CMPE, CPC, CPB, CPMA, CPPM, CEMC, CHCO - Presented by: Stacey Stuhrenberg - KraftCPAs
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2021 Medicare
Physician Fee Schedule
Presented by:
Stacey Stuhrenberg
CMPE, CPC, CPB, CPMA, CPPM, CEMC, CHCO
2
Speaker Introduction
Stacey Stuhrenberg
CMPE, CPC, CPB, CPMA, CPPM, CEMC, CHCO
Senior Coding & Compliance Consultant
3
Disclaimer
This material is designed to offer basic information for
coding and billing. The information presented is based
on the experience, training, and interpretation of the
auditor. While the information has been carefully
researched and checked for accuracy and
completeness, Kraft Healthcare and/or the presenter
does not accept any responsibility or liability with
regard to errors, omissions, misuse, or
misinterpretation. This handout is intended as an
educational guide and should not be considered a
legal/consulting opinion.
4
Structure and Timeline of
Medicare Physician
Fee Schedule
52021 Medicare Physician Fee
Schedule (MPFS) Timeline
• August 3, 2020
CMS released Medicare Physician Fee Schedule proposed rule
• October 4, 2020
Public comment period closed
• December 1, 2020
CMS released the 2021 Medicare Physician Fee Schedule final rule, which
became effective January 1, 2021
• December 21, 2020
The 2021 Consolidated Appropriations Act (CAA) released
• December 27, 2020
The 2021 Consolidated Appropriations Act (CAA) signed into law
6MPFS RBRVS System
• The Medicare Physician Fee Schedule uses RBRVS
(resource-based relative value system) to assign a relative
value to CPT codes.
o The RBRVS values are based on three criteria
o Physician Work (51%)
o Practice Expense (45%)
o Malpractice Expense (4%)
• Each type of RVU is added together and then multiplied by the
Geographic Practice Cost Index (GPCI), which accounts for the
cost of doing business in different parts of the country.
7MPFS RBRVS System
RBRVS Formula
8Why did the AMA change
RVUs and Guidelines for
E&M Codes?
AMA’s RVU Update Committee (RUC) stated the purpose
for increasing the wRVU values for E&M codes included:
• removal of regulatory burden of documentation
requirements that hampered physician's ability to spend
time with patients
• recognition of added physician responsibilities
associated with office encounters
• Increased non-patient interactions with patients
• EMR documentation
• Patient status documentation
• Care Coordination
92021 MPFS Conversion Factor
(CF) & Budget Neutrality
CMS policy requires that any time changes are made to
the Medicare Physician Fee Schedule, it must remain
budget neutral.
The final rule released by CMS on December 1, 2020
finalized a conversion factor of $32.41, which was a
decrease of $3.68 compared to the 2020 conversion
factor of $36.09.
The CF is a major factor of the overall Medicare
physician payment methodology and significantly
impacts reimbursement rates.
1011
2021 MPFS Conversion Factor
(CF) & Budget Neutrality
The Consolidated Appropriations Act passed and signed
in December 2020 by Congress authorized a 3.75%
increase in fee schedule payments for all providers in
2021. The conversion factor was raised to $34.89.
Implementation of HCPCS code G2211 for three years
resulted in another $3 billion dollars in additional
funding. The money that would have been paid for
HCPCS code G2211 was used to increase the conversion
factor.
12MPFS Conversion Factor
(CF)
Year Conversion Factor
2016 35.80
2017 35.89
2018 35.99
2019 36.04
2020 36.09
2021 34.89 (After CAA signed)
132021 Change in RVUs
CPT/HCPC 2020 Work 2021 RVU 2019
S Code RVU Work Difference Utilization
RVU
99202 0.93 0.93 0.00 2,670,872
99203 1.42 1.6 0.18 11,349,523
99204 2.43 2.6 0.17 10,602,766
99205 3.17 3.5 0.33 2,897,019
99211 0.18 0.18 0.00 2,660,415
99212 0.48 0.7 0.22 10,678,725
99213 0.97 1.3 0.33 91,601,723
99214 1.5 1.92 0.42 105,752,974
99215 2.11 2.8 0.69 10,321,248
Source: CMS CMS-1734-F_Calculation of volume-weighted average of increase to Office Outpatient E/M visits - FR 2021
14Changes in Medicare
Allowable Charges
The anticipated impact on Total Allowed
Charges by specialty based on the Work RVU
as reported in Table 106 of the Final Rule on
December 28, 2020 range from -10% to
+16%.
