AAFP to CMS: Lock In E/M Increase, Acknowledge Pandemic
Academy Advises on Payment Formulation in Medicare Physician Fee Schedule
October 8, 2020, 4:03 pm News Staff -- In detailed comments sent Sept. 28 to CMS, the AAFP reiterated the vital importance of CMS implementing its planned 2021 increase to office visit evaluation and management codes for family physicians as scheduled on Jan. 1.
These primary care payment increases were finalized last year but have taken on new weight in the wake of the COVID-19 pandemic, which has hit independent family physician practices especially hard.
“The AAFP supports CMS’ plans to adopt the changes made to the office/outpatient E/M visit codes by the Current Procedural Terminology Editorial Panel and to revalue the codes consistent with the recommendations of the Relative Value Scale Update Committee,” the Academy said in its formal response to the 2021 Medicare physician fee schedule proposed rule, as published in the Aug. 17 Federal Register. “These actions will support the continuous, comprehensive, coordinated and first-contact care that family physicians and other primary care physicians provide to Medicare beneficiaries daily.”
The letter was sent to CMS Administrator Seema Verma, M.P.H. It was signed by Board Chair John Cullen, M.D., of Valdez, Alaska.
The Academy’s correspondence echoed initial impressions about the proposed rule conveyed to members in August, while also offering insights about the revised payment protocols and pushing back against a handful of elements that could negatively affect family physicians.
Story Highlights
New Add-on Code
The Academy welcomed the agency’s plan to implement the new add-on code GPC1X, which acknowledges the unique complexity of primary care E/M visits, and the importance of ongoing care coordination.
“We support CMS’ proposal to value code GPC1X at 100% of the work and time values for code 90785, which would yield a proposed work relative value unit of 0.33 and a physician time of 11 minutes,” the letter said.
The Academy made it clear that this add-on code is essential to appropriately valuing and paying for primary care visits, but recommended that CMS revise its utilization estimates for the code to avoid negatively affecting the 2021 conversion factor.
Effect of Budget Neutrality
In the proposed rule, CMS cited a law that requires Medicare spending to be budget-neutral, or remain steady from year to year. The agency indicated that this mandate is the cause of a significant reduction to the 2021 conversion factor of $32.26, down $3.83 from 2020 — a drop of more than 10%.
“The AAFP recognizes that the significant reduction in the conversion factor is partially due to the 2021 changes to office/outpatient E/M services, which we wholeheartedly support and believe should go into effect as planned,” the letter said, noting that family physicians have experienced months of spiraling revenue losses because of the pandemic.
“However, the AAFP is concerned that the significant reduction to the conversion factor will partly negate the positive impact of these changes and instead further jeopardize the stability of physician practices and patients’ access to care.”
Pandemic-related Practice Expenses
The Academy has been participating in extensive discussions with the CPT Editorial Panel regarding the increased operating costs that practices are facing because of COVID-19.
Given that, the Academy wrote, “we were disappointed that CMS made no mention of the impact that the current public health emergency is having on the practice expenses of physician practices nor made any proposals to account for those ongoing expenses in the 2021 Medicare physician fee schedule.”
“As a part of the PHE, practices have incurred significant costs of maintaining safe offices, particularly in implementing specific infection control measures related to screening patients, purchasing personal protective equipment and implementing office redesign measures to ensure social distancing. Grants and loans were initially provided to physicians to assist with revenue loss during the initial months of the pandemic and to partially address immediate costs of re-opening. However, new funding and payment is needed to assist physicians and qualified health professionals for ongoing costs during the PHE.”
Noting that the CPT Editorial Panel, with input from the AAFP, recently approved the new CPT code 99072 for such pandemic-related expenses, the letter urged CMS “to consider implementation of relative values and payment (outside of budget neutrality) for CPT code 99072 as part of the 2021 Medicare physician fee schedule to address the practice expense impact of the PHE.”
Audio-only telehealth
COVID-19 has made audio-only E/M critical for reaching patients behind technological barriers. Yet the fee schedule repeats CMS’ assertion that it lacks the authority to change the definition of “interactive telecommunications system” — a stance the Academy challenged in its letter.
“The AAFP requests that CMS make an interim final rule with comment to amend the definition of ‘telecommunications system’ … to allow for audio-only services.”
The Academy also supported other methods to improve coverage and payment of audio-only telehealth visits for Medicare beneficiaries after the end of the public health emergency.
“Absent legislative action to amend geographic and originating site restrictions, the AAFP supports the development of coding and payment mechanism, similar to virtual check-ins but with significantly higher value and longer unit of time. CMS should work through the CPT and RUC processes to develop and value a new code to allow all beneficiaries, regardless of geography or location, to access audio-only visits.”
Immunization Administration
The Academy praised the proposed increase to the base payment rate for immunizations in light of the COVID-19 pandemic, while raising concern about a proposal to reduce payments for immunization add-on codes, which are billed when multiple immunizations are administered during the same visit.
“The AAFP appreciates and supports the proposed revaluation of the immunization administration base codes (90460, 90471, 90473) through a crosswalk to code 36000 (and) requests that CMS reconsiders its proposal to value the add-on immunization administration codes (90461, 90472, 90474) at half the valuation of the base codes,” the letter said.
New Merit-based Incentive Payment System Pathway
“We believe CMS should automatically apply the extreme and uncontrollable circumstances exception for the 2020 performance period,” the Academy wrote. In previous rules, CMS indicated that events such as a public health emergency could trigger the automatic extreme and uncontrollable circumstances policy, but the 2021 fee schedule did not propose to automatically apply it; the 2020 Quality Payment Program Exception Applications Fact Sheet fails to identify any qualifying event for the 2020 performance period.
“The AAFP believes that a global pandemic and twice-declared national public health emergency should qualify for such an exemption. Without the automatic application of the policy, practices that were severely impacted but failed to submit an application would receive the maximum negative payment adjustment. This could be a significant, if not fatal, financial hit to many practices.
“We implore CMS to provide automatic relief to practices. We ask that CMS make this determination and announcement as soon as possible, since practices will soon be facing increased stressors as the flu season begins.”
The Academy also objected to the proposed rule’s termination of the existing Alternative Payment Model Scoring Standard, which CMS proposes to replace with a Merit-based Incentive Payment System “APM Performance Pathway.” Though the AAFP supports the new APM Performance Pathway reporting option, the letter urged CMS to also maintain the APM Scoring Standard for non-accountable care organization APMs.
“Should a non-ACO APM entity participate in MIPS, the administrative burden would be double,” the letter said. “A practice participating in the Primary Cares First initiative is required to report three measures. However, if they were to participate in traditional MIPS, they would need to identify three additional measures to satisfy the quality performance category requirements.
“Additionally, they would be held accountable for cost in both the PCF program and in MIPS should CMS eliminate the APM Scoring Standard. Practices currently participating in the Comprehensive Primary Care Plus program would also be subject to the increased quality reporting and would be held doubly accountable for cost. The increased burden these entities would face far outweighs the benefits they receive by participating in an APM.”
“The AAFP asks CMS to continue the APM Scoring Standard for non-ACO APM entities.”