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Proposed 2021 Medicare Physician Fee Schedule: What Emergency Physicians Need to Know

Proposed 2021 Medicare Physician Fee Schedule: What Emergency Physicians Need to Know

The Centers for Medicare and Medicaid Services (CMS) recently published the proposed draft of the Medicare Physician Fee Schedule (PFS) for 2021. At the heart of the MPFS is the annual conversion factor update. After legislatively mandated adjustments, the 2021 conversion factor will be $32.26, a $3.83 (or 11 percent) decrease from the 2020 PFS conversion factor of $36.09.

In addition to changing the payment rates for 2021, the Proposed Rule also recommends changes to several payment policies. We’ve highlighted a few of the biggest changes that will impact emergency physicians.

E/M Changes

In the 2020 Medicare Physician Fee Schedule, CMS finalized simplified coding and billing requirements for office/outpatient E/M visit codes that will go into effect January 1, 2021. Along with those changes, RVUs for the three highest E/M levels for both new and established patients will be increased to reflect “the changes in the practice of medicine, recognizing that additional resources are required of clinicians to take care of their Medicare patients, of which two-thirds have multiple chronic conditions,” according to CMS.

In the proposed 2021 rule, CMS also recommended similar increases to the value of many other services that are comparable to or include office/outpatient E/M visits, including emergency department visits, end-stage renal disease capitated payment bundles, physical and occupational therapy evaluation services, and others. The agency says these changes will “help to ensure that CMS is appropriately recognizing the kind of care where clinicians need to spend more face-to-face time with patients, like primary care and complex or chronic disease management.”

For emergency medicine particularly, the adjustments to RVU values are as follows: 

LevelCurrent wRVUsProposed wRVUs

However, even with these increases, CMS estimates that the payment impact on emergency department services based on the policies contained in the proposed rule will be -6 percent.

“For emergency medicine practitioners, estimated impacts of -6 percent reflect a 3 percent gain as a result of proposed increased valuations to emergency department visits using specialty society recommendations to maintain relativity with office/outpatient E/M visits.  However, the magnitude of the office/outpatient E/M visit valuations are dampening the effect of increased valuations for the emergency department visits,” CMS explains in the proposed rule.


During the COVID-19 public health emergency (PHE), CMS temporarily added numerous codes to the list of approved telehealth services. These temporary codes are known as Category 2 telehealth codes. In the proposed rule, CMS is recommending that some of these services be permanently added to the approved telehealth services list (Category 1 codes), some be extended through the calendar year in which the PHE ends (what are now called Category 3 codes), and some be removed from the list at the end of the PHE (or remain Category 2 codes). 

Some services added as Category 2 codes during the PHE are so similar to other Category 1 codes that CMS is recommended they be added to the permanent list. Those services include the following:

  • 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)

According to CMS, services which do not present “significant concerns” with regards to “patient safety, quality of care, or the ability of clinicians to provide all elements of the service remotely” are proposed for continuation on the temporary list of telehealth services (Category 3) through the calendar year in which the PHE ends. Those services include the following:

  • Emergency Department Visits (99281-99283)
  • Domiciliary, Rest Home, or Custodial Care services, Established patients (99336, 99337)
  • Home Visits, Established Patient (99349, 99350)
  • Nursing facilities management (99315, 99316)
  • Psychological and Neuropsychological Testing (96130-96133)

While all the services CMS has added to the temporary list during the COVID-19 public health emergency will continue for the duration of the emergency period as Category 2 codes, some have been identified as not appropriate for Category 3 status (continuing through the end of the year in which the PHE ends) because of “increased concerns for patient safety or jeopardizing quality of care; and furnished fully and effectively, including all elements of the service, by a remotely located clinician via two-way, audio/video telecommunications technology.”

The extensive list includes the following:

  • Initial and final/discharge interactions (CPT codes 99234-99236 and 99238-99239)
  • Higher level emergency department visits (CPT codes 99284-99285)
  • Hospital, Intensive Care Unit, Emergency care, Observation stays (CPT codes 99217-99220; 99221-99226; 99484-99485, 99468-99472, 99475- 99476, and 99477- 99480)

At the same time, CMS is requesting comment on the specific codes mentioned above to see if they should be considered for Category 3 status. About the higher level emergency department visits, CMS said specifically: “We are concerned that the full scope of service elements of these codes cannot be met via two-way, audio/video telecommunications technology as higher levels are indicated by patient characteristics, clinical complexity, urgency for care, and require complex decision-making. We also believe, due to the acuity of the patient described by these codes, that an in-person physical examination is necessary to fulfill the service requirements.” 