15Anticipated Impact
by Specialty
Positive Neutral Negative
Endocrinology +16% Cardiology 1% Radiology -10%
Rheumatology +15% CSW +1% Chiropractor -10%
Hematology/Oncology +14% Pulmonary Disease 1% PT/OT -9%
Family Practice +13% Clinical Psychologist 0% Cardiac Surgery -8%
Allergy/Immunology +9% Anesthesiology -8%
Urology +8% Plastic Surgery -7%
OB/GYN +7% Critical Care -7%
Psychiatry +7% Vascular Surgery -6%
Neurology +6% Neurosurgery -6%
Pediatrics +6% General Surgery -6%
Internal Medicine +4% Emergency Med -6%
162021 MPFS E&M Allowable
Amounts
CPT Code 2020 Non-Fac 2021 Non-Fac 2020 vs 2021
Allowable Allowable
99202 $71.47 $68.23 ($3.24)
99203 $101.55 $105.40 $3.85
99204 $155.84 $158.16 $2.32
99205 $197.24 $208.99 $11.75
99211 $21.57 $21.08 ($0.49)
99212 $42.52 $52.67 $10.15
99213 $70.79 $85.98 $15.19
99214 $103.09 $122.31 $19.22
99215 $138.79 $171.03 $32.24
**Source Palmetto GBA Fee Schedule (Participating Provider, Non-Facility
Setting, Tennessee Carrier Code/Locality) 172021 Evaluation &
Management Changes
• E/M services will see a net payment increase due to the
raise in RVUs.
• Changes are for CPT codes 99202-99215 only.
Requirements for all other codes remain the same.
• 99201 has been deleted. It had same level of decision
making as 99202.
• Code levels are based on medical decision making (MDM)
or time. History and exam are not counted in the
selection of a level of service.
• Prolonged service codes are used for 99205 or 99215
only
182021 Evaluation &
Management Changes
• E&M 2021 coding guidelines brought in a
new way of thinking. The focus is now on a
complete view of the patient, the problem,
and the risks.
192020
202021
History
+
+ Medical
OR
and/or
Decision Total Time
Exam as
Making (Day of)
Medically
(MDM)
Appropriate
21Office or Other Outpatient
E/M Services
History and/or Examination
Office or other outpatient services include a medically appropriate
history and/or physical examination, when performed.
The nature and extent of the history and/or physical examination is
determined by the treating physician or other qualified health care
professional reporting the service.
The care team may collect information and the patient or caregiver
may supply information directly (eg, by portal or questionnaire)
that is reviewed by the reporting physician or other qualified health
care professional.
The extent of history and physical examination is not an element in
selection of office or other outpatient services.
222021 MDM/Time
Component for Office or Outpatient Other E/M services (Hosp., Obs, IP,
Code Selection Services (99202-99215) Consults, ER, NF, Domiciliary, Rest
Home, Custodial Care, Home
(1995/1997)
History & Exam As medically appropriate Use key components (History, Exam, MDM)
Not used in code selection
Medical Decision May use MDM or total time on the dos Use key components (History, Exam, MDM)
Making
Time Total time on the date of encounter It includes both the face-to-face and non-face-to-face
time personally spent by the physician and/or other
QHP(s) on the day of the encounter (includes time in
activities that require the physician or other QHP and
does not include time in activities normally performed
by clinical staff).
