On August 3^rd, 2020, the Centers for Medicare and Medicaid Services (CMS) released their proposed rule for the calendar year of 2021. These changes would affect the Physician Fee Schedule and are said to be part of their strategy of improving accessibility, quality, affordability, empowerment, and innovation. While these are only the proposed rules and the final ruling will be forthcoming in the 4^th quarter of CY 2020, the proposed rule does serve as a good indicator of the direction CMS wants to take the US healthcare system. While there are too many proposed changes to discuss them all in one newsletter, the following are some of the highlights.

CPT Code Additions, Changes, and Reimbursement

As part of CMS’ response to the CoVID-19 pandemic, they reduced the regulatory burden on telehealth and virtual care, allowing providers who previously had not offered virtual care to develop these services. There has been much speculation about whether these reduced burdens will become permanent and CMS is taking its first step towards ‘the new normal’ with telehealth. In the CY2021 proposed rule:

• There is a host of CPT codes which will be added to the PFS as a permanent addition to the telehealth suite of codes.
• CMS is also proposing to create a new, temporary category of HCPCS codes to the telehealth suite of codes. These would be temporary, as part of their pandemic response strategy.
• CMS is proposing that the frequency limitation on nursing facility visits be reduced from one visit every 30 days to one visit every 3 days.

E/M Structure Change

In 2019, CMS proposed changes to the PFS and E/M visits for the 2021 calendar year.  Their initial proposal was to combine various E/M codes to reduce the redundancies and documentation burden on providers. After stakeholder feedback however, CMS altered its final ruling and has opted for to implement the E/M changes depicted below in the CY 2021.

In addition to these changes, CMS is proposing to alter the documentation requirements for E/M visits and removing the required categories of exam and history. Instead, the documentation of levels 2-5 would be based wholly on either medical decision making or total time spent on the visit on the date of service, both in-person and non-face-to-face. These changes would take effective on January 1, 2021.

Supervision Changes

One of the many changes implemented by CMS during the public health emergency related to CoVID-19 is that direct supervision by interactive telecommunications technology was allowed on a temporary basis. This was done to limit providers’ exposure to CoVID-19 patients and since the public health emergency has not resolved yet, CMS is proposing to extend this provision through December 31, 2021. This provision allows supervising providers to conduct their supervisory responsibilities via telecommunications technology, effectively temporarily eliminating the mileage restrictions that were previously in place.

Secondly, CMS is proposing to allow mid-level providers and therapists to review and verify documentation that was entered by members of the medical team for their own services billed under the physician fee schedule. Students, however, still need to have their documentation reviewed by the billing physician.

In a similar vein to supervision is the proposed rule to permanently remove the burden of diagnostic testing supervision. Under this proposal, CMS will permanently allow mid-level providers to oversee diagnostic testing, which was a temporary rule enacted by CMS as part of their response to the CoVID-19 pandemic.

QPP Changes

Another key category of updates for the CY2021 is in the Quality Payment Program, or QPP. To read the entire QPP Fact Sheet, click here. This program has been CMS’ rollout of a payment model centered more and more around quality, as opposed to the current fee-for-service model. The QPP has several key aspects, most notably the Merit-Based Incentive Payment System (MIPS), MIP Value Pathways (MVPs), and the Alternative Payment Model (APM) and Performance Pathway (APP). Here are some key takeaways from this year’s proposed rule:

Participation Pathways (MVPs and APPs)

• CMS was set to introduce a set of guiding principles to help shape what MVPs look like in future years but they have delayed its implementation to allow providers to focus more on addressing the CoVID-19 pandemic.
• CMS is proposing a new APP for CY2021 that would be complementary to MVPs. It would only be available to providers who have elected into an APM and may be reported by the individual eligible clinician, group, or APM entity. The APP will still consist of the reporting categories of cost, improvement activities, promoting interoperability, quality performance.

MIPS Program Updates

• CMS is proposing to reweight the reporting categories:
  • Quality: 40% (Down from 45% in the 2020 reporting period)
  • Cost: 20% (Up from 15% in the 2020 reporting year)
  • Promoting Interoperability: 25% (No change)
  • Improvement Activities: 15% (No change)
• Further, CMS is making adjustments to and creating new improvement activities and quality measures for eligible clinicians and entities to choose from.
• The performance threshold will be increased from 45 points in CY2020 to 50 in CY2021
• One last notable change that we want to highlight within MIPS is the complex patient bonus. In CY2020 CMS awarded up to 5 bonus points to account for patient complexity. In CY2021, CMS is proposing to increase the allowable bonus points up to 10 to account for managing complex patients due to CoVID-19.

CMS has proposed a bold set of rules for CY2021, of which these are just a few. Among the other proposed rules are changes or clarifications to remote monitoring services, immunization services, pharmacists billing incident to, therapy assistants furnishing maintenance therapy, payment for services of teaching physicians, treatment of Opioid Use Disorder by Opioid Treatment Programs (OTP), and several others.

For a complete list of the proposed rules for CY2021, please click here (for information related to hospitals, IRF, and other proposed changes, click ‘next’ at the bottom of the page). As always, WebsterRogers has a dedicated team of healthcare consultants to help answer questions and provide timely guidance so you can safely navigate the ever-changing landscape of the US healthcare industry.

Contact our Healthcare Services Team for more information or to get assistance: [email protected].