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The Final Rule? It Wasn’t Really Final.

January 20, 2021

The Final Rule? It Wasn’t Really Final.
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The Medicare Physician Fee Schedule (MPFS) Final Rule  was published on December 1, 2020. On December 27, 2020, the Consolidated Appropriations Act, 2021 (CAA) was enacted. This lengthy, last-minute bill included COVID-19 relief and changes that impacted the MPFS. The CAA altered the Medicare fee schedule and delayed, suspended and extended other CMS policies. Below are a few of the highlights from the Final Rule and the CAA and a few things to keep an eye on in 2021.

Medicare Fee Schedule

The CAA increased the fee schedule by 3.75% establishing a final conversion factor rate of $34.89 ($21.56 for anesthesia). This increase in the conversion factor, along with the allocation of an additional $3 billion into the MPFS budget and the delayed implementation of the add on complexity code G2211 reversed the overall cut (approximately 10%) to the physician fees but still results in a decrease in reimbursement rates from the 2020 rates. The actual Medicare payment schedules for Arkansas, Louisiana and Mississippi have not been published (as of this article) but will be posted on the Novitas Fee Schedule Center when available.

Office and Outpatient E/M Code Changes

  • The code selection and documentation requirements have changed for codes 99202-99205. Code selection is now based on time or medical decision making for these specific E/M codes.
  • Two new E/M add-on codes were added in the Final Rule:
    • G2211 for visit complexity
    • G2212 for extended time

NOTES: 

  • The implementation for payment of the G2211 code has been delayed until 2024.
  • Many of the private payors are expected to adopt the E/M changes above.
  • For extended time, some payors may prefer CPT code 99417 in lieu of G2212.

Other Coding Changes

  • CMS has stated that the audio-only codes (99441-99443) will not be covered after the public health emergency (PHE). Code G2252 was created in the Final Rule as an interim code, to allow for audio-only services after the PHE expires. The code is similar to the “virtual check-in” code G2012 and has the same billing requirements. The payment for this code is equivalent to the 99442.
  • More services have been added to the permanent Medicare telehealth list. In addition, some services (Category 3 codes) have been added to the list on a temporary basis. These codes will no longer be payable after December 31 in the year the PHE expires.

Telehealth

  • The CAA did not remove the originating site requirement or the geographic requirements for telehealth post PHE for all services. We will continue to monitor CMS and the other payors.
  • Many commercial payors have updated their Telehealth/Virtual Care and patient cost share policies for the new year. Be sure to check payor websites or refer to the LAMMICO Telehealth Matrix and Upcoming Dates resources by logging in as a Member at lammico.com and clicking the red COVID-19 banner at the top of the page.

COVID-19 Relief

  • The 2% Medicare sequestration suspension will continue until March 31, 2021.
  • Additional dollars were added to the original $175 billion Provider Relief Funds budget, and clarity was provided on how the funds can be used.
  • The SBA Paycheck Protection Program was modified and clarified. Second Draw Loans are available to qualified applicants. CAA also increased the maximum loan amount and decreased the application burden.
  • The CAA addressed the issue of surprise medical bills and has mandated an “arbitration” method to resolve out-of-network disputes. Additional rulemaking by a few federal agencies should provide more details and information on the process. The implementation of these rules are delayed until 2022.
  • Changes to the Families First Coronavirus Response Act (FFCRA) were included in the CAA. New guidance in the FAQs is available.
  • CAA injected an additional $3 billion in additional funding to the Provider Relief Fund and included more details on the reporting requirements. On January 15, 2021, HHS opened the Reporting Portal for registrations, but has not established a time frame for reporting.

Quality Payment Program

  • The reporting portal for performance year 2020 opened on January 4, 2021, and will close on March 31, 2021. Eligible clinicians and groups must submit data to avoid a 9% penalty if they have not been granted an exception!
  • Payment adjustments for 2021 dates of service will be appearing on Medicare EOBs soon. These adjustments are based on a clinician or group’s 2019 MIPS score. For information on how the payment adjustment is calculated, click here.
  • CMS will be using the Extreme and Uncontrollable Circumstances policy to allow MIPS-eligible clinicians, groups and virtual groups to submit an application requesting re-weighting of one or more MIPS performance categories to 0% due to the current PHE. Clinicians calculating lower than anticipated scores in 2020 (e.g., as a result of the COVID-19 pandemic), can submit an application through February 1, 2021.  
    NOTE: Louisiana clinicians were granted an automatic exception due to Hurricane Laura. For more information, click here.
  • The Quality Payment Program (QPP) Participation Status Tool has been updated with the 2021 eligibility.
  • The APM Performance Pathway (APP) is a new reporting framework for MIPS-eligible providers participating in an APM (e.g., MSSP/ACO, Bundled Payment Model, etc.).

For more information, contact LAMMICO Practice Management Specialist, Natalie Cohen, MBA, MHA, at 504.841.2727 or ncohen@lammico.com.

Participation in the Quality Payment Program may help you mitigate your malpractice risk through tracking and improving quality care (Quality measures), increasing patient engagement and satisfaction (Improvement Activities) and improving communications using secure electronic transmissions between providers and with patients (Promoting Interoperability). 

This information is accurate as of January 20, 2021. 
 


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