On August 3, 2020, the Centers for Medicare & Medicaid Services (CMS) published the Calendar Year (CY) 2021 Proposed Rule for the Medicare Physician Fee Schedule (MPFS), addressing Medicare Part B payment and quality provisions for 2021.
Why should you review and comment on the PFS?
It is important to review and comment on the provisions of the proposed rule because it is a way to voice your concerns and views on regulations that can have a large impact on your #medtech Products, their associated services, and your accounts.
Below are a few main proposed changes that are relevant to our clients that you should know about and comment:
1) Proposed Decrease in Conversion Factor
The proposed CY 2021 PFS conversion factor is $32.26; it represents a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09.
2) Medicare Telehealth and Other Services Involving Communications Technology
CMS proposes to add a list of services to the Category I Medicare telehealth list that will remain permanent beyond the COVID-19 public health emergency. This list is in addition to the telehealth codes that were added to the Category I services during the Public Health Emergency (PHE). These were discussed in our Telehealth Expansion Blog on July 16, 2020. CMS also proposed creating and adding a temporary category (Category 3). The proposed Category 3 services complement the Category I services that are proposed to extend through the calendar year in which the PHE ends.
- Emergency Department Visits
- Nursing facilities discharge day management
- Psychological and Neuropsychological Testing
- Domiciliary services
- Home visits, Established Patient
3) Remote Physiologic Monitoring Services (RPM)
CMS is clarifying how to read CPT code descriptors and instructions associated with the following CPT codes:
- 99453
- 99454
- 99091
- 99457
- 99458
Due to numerous questions from stakeholders about RPM, CMS is clarifying in this proposed rule their payment policies related to the RPM services described by CPT codes 99453, 99454, 99091, 99457, and 99458. In addition, they are proposing clarifications to RPM services that were finalized in response to the PHE for the COVID-19 pandemic. CMS proposed to follow the PHE for COVID-19 to require RPM services be rendered to patients that had a patient-physician relationship before the pandemic.
CMS is proposing as permanent policy that for RPM services to be furnished, the following requirements are fulfilled:
- there will be a need for consent
- auxiliary personnel including contracted employees furnish CPT codes 99453 and 99454 services under physician’s supervision.
- a medical device supplied to a patient as part of CPT code 99454 must be a medical device that is reliable and valid, and that the data must be electronically collected and transmitted rather than self-reported.
- the services are billed by physicians and NPPs who are eligible to furnish E/M services.
- patients with acute conditions as well as patients with chronic conditions receive RPM services.
4) Direct supervision by interactive telecommunication technology
For the duration of the PHE for the COVID-19 pandemic, for purposes of limiting exposure to COVID-19, CMS proposed changing the definition of direct supervision to allow the supervising physician or practitioner to be remote and use real-time, interactive audio-video technology CMS proposes to continue this policy through December 31, 2021 and is seeking comments on whether it should be extended beyond 2021.
5) Revisions and Revaluation of Office/Outpatient Evaluation and Management Codes
As finalized in the CY 2020 PFS final rule, in 2021 CMS will be largely aligning E/M visit coding and documentation policies with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits, beginning January 1, 2021. CMS is proposing a refinement to explain the times for which extended office/outpatient E/M visits can be reported and are proposing to revise the times used for rate setting for this code set.
The following services have the definition and valuation for office/outpatient E/M visits built into them. CMS is proposing to adopt revised coding definitions recommended by the CPT Editorial Panel and pay for each level of service rather than use a blended rate. CMS is proposing to adjust the valuation of the following codes for 2021:
- Certain End-Stage Renal Disease (ESRD)
- Transitional Care Management (TCM) Services
- Maternity Services
- Cognitive Impairment Assessment and Care Planning
- Annual Wellness Visit (AWV) and Initial Preventive Physical Examination (IPPE)
- Emergency Department Visits
- Therapy Evaluations
- Psychiatric Diagnostic Evaluations and Psychotherapy Services
6) Proposals Regarding Professional Scope of Practice and Related Issues
CMS proposes that in 2021, nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs) and certified nurse-midwives (CNMs) will now be allowed to supervise diagnostic tests as allowed by state law and scope of practice.
7) Medical Record Documentation Clarification
CMS clarifies that physicians and NPPs, including therapists can review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the PFS. CMS also clarified that therapy students, and students of other disciplines, working under a physician or practitioner who furnishes and bills directly for their professional services to the Medicare program, may document in the record so long as it is reviewed and verified (signed and dated) by the billing physician, practitioner, or therapist.
8) Removal of Outdated National Coverage Determinations (NCDs)
CMS has proposed to remove nine outdated National Coverage Determinations (NCDs). This means that Medicare Administrative Contractors (MACs): 1) no longer are required to follow those outdated coverage policies; 2) it will allow flexibility for the MACs to determine coverage in their geographic areas based on current indications and data.
9) Part B Drug Payment for Drugs Approved under Section 505(b)(2) of the Food, Drug, and Cosmetic Act
CMS is proposing to continue assigning certain 505(b)(2) drug products to existing multiple source drug codes. By this proposal a billing code descriptor for an existing multiple source code describes the product and other factors, such as the product’s labeling and uses, are like products that are already assigned to the code. The proposed approach paying similar amounts for similar drugs, curbs drug prices, and fosters competition among products that are described by one billing code and share similar labeling.
Opportunities and Issues for Commenting
Below are a few of the key issues that CMS is seeking public and stakeholder comments on:
- services added to the Medicare telehealth list during the PHE for COVID-19 that CMS is not proposing to add to the Medicare telehealth list permanently or proposing to add temporarily on a Category 3 basis.
- whether it would enhance patient access to care if for subsequent nursing facility (NF) visits furnished via Medicare telehealth CMS were to remove frequency limitations altogether, and how best to ensure that patients would continue to receive necessary in-person care.
- whether to develop coding and payment for a more extended service like the virtual check-in during the PHE with a higher value. They are seeking input from the public on the duration of the services and the resources in both work and practice expense associated with furnishing this service. They are seeking comment on whether this should be a provisional policy to remain in effect until a year after the end of the PHE for the COVID-19 pandemic or if it should be PFS payment policy permanently.
- whether the RPM codes, as described in the proposed rule, adequately capture the work furnished to patients with acute conditions or whether coding revisions are needed.
- whether the current RPM codes accurately and adequately describe the full range of clinical scenarios where RPM services may be of benefit to patients.
- how CMS might clarify the definition of HCPCS add-on code GPC1X, previously finalized for office/outpatient E/M visit complexity, and whether they should refine utilization assumptions for this code.
- removing the nine obsolete NCDs.
Comment period.
CMS is accepting comments on the proposed rule until October 5, 2020 and will respond to comments in a final rule.
Disclaimer: The information in this blog is based on payer information which is dynamic. It is accurate at the time of posting but should not be construed to be reimbursement or legal advice. CPT® is the trademark of the American Medical Association (AMA).
About GIRS
For more than 17 years, GIRS has been assisting medical technology manufacturers with their market uptake and reimbursement strategies so that patients can have access to the care that they need. To implement successful market access strategies, the GIRS Value Discovery Landscape Assessments® team and the Payer Advocacy Compass® team work together to develop and implement foundation reimbursement landscape and payer advocacy strategies to obtain positive coverage, appropriate payment, and innovative payer contracting arrangements to improve market uptake. For more information, email us at info@girsinc.com or call us at 901-834-9119.
Sources:
The full proposed rule can be viewed here: https://bit.ly/2F9NImR.
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched