CY 2021 Medicare Physician Fee Schedule and Quality Payment Program Final Rule - Overview December 10, 2020
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CY 2021 Medicare Physician Fee Schedule and
Quality Payment Program
Final Rule - Overview
December 10, 2020
©2020 All Rights Reserved
Overview
Physician Fee Schedule
• Evaluation and Management (E/M) services and Conversion Factor
• AMGA Consulting
• Documentation
• Telehealth Additions
Quality Payment Program
• MIPS Value Pathways
• APM Performance Pathway
Medicare Shared Savings Program
• Quality Performance Standard
©2020 All Rights Reserved 2
E&M, Work RVUs and the
Conversion Factor
©2020 All Rights Reserved 3
CY 2021 PFS and Conversion Factor
• CMS finalizes conversion 2020:
factor decrease of 10% $36.09
• Lower conversion factor
required by budget Proposed:
neutrality rules $32.26
• Significant increase in
work RVUs for E/M codes Final:
$32.41
©2020 All Rights Reserved 4
Conversion Factor: 2008 – 2021
$39.00
$38.00
$37.00
$36.00
$35.00
$34.00
$33.00
$32.00
$31.00
$30.00
$29.00
2008 2009 2010 2010 2011 2012 2013 2014 2015 2015 2016 2017 2018 2019 2020 2021
(1st (2nd (1st (2nd
half) half) half) half)
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CY 2021 Work RVUs
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Estimated Impact by Specialty
Allowed Work RVU PE RVU MP RVU Combined
Service
Charges Change Change Change Impact
Endocrinology $506 11% 6% 1% 17%
Family
$5,982 9% 4% 1% 13%
Practice
Urology $1,803 4% 4% 0% 8%
Oncology $1,702 9% 5% 1% 14%
Internal
$10,654 2% 2% 0% 4%
Medicine
Allowed charges in millions
©2020 All Rights Reserved 7Estimated Impact by Specialty
Allowed Work RVU PE RVU MP RVU Combined
Service
Charges Change Change Change Impact
Orthopedic
$3,792 -3% -1% 0% -5%
Surgery
Vascular
$1,287 -2% -5% 0% -7%
Surgery
Anesthesiology $74 -4% -2% 0% -7%
Radiology $5,253 -6% -5% 0% -11%
Allowed charges in millions
©2020 All Rights Reserved 8Revalue Services Similar to E/M
• End-Stage Renal Disease Monthly Capitation Payment Services
• Transitional Care Management Services
• Maternity Services
• Cognitive Impairment Assessment and Care Planning
• Initial Preventive Physical Examination and Initial Subsequent
Annual Wellness Visits
• Emergency Department Visits
• Therapy Evaluations
• Psychiatric Diagnostic Evaluations & Psychotherapy Services
©2020 All Rights Reserved 9Documentation
• Finalized in 2020 rulemaking
• CMS finalized CPT descriptors, guidelines, and
payment rates effective on Jan. 1, 2021
• Significant modification to the coding, documentation,
and payment of E/M services
©2020 All Rights Reserved 10Documentation
Medical Decision Making Time
• Number and complexity of • Total Time on date of the
problems addressed in the encounter
– Reviewing tests in preparation for a
encounter patient’s visit
• Amount or complexity of data – Counseling or educating a patient,
to be reviewed and analyzed family or caregiver
– Reporting test results to a patient
• Risk of complications or by phone
morbidity of patient – Ordering medications, tests or
management procedures
– “Pajama time”
©2020 All Rights Reserved 11Congress and E/M ©2020 All Rights Reserved 12
Legislative Action?
• Congressional interest in
preventing cuts
– In Dec. 18th package?
• Multiple approaches to
address cuts
• Payfors?
©2020 All Rights Reserved 13AMGA Consulting ©2020 All Rights Reserved 14
15
Online Survey Results
Question 1: Percent Overall Type
If the E&M changes are enacted by CMS, how will your commercial payers respond: All Independent System Affiliated
All of our commercial payers will likely follow CMS’s lead 19.3% 25.5% 14.9%
Most of our commercial payers will likely follow CMS’s lead 37.8% 33.3% 40.3%
Some of our commercial payers will likely follow CMS’s lead 11.8% 9.8% 13.4%
Few or none of our commercial payers will likely follow CMS’s lead 0.8% 0.0% 1.5%
Uncertain how commercial payers will respond 30.3% 31.4% 29.9%
Question 2: Percent Overall Type
How are your non-Medicare payer fee schedules constructed? All Independent System Affiliated
Most built upon % of Medicare 58.8% 72.5% 49.3%
Most built upon wRVU conversion factors 16.8% 7.8% 23.9%
Most built on a per code rate 13.4% 7.8% 16.4%
Combo of the above 10.9% 11.8% 10.4%
There is uncertainty on how commercial payors will respond; however,
it is expected most will follow CMS’s lead (eventually).