MDM Elements • Number & complexity of problems • Number of diagnoses or management options
addressed at the encounter • Amount and/or complexity of data to be reviewed
• Amount and/or complexity of data • Risk of complications and/or morbidity or mortality
to be reviewed and analyzed
• Risk of complications and/or
morbidity or mortality of patient
management
232021 E& M Prolonged
Service Add-on Codes
+ 99417
Prolonged office or other outpatient E & M service(s)
beyond the minimum required time of the primary
procedure which has been selected using total time,
requiring total time with or without direct patient contact
beyond the usual service, on the date of the primary
service, each 15 minutes of total time
• List separately in addition to code 99205, 99215 for
office/outpatient E & M services
242021 E& M Prolonged
Service Add-on Codes
+G2212
Prolonged office or other outpatient evaluation and management
service(s) beyond the maximum required time of the primary
procedure which has been selected using total time on the date of the
primary service; each additional 15 minutes by the physician or
qualified healthcare professional, with or without direct patient
contact
• List separately in addition to CPT codes 99205, 99215 for office or
other outpatient evaluation and management services
• Do not report G2212 on the same date of service as 99354, 99355,
99358, 99359, 99415, 99416
• Do not report G2212 for any time unit less than 15 minutes
25CPT Code 99205 - New Patient
(60-74 minutes)
AMA/CPT Time CMS/HCPCS Time
CPT Code 99417 Code(s) HCPCS G2212 Code(s)
less than 75 Not separately less than 89 Not separately
minutes reportable minutes reportable
75-89 minutes 99205 x 1 AND 89-103 minutes 99205 x 1 and
99417 x1 G2212 x1
90-104 minutes 99205 x 1 AND 104-118 minutes 99205 x 1 AND
99417 x 2 G2212 x 2
>105 minutes 99205 x 1 AND >105 minutes 99205 x 1 AND
99417 x 3 Or more G2212 x 3 Or more
for each additional for each additional
15 minutes 15 minutes
26CPT Code 99215 - Established
Patient (40-54 minutes)
AMA/CPT Time CMS/HCPCS Time
CPT Code 99417 Code(s) HCPCS G2212 Code(s)
less than 55 Not separately less than 69 Not separately
minutes reportable minutes reportable
55-69 minutes 99215 x 1 AND 69-83 minutes 99215 x 1 and
99417 x1 G2212 x1
70-84 minutes 99215 x 1 AND 84-98 minutes 99215 x 1 AND
99417 x 2 G2212 x 2
>85 minutes 99215 x 1 AND >99 minutes 99215 x 1 AND
99417 x 3 Or more G2212 x 3 Or more
for each additional for each additional
15 minutes 15 minutes
27MPFS CPT CODE
ALLOWABLES
28CPT Code 99214
According to CMS, CPT code 99214 was the most
utilized code of all CPT codes in 2019.
