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Breaking: CMS proposes 11% cut to 2021 conversion factor, confirms E/M coding overhaul

You can expect to see wild swings to Medicare pay rates in 2021, according to proposals CMS released this morning. The agency announced a nearly 11% cut to the Medicare physician fee schedule’s conversion factor (CF), dropping it to a rate of $32.26 next year, down from $36.09 in 2020.
Influencing the substantial decrease to the CF are the projected pay increases to the core set of E/M office visit codes (99202-99215). CMS confirmed that the E/M office visit codes remain on track for their first major overhaul in 25 years, according to the proposed 2021 Medicare physician fee schedule.
The agency stuck with its previously announced plan to adopt a series of significant revisions to the documentation guidelines for the office visit codes, in line with changes that the AMA is adopting. The updates, which would focus code level selection on medical decision-making or time, are set to take effect Jan. 1, 2021.
“We continue to believe these policies will further our ongoing effort to reduce administrative burden, improve payment accuracy and update the office/outpatient E/M visit code set to better reflect the current practice of medicine,” CMS confirmed in the rule.
The set of E/M codes is getting a financial facelift, as well. CMS plans to increase the relative value units (RVU) for the oft-reported established office codes (99211-99215).
“CMS pays for physician services based on RVUs assigned to the CPT code multiplied by the conversion factor,” explains Betsy Nicoletti, president of Medical Practice Consulting in Northampton, Mass. “Because of budget neutrality, the increase in payment for codes 99202–99215 means there is a significant decrease in the conversion factor, which translates into a decrease in payment for many services.”
The convergence of the E/M RVU boost with the slashed CF is expected to produce some major pay swings among specialties, according to projected financial analysis contained in the proposed rule. For instance, endocrinology is expected to see a 17% increase in allowed charges. Rheumatology is on track for a 16% gain, and family practice will see a 13% boost.
“These increases can largely be attributed to previously finalized policies for increases in valuation for office/outpatient E/M visits which constitute nearly 20 percent of total spending under the PFS,” CMS states.
Conversely, radiology providers and nurse anesthetists are on pace for double-digit losses in allowed charges, at -11% each. Chiropractic is expected to lose 10%, and physical and occupational therapy will be out 9%.
”Prepare for massive lobbying by specialty societies,” Nicoletti says.
The pushback has already begun. Shortly after the proposed fee schedule appeared in the Federal Register, the AMA issued a statement from president Susan R. Bailey, M.D. “The AMA strongly urges Congress to waive Medicare’s budget neutrality requirement for the office visit and other payment increases,” Bailey said. “Physicians are already experiencing substantial economic hardships due to COVID-19, so these pay cuts could not come at a worse time.”
E/M-like codes get valued up
Revalued services that are similar to E/M office visits. CMS has identified a number of services that “are analogous to office/outpatient E/M visits” and is increasing their work RVUs. You can expect modest to significant pay increases in 2021 for the services, which including annual wellness visits (G0438-G0439), the “Welcome to Medicare” services (G0402), transitional care management services (99495-99496) and cognitive assessment services (99483). The revaluation also increases payments for E/M codes in the maternity bundle, some therapy services and emergency department codes, among others.
For example, CMS proposes to increase the work value for the TCM codes, which each include the value of a level 4 or 5 established patient visits, “commensurate with the new valuations” for codes 99214 and 99215, the agency states.
Specifically excluded from E/M-related revaluations: Surgical codes with 0, 10 or 90-day global periods. As CMS states, the work value for the global period codes is set based on “magnitude estimation,” not on the direct value of a certain number of E/M RVUs. Comparing the global surgical codes to maternity package codes, CMS has this burn: “In addition, unlike the global surgical codes, we have reason to believe the visits included in the maternity codes are actually furnished given the evidence-based standards and professional guidelines for obstetrical care.”
Other E/M updates
CMS still seeks feedback on E/M add-on code GPC1X. During the 2020 rulemaking period, CMS finalized the introduction of add-on code GPC1X as a way to better reflect the resources provided during E/M encounters. Yet questions remain on the scope of the code and in which instances it might apply. “We are soliciting from the public comments providing additional, more specific information regarding what aspects of the definition of HCPCS add-on code GPC1X are unclear, how we might address those concerns, and how we might refine our utilization assumptions for the code,” the agency said in the proposed rule.
