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

Earlier this week, the Centers for Medicare and Medicaid Services (CMS) published the final rule 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 $32.41, a 10 percent decrease from the 2020 PFS conversion factor of $36.09, though slightly higher than the $32.26 in the 2021 proposed rule.

In addition to changing the payment rates for 2021, the Final Rule also makes 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.

“The Medicare population is increasing, with over 10,000 beneficiaries joining the program every day. Along with this growth in enrollment is increasing complexity of beneficiary healthcare needs, with more than two-thirds of Medicare beneficiaries having two or more chronic conditions,” CMS said in a press release announcing the changes. “Increasing the payment rate of E/M office visits recognizes this demand and ensures clinicians are paid appropriately for the time they spend on coordinating care for patients, especially those with chronic conditions.”

CMS also is increasing 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:

Level	Current wRVUs	New wRVUs
99283	1.42	1.60
99284	2.60	2.74
99285	3.80	4.00

For many office-based specialties, the changes are expected to result in a positive net increase in Medicare allowable charges, including the following:

Allergy/Immunology: +9%
Endocrinology: +16%
Family Practice: +13%
Hematology/Oncology: +14%
Interventional Pain Management: +7%
Rheumatology: +15%

For other specialities, especially hospital-based and non-patient facing specialties, the policy changes are expected to result in significant decreases in Medicare allowable charges, including the following:

Anesthesiology: -8%
Cardiac Surgery: -8%
Interventional Radiology: -8%
Nurse Anesthetists/Anesthesiologist Assistants: -10%
Pathology: -9%
Physical Therapists/Occupational Therapists: -9%
Radiology: -10%

And even with these increases in work RVUs for emergency department E/Ms, CMS estimates that the payment impact on emergency department services based on the policies contained in the final rule will be -6 percent.

“For emergency medicine practitioners, estimated impacts of -6 percent reflect a 2 percent gain as a result of 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 (ED) visits” CMS explains in the final rule.

At issue is the statutorily required policy of budget neutrality. Because the increase in RVUs for office/outpatient E/Ms will result in higher payouts for providers using those codes, CMS must offset those increases elsewhere within the Medicare program. For 2021, the Budget Neutrality Adjustment was -10.20 percent, or $3.68 subtracted from the 2020 conversion factor.

The American College of Emergency Physicians and other physician organizations are hoping Congress can bring some relief to the problem of budget neutrality. Currently, two bills have been introduced in the House to temporarily lift the budget neutrality requirements.

H.R. 8505 was introduced in the House on October 2, 2020, by Rep. Burgess, Michael C. (R-Tx) and 7 bipartisan cosponsors. The bill seeks a “one-year waiver of budget neutrality adjustments under the Medicare physician fee schedule” and was referred to the Committee on Energy and Commerce and the Committee on Ways and Means, and Appropriations.

H.R. 8702 Holding Providers Harmless From Medicare Cuts During COVID-19 Act of 2020 was introduced in the House on October 30, 2020, by Congress members Ami Bera, M.D. (D-Calif.) and Larry Bucshon, M.D. (R-Ind.) following an earlier letter to House leadership. H.R. 8702 seeks to offset the significant budget neutrality cuts for physicians in 2021 and 2022 by paying them at minimum according to the 2020 Medicare Physician Fee Schedule payment rates.

According to Jeffrey Davis, Director of Regulatory Affairs at ACEP, his group, “along with a coalition of organizations representing more than 1 million physicians and allied health professionals, support including the “Holding Providers Harmless From Medicare Cuts During COVID-19 Act of 2020” in any year-end legislative package.”

However, Healthcare Dive’s Rebecca Pifer, thinks “it’s unlikely Congress will step in before the rule kicks into gear January 1.”

Telehealth

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 final rule, CMS is permanently adding some of these services to the approved telehealth services list (Category 1 codes), is extending others through the calendar year in which the PHE ends (what are now called Category 3 codes), and removing some 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 adding them to the permanent list. Those services include the following:

Group Psychotherapy (90853)
Psychological and Neuropsychological Testing (96121)
Domiciliary, Rest Home, or Custodial Care services, Established patients (99334- 99335)
Home Visits, Established Patient (99347- 99348)
Cognitive Assessment and Care Planning Services (99483)
Visit Complexity Inherent to Certain Office/Outpatient E/Ms (G2211)
Prolonged Services (G2212)

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 approved for continuation on the temporary list of telehealth services (Category 3) through the calendar year in which the PHE ends. However, they will be available only to rural patients as allowed by program requirements between the time the PHE ends and the end of that calendar year. Those services include the following:

Emergency Department Visits (99281-99285)
Domiciliary, Rest Home, or Custodial Care services, Established patients (99336, 99337)
Home Visits, Established Patient (99349, 99350)
Nursing facilities discharge day management (99315, 99316)
Psychological and Neuropsychological Testing (96130-96133; 96136-96139)
Therapy Services, Physical and Occupational Therapy, All levels (97161- 97168; 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524 , 92507)
Hospital discharge day management (99238- 99239)
Inpatient Neonatal and Pediatric Critical Care, Subsequent (99469, 99472, 99476)
Continuing Neonatal Intensive Care Services (99478-99480)
Critical Care Services (99291-99292)
End-Stage Renal Disease Monthly Capitation Payment codes (90952, 90953, 90956, 90959, and 90962)
Subsequent Observation and Observation Discharge Day Management (99217; 99224- 99226)

Originally, some of the codes finalized for the Category 3 list, like 99284-99285 and 99291-99292, were considered inappropriate for that list because of “increased concerns for patient safety or jeopardizing quality of care.’ However, once the PHE ends and “all of the statutory restrictions will also apply,” CMS does not “anticipate any significant increase in utilization.” Also, adding them to the Category 3 list may allow for additional analysis to determine if they should be added to the telehealth list permanently.

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, CMS has finalized the creation of add-on G-code, G2213, to be billed with E/M visit codes used in the ED setting. The new code will cover the resource costs involved with initiation of medication for the treatment of opioid use disorder and referral for follow-up care. G2213 also includes payment for assessment, referral to ongoing care, follow-up after treatment begins, and arranging access to supportive services. The drug itself will be paid separately.

CMS used a direct crosswalk to the work and direct PE inputs for HCPCS code G0397 (Alcohol/subs interv >30 min), because of the “similar nature and magnitude” of the two services. Which means that G2213 will be assigned a work RVU of 1.30.

MIPS

In light of the COVID-19 PHE, CMS has finalized 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

For 2021, performance categories will be weighted as follows for individual MIPS eligible clinicians, groups, and virtual groups reporting traditional MIPS. These values represent 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.

For APM Entities reporting traditional MIPS in 2021, performance categories will be weighted as follows:

Quality = 50%
Cost = 0%
Promoting Interoperability = 30%
Improvement Activities = 20%

Performance Threshold and Payment Adjustments

For the 2021 performance period, the performance threshold will increase to 60 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 Period	Performance Threshold	Exceptional Performance Bonus	Payment Adjustment
2017	3	70	Up to +/- 4%
2018	15	70	Up to +/- 5%
2019	30	75	Up to +/- 7%
2020	45	85	Up to +/- 9%
2021	60	85	Up to +/- 9%

Performance Category Updates

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

Quality: Address substantive changes to 113 existing MIPS quality measures, removing 11 quality measures from the MIPS program, and proposing a total of 209 quality measures starting in the 2021 performance year, including two new administrative claims-based measures; 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 final rule does provide several tweaks to the program, including allowing qualified clinical data registries (QCDRs) to support MVPs starting in 2022. According to Davis, 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 doubling 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.