2020 Prt B Allow 2021 Prt B Allow
Allowed Services
Specialty $103.03 $122.31 Difference
(# of Services)
(Non-Fac, TN) (Non-Fac, TN)
General Surgery 635,679 $ 65,494,007 $ 77,749,898 $ 12,255,891
Pediatric Medicine 123,461 $ 12,720,187 $ 15,100,515 $ 2,380,328
Orthopedic Surgery 2,251,218 $ 231,942,991 $ 275,346,474 $ 43,403,483
Family Practice 19,069,021 $ 1,964,681,234 $ 2,332,331,959 $ 367,650,725
Internal Medicine 19,565,773 $ 2,015,861,592 $ 2,393,089,696 $ 377,228,103
OB/GYN 640,191 $ 65,958,879 $ 78,301,761 $ 12,342,882
Neurology 2,630,653 $ 271,036,179 $ 321,755,168 $ 50,718,990
Cardiology 9,156,329 $ 943,376,577 $ 1,119,910,600 $ 176,534,023
Dermatology 2,347,559 $ 241,869,004 $ 287,129,941 $ 45,260,938
Ophthalmology 1,431,661 $ 147,504,033 $ 175,106,457 $ 27,602,424
Source: Medicare Part B National Data CY2019 29Common Procedure CPT
Codes
2021 Part B
CPT Code Description 2020 Part B Allow Difference
Allow
10060 Incision & Drainage $ 114.08 $ 115.45 $ 1.37
12001 Simple Repair $ 84.54 $ 86.98 $ 2.44
17000 Destruction of Lesion $ 61.32 $ 61.67 $ 0.35
Aspiration from or
injection into (shoulder,
20610 hip, knee) $ 58.56 $ 59.58 $ 1.02
27130 Total Hip Replacement $ 1,288.79 $ 1,199.05 $ (89.74)
27447 Total Knee Replacement $ 1,287.45 $ 1,197.78 $ (89.67)
45380 Colonoscopy (Fac Rate) $ 194.90 $ 189.63 $ (5.27)
Colonoscopy w/polyp
45385 removal (Fac Rate) $ 247.64 $ 240.11 $ ( 7.53)
47562 Gallbladder Removal $ 625.14 $ 612.32 $ (12.82)
30Common Procedure CPT
Codes
2021 Part B
CPT Code Description 2020 Part B Allow Difference
Allow
Routine OB care w/Vaginal
59400 Delivery $ 1,997.58 $ 2,195.14 $ 197.56
Routine OB care w/C-
59510 section $ 2,205.19 $ 2,412.28 $ 207.09
66984 Cataract Surgery $ 520.05 $ 509.27 $ (10.78)
71045 Chest X-ray (global) $ 23.70 $ 23.74 $ 0.04
71045-26 Chest X-ray (read only) $ 8.95 $ 8.63 $ (0.32)
Screening Mammogram
77067 (global) $ 126.94 $ 122.00 $ (4.94)
Screening Mammogram
77067-26 (read only) $ 37.41 $ 35.92 $ (1.49)
31CMS and Telehealth
32Telehealth-2021 Policy
Changes
Direct Supervision via Telehealth: “Direct Supervision” can be
provided using real-time, interactive audio-video technology under
42 C.F.R. § 410.21 until December 31, 2021, or at the end of the PHE
(whichever is later)
• The current definition of direct supervision requires a physician to be
physicially present in the office and immediately available to furnish
assistance and direction if needed.
• Under the new definition, direct supervision is met if the supervising
physician is immediately available to engage via interactive audio-
video.
• It is important to note audio-only technology is NOT sufficient to
fulfill direct supervision requirements.
33Telehealth-2021 Policy
Changes
Extended Audio-Only Assessment Services: CMS created HCPCS
code G2252 to be used for the duration of 2021 for extended services
delivered via synchronous communications technology, including
audio-only (e.g., virtual check-ins). The service is considered a
communication technology-based service (CTBS) and is subject to all
CTBS requirements.
• G2252 (Brief communication technology-based service, e.g., virtual
check-in, by a physician or other qualified health care professional
who can report evaluation and management services, provided to an
established patient, not originating from a related E/M service
provided within the previous seven days nor leading to an E/M
service or procedure within the next 24 hours or soonest available
appointment; 11-20 minutes of medical discussion.)
34Telehealth-2021 Policy
Changes
Communications Technology Based Services
(CTSB) CMS Requirements
• Providers/QHP’s must continue to obtain patient
consent. The purpose of the consent is to notify
the patient of copay/cost sharing. CMS stated the
timing, or the way consent is acquired shouldn’t
interfere with the delivery of the service itself. The
consent can be verbal or written and can be
documented by the billing practitioner or by
auxiliary staff under general supervision. Consent
MUST be documented.
35Telehealth-2021 Policy
Changes
• CTBS by Therapists: HCPCS codes G2061 through G2063 may be
billed by licensed clinical social workers, clinical psychologists,
physical therapists, occupational therapists, speech language
pathologists, and other non-physician practitioners who bill
Medicare directly for their services, when the service is within the
applicable scope of the service.