As reference, GPC1X describes the “visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex condition.”
Note adjusted times for new prolonged services code. CMS is tweaking its interpretation and guidance of the new prolonged services code 99XXX that will be out Jan. 1. Previously, CMS asserted that the 99XXX code could be attached to a 99205 or 99215 office visit code 15 minutes after the minimum time threshold was met. But the agency has changed its stance: “We believe that allowing reporting of CPT code 99XXX after the minimum time for the level 5 visit is exceeded by at least 15 minutes would result in double counting time,” the proposed rule states. Instead, you will be able to report 99XXX when the “maximum time” for the Level 5 service has been exceeded by 15 minutes. Example: The maximum time for 99205 is 74 minutes. In that case, you could report 99XXX with 99205 once you’ve reached 89 minutes (74 minutes + 15 minutes).
Some COVID-19 breaks will persist, others will be considered, a few drop
CMS proposes to extend – or consider extending -- some flexibilities allowed in its COVID-19 public health emergency (PHE) interim final rule issued March 31 (PBN blog 4/1/20).
For example, among the extended services:
New remote codes non-physician practitioners (NPPs) can do. To the communication technology-based services (CTBS) G-codes CMS previously allowed certain NPPs to perform for the COVID-19 emergency, CMS also proposes to add new codes for NPPs who can't report E/M services: G20X0 (Remote assessment of recorded video and/or images submitted by an established patient) and G20X2 (Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services). These will be valued similarly to G2010 and G2012.
NPP diagnostic test supervision made permanent. CMS proposes to continue allowing nurse practitioners (NP), clinical nurse specialists (CNS), physician assistants (PA) and certified nurse-midwives (CNM) to supervise the performance of diagnostic tests after the PHE.
Therapy assistant breaks made permanent. CMS proposes to continue to allow physical therapists (PT) and occupational therapists (OT) the discretion to delegate the performance of maintenance therapy services, as clinically appropriate, to a therapy assistant – a physical therapist assistant (PTA) or an occupational therapy assistant (OTA).  
Permanent telehealth services. CMS intends to add nine services to the telehealth list on a permanent basis. The two new codes are the E/M add-on codes discussed elsewhere in this post. Seven codes were added during the COVID-19 public health emergency (PHE) and include home visits (99347-99348).
However, the traditional telehealth restrictions would apply to these codes when the PHE ends. A patient would have to come under an exception that allows a patient’s home to be the originating site. For example, the purpose of the encounter is to treat a substance abuse disorder.
Temporary PHE scope of practice extensions could become permanent. CMS proposes to allow the following scope of practice expansions for NPPs to continue after the PHE expires – either to the end of 2021 or permanently: 
  • Supervision of diagnostic tests by nurse practitioners, certified nurse specialists, physician assistants and certified nurse midwives, 
  • Pharmacists providing services incident-to a physician, with appropriate supervision, and
  • Therapy assistants providing maintenance therapy services.
  • Medical record documentation: Physicians and NPPs, including therapists would be able to review and verify documentation entered into the medical record by members of the medical team for their own services, according to a CMS fact sheet, 
  • Teaching physicians would be able to use telehealth to be virtually present for key portions of a service provided by a resident. 
  • In addition, residents furnishing services at primary care centers would be able to provide an expanded set of services to beneficiaries, including level 4-5 office visits, care management, and communication technology-based services. 
Comments will be taken on several COVID-19 emergency measures post-PHE, including:
  • Phone telehealth. Finding “use of audio-only services was more prevalent than we had previously considered” after allowing these to be billed as telehealth more widely in the PHE, CMS will take comments “on whether CMS should develop coding and payment for a service similar to the virtual check-in but for a longer unit of time and with an accordingly higher value,” according to the proposed rule.
  • COVID test E/M. CMS will take comments on continuing the post-PHE use of E/M code 99211 to bill for “services furnished incident to their professional services, for both new and established patients, when clinical staff assess symptoms and collect specimens for purposes of COVID–19 testing.”