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Online Survey Results Continued
Question 3: Percent Overall
Which preparations has your organization taken regarding the potential changes in
the proposed rule (choose all that apply): All
None or very little action / waiting for the final rule before taking any action 6.7%
We have discussed the potential changes among leadership 25.9%
We have discussed the potential changes with physicians/providers 16.3%
We have calculated the specialty/physician-level compensation changes anticipated 14.5%
We have considered the impact on medical group reimbursement under the
proposal rule 19.2%
We have discussed potential changes to our physician compensation model(s) in
response to the proposed rule 16.3%
Other 1.2%
Results suggest that many groups still have work to do to understand
the operational and financial implications of these changes.
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Online Survey Results Continued
Question 4: Percent Overall Several respondents
Is your organization (per your employment agreements) commented that they
automatically allowed to make adjustments to physician worked through their
compensation to mitigate the potential impacts of work RVU or
reimbursement conversion factor changes?
compensation
All committees to maintain
Yes 38.3%
No 40.8%
2020 wRVU weights and
Some 20.8% conversion factors for
another year.
Question 4.1: Percent Overall
If you answered “no” or “some” in the previous question, which of the Some smaller groups
following might you consider? Check all options that apply.
All use net collections
Requesting physicians voluntarily renegotiate compensation formula(s)
models which will not
before January 1, 2021, to minimize the financial impact on the group overall be impacted the same
15.9%
way.
Offering a modest one-time bonus as an incentive to agree to a change in the
compensation per work RVU to manage budget impact for the group
3.2%
Including language in all future employment agreements that CMS work RVU
weight or reimbursement conversion factor changes will trigger contract re-
negotiation (or will be neutralized) 34.9%
Other 46.0%
©2020 All Rights Reserved 1718
Online Survey Results: Action Steps
Immediate actions to take if you have not done so already:
Analyze the financial impact of these changes on your organization
Determine your best option(s) for moving forward (e.g., maintain 2020
values, etc.)
Validate your best options with legal/compliance
Educate leaders and physicians/providers on the changes that need to occur
Manage the change management/implementation process
©2020 All Rights Reserved 18Telehealth ©2020 All Rights Reserved 19
CARES Act and Telehealth
• CMS temporarily removed the geographic and site of
service originating site restrictions for Medicare telehealth
services.
• This rule does not address these provisions.
• CMS is limited by statute and cannot permanently expand
the list of telehealth providers. CMS notes that making
these flexibilities permanent requires an act of Congress.
©2020 All Rights Reserved 20Additions to Telehealth Category 1
• Group Psychotherapy (CPT 90853)
• Domiciliary, Rest Home, or Custodial
Care services, Established patients (CPT
99334-99335)
• Home Visits, Established Patient (CPT
99347- 99348)
Finalized as permanent additions as • Cognitive Assessment and Care Planning
Medicare Telehealth services Services (CPT 99483)
• Visit Complexity Inherent to Certain
Office/Outpatient E/Ms (HCPCS G2211)
• Prolonged Services (HCPCS G2212)
• Psychological and Neuropsychological
Testing (CPT 96121)
©2020 All Rights Reserved 21Temporary Additions
• Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT 99336-99337)
• Home Visits, Established Patient (CPT 99349-99350)
• Emergency Department Visits, Levels 1-5 (CPT 99281-99285)
• Nursing facilities discharge day management (CPT 99315-99316)
• Psychological and Neuropsychological Testing ( CPT 96130- 96133; CPT 96136- 96139)
• Therapy Services, Physical and Occupational Therapy, All levels (CPT 97161- 97168; CPT 97110, 97112, 97116,
97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507)
• Hospital discharge day management (CPT 99238- 99239)
• Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT 99469, 99472, 99476)
• Continuing Neonatal Intensive Care Services (CPT 99478- 99480)
• Critical Care Services (CPT 99291-99292)
• End-Stage Renal Disease Monthly Capitation Payment codes (CPT 90952, 90953, 90956, 90959, and 90962)
• Subsequent Observation and Observation Discharge Day Management (CPT 99217; CPT 99224- 99226)
Bold = Not included in Proposed Rule
©2020 All Rights Reserved 22Not Adding Permanently or Temporarily
• Initial Nursing Facility Visits, All Levels (Low, Moderate, and High Complexity)
(CPT 99304-99306)
• Initial hospital care (CPT 99221-99223)
• Radiation Treatment Management Services (CPT 77427)
• Domiciliary, Rest Home, or Custodial Care services, New (CPT 99324- 99328)
• Home Visits, New Patient, all levels (CPT 99341- 99345)
• Inpatient Neonatal and Pediatric Critical Care, Initial (CPT 99468, 99471,
99475, 99477)
• Initial Neonatal Intensive Care Services (CPT 99477)
• Initial Observation and Observation Discharge Day Management (CPT 99218
– 99220; CPT 99234- 99236)
• Medical Nutrition Therapy (CPT G0271)
©2020 All Rights Reserved 23Remote Physiologic Monitoring Services
• Once the public health emergency ends, a care provider must have an established patient-physician relationship for
Remote Physiologic Monitoring (RPM) services to be furnished.