• This billing has been temporarily allowed under the PHE waivers, but
this new rule change is permanent, effective January 1, 2021.
• When billed by a private practice PT, OT, or SLP, the codes would need
to include the corresponding -GO, -GP, or -GN therapy modifier to
signify the CTBS is furnished as therapy services furnished under an
OT, PT, or SLP plan of care.
36Telehealth-2021 Policy
Changes
• CTBS by QHP’s Who Do Not Bill E/M. - Two new “G codes” were set up to
be used by QHP’s who can’t independently bill for E/M services.
• G2250 (Remote assessment of recorded video and/or images submitted
by an established patient (e.g., store and forward), including
interpretation with follow-up with the CMS-1734-P 114 patient within
24 business hours, not originating from a related service provided within
the previous 7 days nor leading to a service or procedure within the next
24 hours or soonest available appointment.)
• G2251 (Brief communication technology-based service, e.g. virtual
check-in, by a qualified health care professional who cannot report
evaluation and management services, provided to an established patient,
not originating from a related service provided within the previous seven
days nor leading to a service or procedure within the next 24 hours or
soonest available appointment; 5-10 minutes of medical discussion.)
37Telehealth-2021 Policy
Changes
• New Frequency Limitations for Telehealth in
Nursing Facilities: CMS reduced the frequency
limitation for coverage of subsequent nursing facility
care services furnished via telehealth from once every
30 days to once every 14 days.
• Frequency limitations were temporarily waived for the
duration of the PHE, but CMS made this rule change is
permanent, effective January 1, 2021.
• CMS did not make changes to the telehealth frequency
limitations for hospital inpatient visits and critical care
consultations.
38Expanding Services and
Coverage-Category 1
For 2021, CMS finalized the addition of approximately 60 new Category 1
telehealth services that will be reimbursed become permanent under
Medicare, effective January 1, 2021.
CMS defines Category 1 codes as follows:
Services that are similar to professional consultations, office visits, and
office psychiatry services that are currently on Medicare telehealth services
list. In reviewing these requests, we look for similarities between the
requested and existing telehealth services for the roles of, and interactions
among, the beneficiary, the physician (or other practitioner) at the distant
site and, if necessary, the telepresenter, a practitioner who is present with
the beneficiary in the originating site. We also look for similarities in the
telecommunications system used to deliver the service; for example, the use
of interactive audio and video equipment.
39Expanding Coverage-
Category 1
• Group Psychotherapy (CPT code 90853)
• Psychological and Neuropsychological Testing (CPT code 96121)
• Domiciliary, Rest Home, or Custodial Care services, Established
patients (CPT codes 99334-99335)
• Home Visits, Established Patient (CPT codes 99347-99348)
• Cognitive Assessment and Care Planning Services (CPT code
99483)
• Visit Complexity Inherent to Certain Office/Outpatient Evaluation
and Management (E/M) (HCPCS code G2211)
• Prolonged Services (HCPCS code G2212)
40Expanding Coverage-
Category 3
CMS also finalized the creation of a third temporary
category of criteria for adding services to the list of
Medicare telehealth services.
CMS defines Category 3 codes as follows:
Category 3 describes services added to the Medicare
telehealth list during the public health emergency
(PHE) for the COVID-19 pandemic (COVID-19 PHE)
that will remain on the list through the calendar
year in which the PHE ends.
