligible clinicians who believe they were erroneously excluded from an APM entity's participation list."

    Medicare Shared Savings Program

    To align the MSSP quality standard with the proposed performance pathway, the proposed rule would require MSSP ACOs to report quality data via the pathway. "The number of quality measures for MSSP ACOs would be reduced from 23 to six, with ACOs required to actively report on three measures," the summary says. "CMS is also proposing to increase quality performance standard for MSSP ACOs."

    Additionally, the proposed rule would

    • revise how the final sharing rate is set for all MSSP tracks,
    • update its extreme and uncontrollable circumstances policy to allow an affected ACO to receive the minimum quality performance score equal to the 40th percentile, and
    • expand the list of primary care services used in beneficiary assignment.

    Federally Qualified Health Center and Rural Health Clinic Payments

    The proposed rule would "rebase and revise the 2013-based FQHC market basket to reflect a 2017 base year," the summary says. "The 2017-based FQHC market basket is based primarily on Medicare cost report data for FQHCs for 2017."