• RPM can be ordered and billed only by physicians or non-physician practitioners who are eligible to bill Medicare for
E/M services.
– CPT code 99091 can only be furnished by a physician or other qualified healthcare professional, CPT codes 99457 and
99458 can be furnished by a physician or other qualified healthcare professional, or by clinical staff under the general
supervision of the physician.
• Consent to receive RPM services may be obtained at the time that RPM services are furnished.
• RPM services may be medically necessary for patients with acute conditions as well as patients with chronic
conditions.
• “Interactive Communication” for purposes of CPT codes 99457 and 99458 requires, at a minimum, a real-time
synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data
transmission
©2020 All Rights Reserved 24Telehealth Direct Supervision
• CMS is finalizing proposal to allow direct supervision
using real-time, interactive audio and video technology
– Does not included audio-only
– Available until the later of the end of the calendar year
in which the Public Health Emergency ends or Dec. 31,
2021
©2020 All Rights Reserved 25Audio Only
Separate Payment Final Rule
• March 31 IFC established separate • After the end of the PHE, there
payment for audio-only E/M services
– CPT codes 99441, 99442, and 99443
will be no separate payment for
the audio-only E/M visit codes.
• CMS is not proposing to continue • At the end of the PHE CMS will
payment beyond the PHE assign a status of “bundled” and
– Cannot waive the requirement that
telehealth services be furnished using post the RUC-recommended
an interactive telecommunications RVUs for these codes
system that includes two-way,
audio/video communication
technology.
©2020 All Rights Reserved 26Quality Payment Program ©2020 All Rights Reserved 27
MIPS Value Pathways (MVPs)
• CMS finalized in the CY 2020 PFS final rule the definition of MVPs at §
414.1305 as “a subset of measures and activities established through
rulemaking.”
• MVPs would:
– Connect measures and activities across the 4 MIPS performance categories
– Incorporate a set of administrative claims-based quality measures
– Provide data and feedback to clinicians
– Enhance information provided to patients
• CMS has delayed MVPs until at least performance year 2022 due to the
novel coronavirus (COVID-19) PHE.
Note: Merit-based Incentive Payment System (MIPS)
©2020 All Rights Reserved 28MVP: Diabetes Example
Source: Centers for Medicare & Medicaid Services (CMS) QPP
©2020 All Rights Reserved 29APM Performance Pathway
• APM Performance Pathway (APP) is a new framework that CMS seeks to
have align with the MVP:
– Available only to participants in MIPS APMs
– APP will begin in the 2021 performance year
• APP would consist of six measures (3 active reporting measures, 2 claims-
based measures, and CAHPS for MIPS).
– For performance year 2021 only, ACOs will be able to report through the
CMS web interface
• The four categories in the proposed APP framework would be weighted as
follows:
– Quality: 50%, Promoting Interoperability: 30%, Improvement Activities:
20%, Cost: 0%
©2020 All Rights Reserved 30APP Measure Set
©2020 All Rights Reserved 31CY 2021 MIPS:
Category Weights and Performance Threshold
Promoting
Improvement
Quality 40% Cost 20% Interoperability
Activities 15%
25%
The Performance threshold: 60 points
The Exceptional Performance threshold: 85 points
©2020 All Rights Reserved 32MIPS Proposals: Quality & Cost
Quality Performance Category
• CMS will extend the use of the CMS Web Interface as a collection
type and submission type through the 2021 performance period.
The agency will sunset its use in performance year 2022.
• Finalized changes to MIPS quality measures
Cost Performance Category
• CMS will add costs associated with telehealth services to the
previously established cost measures.
©2020 All Rights Reserved 33MIPS Proposals: IA & PI
Improvement Activities Performance Category
• Modify two existing Improvement Activities, remove one
• Establish policies in relation to the Annual Call for Activities
• Establish a process for agency-nominated improvement activities
Promoting Interoperability Performance Category
• The Query of Prescription Drug Monitoring Program (PDMP) measure will remain an
optional measure, worth 10 bonus points.
