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The Centers for Medicare and Medicaid Services (CMS) published its proposed 2021 Medicare Physician Fee Schedule on August 3. Notable in the proposal, CMS is moving forward with the overhaul of the Evaluation and Management (E/M) office visit coding, documentation and payment system, as well as the previously promised expanding of the list of telehealth services covered by Medicare. 

Certain services such as home visits, emergency department visits and nursing facility discharges would be added to the proposed rule for the remainder of the calendar year, however these services will not be permanently added. However, CMS officials state that a more sweeping extension of pandemic telehealth policies, including enabling patients to get telehealth visits at home, would require Congressional action.

With changes laid out by the CPT Editorial Panel for office/outpatient E/M visits, the agency also plans to align its evaluation and management (E/M) visit coding and documentation policies, beginning Jan. 1, 2021.

"We are proposing a refinement to clarify the times for which prolonged office/outpatient E/M visits can be reported, and are proposing to revise the times used for rate setting for this code set," the agency said in a fact sheet.

The American Medical Association (AMA) issued a statement supporting the E/M modifications that implement significant increases to the payment for office visits. However, these office visit payment increases, as well as a number of other new proposed payment increases, are required by statute to be offset by payment reductions to other services. This results in an "unsustainable" reduction of nearly 11% to the Medicare conversion factor, AMA said.

"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. For this reason, the AMA strongly urges Congress to waive Medicare’s budget neutrality requirement for the office visit and other payment increases. Physicians are already experiencing substantial economic hardships due to COVID-19, so these pay cuts could not come at a worse time," said AMA President Susan R. Bailey, M.D. in a statement

“Overall, there is an unsustainable 11% reduction in the Medicare conversion factor, the California Medical Association added. “CMA is extremely concerned that CMS did not adopt the entirety of the American Medical Association (AMA) Specialty Society RVS Update Committee (RUC) recommendations for the E/M overhaul that includes the E/M office visit payment increases in the global surgery payment bundles.” 

Additional proposals in the fee schedule include: 

Telehealth: Making several temporary codes permanent, including the prolonged office or outpatient E/M visit code and certain home visit services. The proposal would also maintain certain services, including emergency department visits in the telehealth waiver until at least the end of the year. 

Appropriate Use Criteria: Implementing the Appropriate Use Criteria (AUC) which requires physicians to consult the AUC prior to ordering advanced imaging services. 

MIPS Quality Payment Program: CMS will continue to allow physicians to opt out of Medicare Quality Payment Program (QPP) Merit-Based Incentive Payment System (MIPS) for the 2020 performance year without penalties because of the pandemic. CMS is also proposing a new MIPS pathway for participants in alternative payment models (APM) called the APM Performance Pathway (APP). The performance threshold would increase from 45 points in 2020 to 50 points in 2021, instead of the 60 points as had been previously proposed. CMS also proposes to reduce the weight of the Quality Category score from 45 to 40% of the final score and increase the weight of the Cost Category from 15 to 20%. CMS is adding telehealth services to the existing cost measures and applying performance period benchmarks rather than historical benchmarks for quality measures, as the 2020 data may not be accurate due to the pandemic. 

Accountable Care Organizations (ACOs): CMS is reducing many of the reporting requirements, including allowing ACOs to only report one set of quality metrics for both MIPS and the Medicare Shared Savings Program (MSSP)and reducing the quality measure set from 23 to 6 measures. However, CMS has raised the quality performance standard for ACOs to receive shared savings. For the 2020 performance year, ACOs will continue to be allowed to opt out of reporting because of the COVID-19 pandemic and will waive the patient surveys but provide full credit.

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