Medication Assisted Treatment (MAT) in the ED

In 2020, CMS sought comments on the use of medication-assisted treatment (MAT) in the ED in order to better understand typical practice patterns and to help determine whether the separate payment for such services in the ED would be justified in future years. Based on the feedback they received, for 2021 CMS is proposing to create one add-on G-code, GMAT1, to be billed with E/M visit codes used in the ED setting to account for the resource costs involved with initiation of medication for the treatment of opioid use disorder and referral for follow-up care. GMAT1 would include payment for assessment, referral to ongoing care, follow-up after treatment begins, and arranging access to supportive services. The drug itself would be paid separately.

CMS has proposed a direct crosswalk to the work and direct PE inputs for HCPCS code G0397 (Alcohol/subs interv >30 min), which is assigned a work RVU of 1.30, because of the “similar nature and magnitude” of the two services.


In light of the COVID-19 PHE, CMS has proposed limited changes to MIPS policies that “focus on the highest priorities for the program.” Here are a few changes to particularly take note of.

Quality and Cost Performance Category Weighting

Performance categories will be weighted as follows for 2021, representing slight changes from 2020 (as noted below):

  • Quality = 40% (down 5% from 2020)
  • Cost = 20% (up 5% from 2020)
  • Promoting Interoperability = 25%
  • Improvement Activities = 15%

By law, the Cost and Quality performance categories must be equally weighted at 30% beginning in the 2022 performance period.

Performance Threshold and Payment Adjustments

Also proposed for the 2021 performance period, the performance threshold would increase to 50 points, up from 45 in 2020, and the exceptional performance threshold would remain at 85 points,

As well, in 2020, the MIPS program reached the maximum negative payment adjustment of -9 percent, with positive payment adjustments up to a factor of 9 percent, and those adjustments will remain the same for 2021.

Performance PeriodPerformance ThresholdExceptional Performance BonusPayment Adjustment
2017370Up to +/- 4%
20181570Up to +/- 5%
20193075Up to +/- 7%
20204585Up to +/- 9%
20215085Up to +/- 9%

Performance Category Updates

Among the various performance categories, the following updates and changes have been proposed for 2021 and beyond:

  • Quality: Use performance period, not historical, benchmarks to score quality measures for the 2021 performance period; Address substantive changes to 112 existing MIPS quality measures, removing 14 quality measures from the MIPS program, and proposing a total of 206 quality measures starting in the 2021 performance year, including two new administrative claims-based measures; add one measure proposed to the emergency medicine quality measure set: 418 – Osteoporosis Management in Women Who Had a Fracture; remove one measure from the emergency medicine quality measure set: 333 – Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse).
  • Cost: Update existing measure specifications to include telehealth services that are directly applicable to existing episode-based cost measures and the TPCC measure.

MIPS Value Pathways

Because of the COVID-19 PHE, MIPS Value Pathways (MVPs), which were supposed to begin in 2021, will not be available for MIPS reporting until the 2022 performance period, or later. In the meantime, the 2021 proposed rule did propose several tweaks to the program, including allowing qualified clinical data registries (QCDRs) to support MVPs starting in 2022. According to Jeffrey Davis, Director of Regulatory Affairs at the American College of Emergency Physicians (ACEP), ACEP is working with CMS to develop an MVP for emergency medicine along with determining how ACEP’s QCDR, the Clinical Emergency Data Registry (CEDR), could facilitate emergency physicians to participate in an MVP.

Complex Patient Bonus

Finally, CMS is proposing to double the complex patient bonus for the 2020 performance period only. Clinicians, groups, virtual groups and APM Entities would be able to earn up to 10 bonus points (instead of 5 bonus points) to account for the additional complexity of treating their patient population due to COVID-19.


Submit comments about the 2021 Medicare Physician Fee Schedule using one of the methods below, no later than 5 p.m. on October 5, 2020. In commenting, please refer to file code CMS-1734-P.

Electronically: Visit http://www.regulations.gov and follow the “Submit a comment” instructions.

Regular Mail: Send comments to the following address: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1734-P, P.O. Box 8016, Baltimore, MD 21244-8016.

Express or Overnight Mail: Send comments to the following address: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1734-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Learn More

For more information about the proposed rule, check out the following resources:

CMS also is hosting two online listening sessions about the proposed rule.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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