• Finalized a name change for a measure (Support Electronic Referral Loops by
Receiving and Reconciling Health Information)
• Added new measure: Health Information Exchange (HIE) Bi-Directional Exchange
©2020 All Rights Reserved 34MIPS APM Scoring Standard
CMS will terminate Effective
the APM scoring
standard January 1, 2021
©2020 All Rights Reserved 35Methodology for MIPS Final Score: Quality
Measure Benchmarks
CY 2021 proposed rule
• CMS may not have as representative of a sample of data as they would have had
due to the national PHE for COVID-19.
• CMS intends to use performance period benchmarks for the CY 2021 performance
period in accordance with §414.1380(b)(1)(ii)
CY 2021 final rule
• CMS has determined that sufficient data were submitted for the 2019 performance
period to allow them to calculate historical benchmarks for the 2021 performance
period.
©2020 All Rights Reserved 36Advanced APMs
• CMS finalized a policy related to calculating Qualifying APM Participant (QP)
Threshold Scores used in making QP determinations, beginning in the 2021
QP performance period.
– The effect of this finalized policy would be to remove such attributed
Medicare patients from the denominator of the QP Threshold Score
calculations for APM Entities or individual eligible clinicians in APMs that
do not allow for attribution of Medicare patients who have already been
prospectively attributed to another APM Entity.
– Prevent the dilution of the QP Threshold Score for the APM Entity or
individual eligible clinician.
©2020 All Rights Reserved 37Medicare Shared Savings
Program
©2020 All Rights Reserved 38APM Performance Pathway for MSSP
• CMS is applying the APP to Medicare Shared Savings Program (MSSP)
accountable care organizations (ACOs) for performance year 2021.
• For performance year 2021, ACOs can choose to report either the 10
measures under the CMS Web Interface or the 3 eCQM/MIPS CQM
measures. ACOs will be required to field the CAHPS for MIPS survey, and
CMS will calculate 2 measures using administrative claims data.
• For performance year 2022 and beyond, ACOs will be required to actively
report quality data on the 3 eCQM/MIPS CQM measures via the APP. In
addition, ACOs will be required to field the CAHPS for MIPS survey, and CMS
will calculate two measures using administrative claims data.
• CMS will retain the pay-for-reporting year for new ACOs
©2020 All Rights Reserved 39MSSP Quality Performance Standard
For performance years 2021 For performance year 2023 and
and 2022 subsequent performance years
• ACOs achieve a quality • ACOs achieve a quality
performance score that is performance score that is
equivalent to or higher than equivalent to or higher than
the 30th percentile across all the 40th percentile across all
MIPS Quality performance MIPS Quality performance
category scores category scores
©2020 All Rights Reserved 40Quality Performance and Shared Savings/Shared
Losses
Quality ACO can share in savings at the maximum rate
performance
standard
met ACOs in two-sided arrangements share in losses based on their
quality performance or a fixed percentage based on their track.
Quality ACOs are not eligible to share in savings
performance
standard not
met ACO owes maximum shared losses
©2020 All Rights Reserved 41Modifications to Quality Reporting for
Performance Year 2020
CAHPS for ACOs
• CMS is finalizing its proposal to waive the CAHPS
for ACOs reporting requirement for performance
year 2020 and to assign all ACOs automatic credit
for each of the CAHPS survey measures within
the patient/caregiver experience domain.
©2020 All Rights Reserved 42Questions/Comments
AMGA’s Regulatory Team
Darryl Drevna, M.A.
Senior Director, Regulatory Affairs
ddrevna@amga.org
Emma Achola
Coordinator, Regulatory Affairs
eachola@amga.org
©2020 All Rights Reserved 4344
Speaker Contact Information
Fred Horton is President with AMGA Consulting. Fred has over 20 years of experience working
inside the healthcare industry. He brings his operational, strategic, and financial acumen to his
clients in order to create effective and market-sensitive solutions to their challenges within their
unique environments. fhorton@amgaconsulting.com
Wayne Hartley is a Vice President with AMGA Consulting. He has worked in the healthcare
industry for 20 years. His operational roles were in large, integrated delivery systems including
Allina Health in Minneapolis, and HealthEast (now Fairview) in St. Paul, MN, where his
responsibilities included physician practice management, clinical service line leadership, and
medical group strategy. whartley@amgaconsulting.com
Kelsi O’Brien is a Director with AMGA Consulting. Kelsi brings over 10 years of health care
experience to the team. Ms. O’Brien received her MHSA from the University of Kansas, School of
Medicine. She also holds a bachelor’s degree in Health Information Management from the
University of Kansas, School of Allied Health.
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