Proposed 2021 Medicare pay schedule: 9 things doctors should know

Andis Robeznieks , Senior News Writer

Significant positive changes are on the way for 2021 related to coding and payment for evaluation and management (E/M) physician office-visit services. Also looming, however, are several potential negative changes, such an offsetting across-the-board payment cut for all physicians and other health professionals, as detailed in the proposed 2021 Medicare physician payment schedule issued by the Centers for Medicare & Medicaid Services (CMS).

E/M coding update checklist

Get step-by-step advice on navigating the office visit documentation coding changes and meet the January 2021 deadline for CMS’ E/M coding update with confidence.

While those two developments have garnered most of the attention, the 1,355-page document also contains a host of other details that signal how COVID-19, budget-neutrality requirements and a myriad of other factors will shape health care operations and economics next year. 

“The AMA appreciates that CMS will implement significant increases to the payment for office visits, based on recommendations on resource costs from the AMA/Specialty Society RVS Update Committee [RUC],” said AMA President Susan R. Bailey, MD.

That having been said, an 11% cut in the Medicare conversion factor is necessitated by proposed additional spending of $10.2 billion. The RUC recommendations for office-visit payment increases account for only half of this additional spending, and therefore, half of the reduction. The remaining spending increases and resulting conversion factor reduction are attributed to various CMS proposals to increase valuation for specific services. 

“Unfortunately, these office-visit payment increases, and a multitude of other new CMS-proposed payment increases, are required by statute to be offset by payment reductions to other services, through an unsustainable reduction of nearly 11% to the Medicare conversion factor,” Dr. Bailey said.

“For this reason, the AMA strongly urges Congress to waive Medicare’s budget-neutrality requirement for the office visit and other payment increases,” she added.

Learn more about why cutting Medicare pay during the COVID-19 pandemic doesn’t make sense.

It will take time to comprehensively analyze the entirety of the proposed rule, but these important points emerged from an early analysis by the AMA’s experts.

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E/M office-visit changes on track for 2021: What doctors must know

Proposed office-visit changes supported. The AMA strongly supports CMS adoption of its proposed office-visit changes and continues to advocate for the agency to incorporate the office-visit payment increases into its global surgery packages.

“Reducing documentation overload and providing physicians more time with patients, not paperwork, was the fundamental purpose of overhauling the E/M office visit guidelines,” said Dr. Bailey.

Key elements of the E/M office-visit overhaul include:

  • Eliminating history and physical exam as elements for code selection. While significant to both visit time and medical decision-making, these elements alone should not determine a visit’s code level.
  • Allowing physicians to choose whether their documentation is based on medical decision-making or total time. This builds on the movement to better recognize the work involved in non-face-to-face services like care coordination.
  • Changing medical decision-making criteria to move away from simply adding up tasks to instead focus on tasks that affect the management of a patient’s condition.

Dig deeper on how 2021 E/M guidelines could ease physicians’ documentation burdens.

“Unconscionable” payment cuts must not be implemented. “Physicians are already experiencing substantial economic hardships due to COVID-19, so these pay cuts could not come at a worse time,” Dr. Bailey said.

The consensus of the AMA and other leading medical organizations is that the budget-neutrality adjustment must be waived in light of the COVID-19 public health emergency, and the AMA strongly urges Congress to do so.

Last month, the AMA and more than 100 leading health care-related organizations also wrote to Health and Human Services (HHS) Secretary Alex Azar urging him to use the authority granted to HHS under the public health emergency declaration to waive the budget-neutrality requirements in order to preserve access to care and mitigate financial distress.

MIPS refinements continue. Gradual implementation of the Merit-based Incentive Payment System (MIPS) would continue under the proposed rule.

Proposed changes include:

  • Lowering the weight of the quality category to 40% from 45% of the MIPS final score.
  • Raising the weight of cost category from 15% to 20% of the final score.
  • Adding telehealth services to the list of cost measures.

Hardship exemptions allowed physicians to opt out of MIPS in 2020 without penalty because of the pandemic, and the AMA is evaluating if the exemptions need to be extended into 2021 or if other adjustments are needed.

A significant new proposal involves an optional and completely attestation-only measure in the promoting interoperability (PI) category that can replace two other PI measures giving physicians 40 points for participating in Health Information Exchanges.

Related Coverage

How 2021 E/M guidelines could ease physicians’ documentation burdens

CMS notes that it will continue “policy development” for its planned MIPS Value Pathways (MVPs), but will is delaying implementation.

“We intended to begin transitioning to MVPs in the 2021 MIPS performance year; however, due to the 2019 Novel Coronavirus pandemic public health emergency and resultant need for clinician focus on the response, our timeline has changed accordingly such that the proposal for initial MVPs will be delayed until at least the 2022 performance year,” the payment schedule states.

The goal behind MVPs is to create a framework that reduces the complexity and administrative burdens associated with MIPS and to develop a program that is more aligned with a physician’s specialty, includes fewer reporting measures, and facilitates movement toward advanced alternative payment models (APMs).

Changes proposed for ACO quality metrics. CMS proposes reducing the number of quality measures for accountable care organizations (ACOs) participating in the Medicare Shared Savings Program from 23 to six.

CMS proposes requiring participating ACOs to earn a quality performance score equivalent to or above the 40th percentile across all MIPS quality performance-category scores to share in savings or avoid owing maximum losses.

Modifying opioid-use disorder (OUD) codes. Recognizing the evolving nature of the nation’s drug overdose epidemic, CMS proposes broadening the use of G-codes used in the treatment of OUD. This year, CMS established codes for the development of a treatment plan, care coordination and individual and group counseling.

For 2021, CMS proposes modifying these codes so they can be used to report monthly treatment for patients with any substance-use disorder—not just OUD.

Read why the nation’s drug overdose epidemic requires a new policy focus.

More options offered for virtual MDPPs. The CMS has allowed Medicare Diabetes Prevention Programs to be offered virtually during the public health emergency but requires the first core session to be in-person, which may prevent new patients from participating.

The AMA has urged CMS to remove this requirement and it has been dropped from the proposed rule, which calls for allowing all MDPP services to be delivered virtually during the current public health emergency and future declared emergencies.

Virtual teaching/supervision during the pandemic and beyond. CMS has let teaching physicians use real-time audio-visual communication to satisfy requirements for resident supervision during the COVID-19 public health emergency.

The agency is proposing to allow this to continue until the end of the public health emergency or up to Dec. 31, 2021. CMS is seeking comment on whether any “guardrails or limitations” might be necessary to maintain quality of care and education if the policy is further extended or made permanent.

Proposal to expand supervision scope. Certain nonphysician practitioners (NPPs) have been allowed to order diagnostic tests when used in the management of a specific problem, though only physicians may supervise diagnostic tests. During the public health emergency, however, a temporary policy was established allowing other NPPs to supervise these tests.

Concerns have been raised over a CMS proposal to make the change permanent “to the extent that [NPPs] are authorized to perform the tests under applicable state law and scope of practice.”

Final rule to arrive later. Comments are due to CMS by Oct. 5. Typically, CMS releases the final rule around Nov. 1, which is 60 days before it takes effect on Jan. 1. Citing the pandemic, the agency is waiving that requirement and replacing it with a 30-day notification requirement, so the final payment schedule is not expected to be released until Dec. 1.