CMS 2021 Physician Fee Schedule Final Rule
Season’s greetings fellow coders! On December 1, 2020, CMS gifted us with its long awaited 2021 Physician Fee Schedule (PFS), that bundle of regulations that governs physician payments.
The good news is that with changes made to E/M documentation and code assignment, primary care providers are likely to see an 11%-15% increase in their Medicare payments. According to CMS Administrator Seema Verma, the increases are supportive of “clinicians who manage the ongoing care of patients with a host of chronic diseases, or patient transition between hospitals, nursing facilities, and home.”
Alas, there is bad news as well. Because Congress requires that the Physician Fee Schedule be budget neutral, the increase for primary care providers means decreased payments to some specialty care providers.
TELE-HEALTH UPDATES
CMS added 60 services to Medicare's tele-health list, ensuring coverage beyond the COVID-19 public health emergency. It’s important to note here that CMS does not have statutory authority to expand tele-health coverage permanently. That means that without congressional action, tele-health will eventually revert to a rural benefit, though the slate of covered services will be larger.
For CY 2021 the following services have been added to the eligible telehealth list:
Group Psychotherapy (CPT code 90853)
Psychological and Neuropsychological Testing (CPT code 96121)
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 Evaluation and Management (E/M) (HCPCS code G2211)
Prolonged Services (HCPCS code G2212)
CMS also created a list of temporary telehealth services that will be covered through the calendar year in which the Covid-19 Public Health Emergency (PHE) ends:
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 1-5 (CPT codes 99281-99285)
Nursing facilities discharge day management (CPT codes 99315-99316)
Psychological and Neuropsychological Testing (CPT codes 96130-96133; CPT codes 96136-96139)
Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161-97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507)
Hospital discharge day management (CPT codes 99238-99239)
Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT codes 99469, 99472, 99476)
Continuing Neonatal Intensive Care Services (CPT codes 99478-99480)
Critical Care Services (CPT codes 99291-99292)
End-Stage Renal Disease Monthly Capitation Payment codes (CPT codes 90952, 90953, 90956, 90959, 90962)
Subsequent Observation and Observation Discharge Day Management (CPT codes 99217; CPT codes 99224-99226)
Tele-health Services Provided by Non-physician Practitioners
CMS created two additional HCPCS G-codes to be billed by non-physician practitioners (e.g., licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists) who cannot independently bill for E/M services. These codes will be identically valued to already established virtual check-in codes, G2010 and G2012. The codes are:
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.
Remote Patient Monitoring (RPM) Coverage
With more healthcare providers looking to extend care into the home, CMS has been gradually expanding coverage for what it calls remote physiologic monitoring services. That coverage is now set in place with the 2021 PFS.
The following RPM rules are included in the final rule:
Once the public health emergency ends, a care provider must have an established patient-physician relationship for RPM services to be furnished.
Consent to receive RPM services may be obtained at the time that RPM services are furnished.
Auxiliary personnel (including contracted employees) may provide services described by CPT codes 99453 and 99454 incident to the billing practitioner’s services and under their supervision.
The technology supplied to a patient in an RPM program must be defined as a medical device under Section 201(h) of the Federal Food, Drug, and Cosmetic Act and must be reliable and valid. The data must be electronically (i.e., automatically) collected and transmitted rather than self-reported.
After the PHE ends, 16 days of data must be collected and transmitted every 30 days to meet the requirements to bill CPT codes 99453 and 99454.
Only physicians and NPPs who are eligible to furnish E/M services may bill RPM services.
RPM services may be medically necessary for patients with acute conditions as well as patients with chronic conditions.
Via CPT codes 99457 and 99458, an “interactive communication” takes place in real-time and includes synchronous, two-way interactions that can be enhanced with video or other kinds of data as described by HCPCS code G2012. In addition, the 20-minutes of time required to bill for the services of CPT codes 99457 and 99458 can include time for furnishing care management services as well as for the required interactive communication.
Payment for Office/Outpatient Evaluation and Management (E/M) and Prolonged Care
For CY 2021 CMS has for the most part aligned its E/M visit coding and documentation policies with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits. We are finalizing revisions to the times used for rate-setting for the office/outpatient E/M visit code set. HOWEVER, CMS made the surprising decision to issue a new HCPCS code for prolonged care.
CMS did not agree with the AMA’s final descriptor for 99417, which calls for reporting the prolonged service code when a time-based office E/M visit exceeds the minimum time for 99205 and 99215.
Instead, next year for your Medicare patients, you will report code G2212, which requires the visit to exceed the maximum time for 99205 and 99215. Here’s the descriptor:
“Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services) (Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes).”
Keep an eye on private payers that may prefer the G code and reach out to your software vendors for an upgrade that will help track time and assign the correct code.
Visit Complexity Add-on Code
It has taken a couple of years, and there are still many questions about who can use it and when, but CMS is rolling out code G2211 (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 condition or a complex condition. [Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established]).
Note that the code can be reported with new patient visits: In the final rule CMS noted that it had accidentally excluded new patients from the descriptor in the proposed rule released earlier this year.
Interim G code for Telephone Visits
CMS finalized its decision to stop separate payment for CPT telephone E/M codes 99441-99443 once the PHE ends. For the remainder of 2021, CMS created an interim code, G2252, for a “brief communication technology-based service (e.g., virtual check-in)” for established patients only. The code would be priced at the same amount as CPT telephone visit code 99442 and would cover an 11-20-minute “medical discussion,” similar to that code.
The code would be used for cases “when the acuity of the patient’s problem is not necessarily likely to warrant a visit, but when the needs of the particular patient require more assessment time from the practitioner,” CMS states in the rule.
For example, the service applies when the patient reports an exacerbation of an ongoing problem and wants to know whether a face-to-face office visit is warranted, CMS states. The agency stated that it does not consider a telephone visit to be a substitute for an E/M service but instead “an assessment to determine the need for one.”
Code G2252 will therefore be considered a communications technology-based service (CTBS) similar to a virtual check-in, not a tele-health service. Like the CPT phone codes, it will not be separately reported if the call occurs within seven days after a previous in-person visit or within 24 hours “or soonest available appointment.”
Expanded Coverage for Direct Supervision
CMS is expanding coverage for direct supervision to allow providers to use tele-medicine platforms to supervise others and monitor patients without being in the same room. The agency will allow coverage for direct supervision through real-time interactive audio-visual technology until the end of the PHE or 2021, whichever comes first.
Finally, CMS announced that it will commission a study on tele-health use during the pandemic to “explore new opportunities for services where tele-health and virtual care supervision, and remote monitoring can be used to more efficiently bring care to patients and to enhance program integrity, whether they are being treated in the hospital or at home.”