  • Teaching physician distance supervision. CMS will take comments on whether to allow teaching physicians to bill for resident supervision via audio/video real time communications technology and for resident services thus supervised.
A few services, however, will definitely end with the PHE. For example, CMS says once the PHE is over, the seven remote physiologic monitoring (RPM) codes for which they waived an established patient-physician relationship will once again require that before the service is initiated. They will also resume other requirements, such as that 16 days of data must be collected and transmitted each 30 days for 99453 and 99454. But they will continue to allow consent to be obtained at the time of service initiation and will let auxiliary personnel furnish 99453 and 99454 services under a physician’s supervision.

Other revalued services
Spinal code could get a boost. CMS proposes just one code for revaluation as a potentially misvalued code: 22867 (Insertion of spinal distraction device), nominated as undervalued because it includes the work of laminectomy code 63047 in addition to insertion of the device. The agency will also examine whether to increase the malpractice RVU for code 22867. The code has a work value of 13.50 and a malpractice value of 3.88, while laminectomy code 63047 has a work RVU of 15.37 and a malpractice RVU of 4.51.
New codes cover cardio, biopsy services
CMS is set to recognize 39 new codes next year, including the new prolonged service code you will use with time-based E/M office visits and seven HCPCS codes, according to Table 24: Proposed CY 2021 Work RVUs for New, Revised, and Potentially Misvalued Codes. Note that the final codes are not available. New codes are represented by fill-in codes that will not be used to report services.
  • Cardiovascular services will make up the bulk of the new codes. You’ll find five new codes in the cardiovascular system section of your 2021 CPT manual, including a primary and add-on code set for the following procedure: Transcatheter intracardiac shunt (TIS) creation by stent placement for congenital cardiac anomalies to establish effective intracardiac flow, all imaging guidance by the proceduralist when performed, left and right heart diagnostic cardiac catherization for congenital cardiac anomalies, and target zone angioplasty, when performed (eg, atrial septum, Fontan fenestration, right ventricular outflow tract, Mustard/Senning/Warden baffles); initial intracardiac shunt.
  • Eight external electrocardiogram recording codes will be added to the Medicine chapter of the 2021 CPT manual. Cardiology practices should note that CMS is only proposing work relative value units (RVUs) for the four codes that involve review and interpretation. For example, 93XX0 (External electrocardiographic recording for more than 48 hours up to 7 days by continuous rhythm recording and storage; includes recording, scanning analysis with report, review and interpretation). Codes that describe recording or recording with analysis and a report have not been assigned work RVUs.
  • Additional updates to the CPT manual will include codes for percutaneous core needle biopsy of the lung or mediastinum, with image guidance when performed, computer-aided mapping of cervix uteri during colposcopy and three codes for vestibular evoked myogenic potential (VEMP) testing.
  • Take note of the new HCPCS codes CMS is considering. The majority do not have proposed work RVUs, including two codes for percutaneous arteriovenous fistula creation (AVF). However, there are work RVUs associated with a time-based code for initial or subsequent psychiatric collaborative care management, a code for initiation of medication assisted treatment in the emergency department and the visit complexity E/M add-on code that has been under discussion for a couple of years.
  • Three category III codes that describe the insertion, replacement or removal of implantable glucose monitors would be assigned coverage status A and work RVUs, according to Table 24.
Chronic care management updates
Chronic care management add-on code G2058 will be replaced by an E/M code with the following descriptor next year:
  • Chronic care management services, with the following required elements:
  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient,
  • Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline,
  • Comprehensive care plan established, implemented, revised, or monitored;
  • each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
The new code will maintain the 0.54 work RVU that’s currently assigned to the G code.

Editor's note: We know you're busy. That's why we're offering a complete rundown of the E/M coding and policy updates contained in the 2021 proposed fee schedule in just one hour. Register for the Key E/M Updates From the 2021 Proposed Fee Schedule: What You Need to Know today. One registration will allow your practice to listen live with a chance to ask questions on Tues, Aug. 25, 1-2 p.m., ET. Your registration includes a free on-demand version that will allow listeners to take in the information when their schedules allow.
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