41Expanding Coverage-
Category 3
• Domiciliary, Rest Home, or Custodial Care services, Established
patients (CPT codes 99336-99337)
• Home Visits, Established Patient (CPT codes 99349-99350)
• Emergency Department Visits, Levels 1-5 (CPT codes 99281-99285)
• Nursing facilities discharge day management (CPT codes 99315-
99316)
• Psychological and Neuropsychological Testing (CPT codes 96130-
96133; CPT codes 96136-96139)
• Therapy Services, Physical and Occupational Therapy, All levels (CPT
codes 97161-97168; CPT codes 97110, 97112, 97116, 97535,
97750, 97755, 97760, 97761, 92521-92524, 92507)
42Expanding Coverage-
Category 3
• Hospital discharge day management (CPT codes 99238-99239)
• Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT
codes 99469, 99472, 99476)
• Continuing Neonatal Intensive Care Services (CPT codes 99478-
99480)
• Critical Care Services (CPT codes 99291-99292)
• End-Stage Renal Disease Monthly Capitation Payment codes (CPT
codes 90952, 90953, 90956, 90959, 90962)
• Subsequent Observation and Observation Discharge Day
Management (CPT codes 99217; CPT codes 99224-99226)
43What now?
44What now?
1. Review practice procedures and
protocols to ensure they are consistent
with the new guidelines.
2. Confirm EHR vendor has implemented
the 2021 E&M visit code changes
correctly.
3. Consistently monitor KPIs such as Days
in A/R, Aging Report by Payer, Net
collection rate, and clean claim rate.
45What now?
4. Perform a CPT code utilization analysis. Most
practice management systems have a report that
provides a detailed list of information for the
specified CPTs for a specified date range.
Depending on the specialty, the E&M code range
represents a significant amount of the total billed
services. For specialties that E/M doesn’t represent a
significant number of billings, it’s important analyze
CPT codes that represent both the top dollar amounts
collected, as well as top volume of services performed.
This will help practices anticipate any increases or
decreases in expected revenue.
46What now?
5. Perform baseline documentation and
compliance audit for E/M code codes
ranges. It’s important to remember that
depending that providers who see
patients both in the office and in the
hospital will need to document using 2
different sets of guidelines (2021 vs 1995
& 1997 guidelines).
47What now?
The financial impact of over/under coding
cannot be overstated. It’s estimated that
E&M codes 99211-99205 represent 40% of
total revenue on average.
Auditing and denial monitoring is vitally
important to ensure no revenue is being
left on the table.
48Is your practice ready for these new changes? Major changes have been made to evaluation and management (E/M) office or other outpatient visit code categories (99202-99215) for the first time in more than 20 years. Is your practice prepared? Kraft Healthcare Consulting can help. We will review up to five records per provider for compliance and documentation purposes to be sure you’re meeting the new guidelines. When that review is complete, we will provide customized training based on those findings. (Rates vary based upon practice size.) Don’t be caught off-guard or risk a potential Medicare or OIG audit. Reach out to us for more information.
What can Kraft’s
healthcare team do for you?
• Provider education for 2021 • Assistance with HHS
E&M guidelines and other Provider Relief Fund
topics Reporting
• Coding and documentation • HIPAA, HITECH,
audits HITRUST compliance
• Revenue Cycle Procedure • CDM reviews and
Code analysis, denial analysis
reviews, appeals help
• RAC appeals and risk
• Medicare/Medicaid cost assessments
reports
• Assurance and tax
preparation services
50Questions?
Stacey Stuhrenberg
(615) 346-2455
Stacey@krafthealthcare.com
51Resources
Revisions to Payment Policies under the
Medicare Physician Fee Schedule, Quality
Payment Program and Other Revisions to
Part B for CY 2021
https://www.cms.gov/medicaremedicare-
fee-service-paymentphysicianfeeschedpfs-
federal-regulation-notices/cms-1734-f
52Resources
Medicare Program; CY 2021 Payment
Policies Under the Physician Fee Schedule
and Other Changes to Part B Payment
Policies
https://www.federalregister.gov/document
s/2020/12/28/2020-26815/medicare-
program-cy-2021-payment-policies-under-
the-physician-fee-schedule-and-other-
changes-to-part
53Resources
MLN Medicare Physician Fee Schedule
Payment System Series
https://ahca.myflorida.com/medicaid/state
wide_mc/pdf/plan_comm/PT_17-
10_Attachment-6_Year-2-Medicare-
Physician-Fee-Schedule.pdf
54You can also read
