AAFP Breaks Down 2021 MPFS Final Rule for Members

E/M Coding and Documentation Changes Remain, but Concerns Linger

(Editor's Note: Legislation that Congress approved on Monday, Dec. 21, delays implementation of the primary care add-on code, G221, which was scheduled to take effect on Jan. 1. All other anticipated payment, coding and documentation changes for 2021 are expected to go into effect as planned. AAFP staff will be updating resources throughout the Academy website to reflect this change.)

December 10, 2020, 3:55 pm News Staff -- The Academy’s summary for members of CMS’ 2021 Medicare physician fee schedule and Quality Payment Program final rule confirms that payment for most office-based evaluation and management services will increase as planned on Jan. 1, and it also highlights other key changes — including some to which the AAFP objects.

The final rule sets the stage for a 13% increase in total allowed charges for family medicine — the largest increase in primary care reimbursement in decades. This includes an add-on code acknowledging the unique complexity of primary care E/M visits. That code was referred to in the proposed rule, and the Academy’s comprehensive comments to CMS, as GPC1X but will be implemented as G2211. (See Editor's Note above.)

By statute, the final rule is required to be budget-neutral — meaning CMS can’t improve payment in any area of the fee schedule without cutting it somewhere else. The E/M changes therefore are offset by a 10% reduction of the 2021 conversion factor (the number multiplied by the relative value of each code in the fee schedule to determine the Medicare payment rate) compared with 2020’s factor. This has led other medical specialties to lobby for congressional intervention that could impede primary care’s payment boost.

The Academy, meanwhile, is continuing its push for a budget-neutrality waiver that would provide equitable relief for all medical specialties next year. (It also has called on AAFP members to add their voices to the effort.)

Story Highlights

Toplining the AAFP’s summary of the MPFS final rule:

Medicare Physician Payment for Family Physicians

The 2021 conversion factor is $32.4085, slightly higher than was listed in the proposed rule but $3.681 lower than the 2020 conversion factor.

Office and Outpatient E/M Improvements

Following AAFP recommendations, CMS will implement previously finalized changes to simplify billing and coding requirements for office-based E/M services. Additionally, and with the Academy’s support, CMS is moving forward with the G2211 code, acknowledging the inherent complexity of primary care office visits. (See Editor's Note above.)

Despite opposition from the AAFP, however, CMS finalized a proposal to allow the prolonged services code (G2212) to be billed only after the maximum total time of a level 5 E/M visit is exceeded by at least 15 minutes. Beyond that, and also in line with AAFP guidance, CMS finalized proposals to increase the values of certain codes commensurate with the increases to outpatient E/M services, including

maternity services,
transitional care management services,
the initial preventive physical examination (i.e., the “Welcome to Medicare” visit) and initial and subsequent annual wellness visits,
ER visits, and
some behavioral health services.

Immunization Administration

CMS reversed a proposal to increase payment rates for immunization administration, which the AAFP strongly supported, and is instead maintaining the 2019 and 2020 payment rates.

Personal Protective Equipment Payment

“Despite encouragement from the AAFP and the broader medical community, CMS declined to implement a new CPT code to account for the increased cost of personal protective equipment amid the COVID-19 pandemic,” the summary says. “The agency finalized this through an interim final rule, on which the AAFP will be commenting.”

Telehealth

In a move the Academy endorsed, CMS will add the following codes permanently to the Medicare Telehealth Services List:

visit complexity inherent to certain office/outpatient E/M services (HCPCS G2211);
prolonged services (HCPCS G2212);
cognitive assessment and care planning services (CPT 99483);
psychological and neuropsychological testing (CPT 96121);
home visits, established patient (CPT 99347-99348);
domiciliary, rest home or custodial care services, established patients (CPT 99334-99335); and
group psychotherapy (CPT 90853).

CMS indicates that when the COVID-19 public health emergency ends, the agency will again require that remote patient monitoring services be furnished only to established patients. That and other PHE-related details are further outlined in the Academy’s summary.

Audio-only Telehealth

The fee schedule contains a new virtual check-in code for audio-only telehealth for interim use next year. The AAFP had instead advocated for the continuation of payment for audio-only E/M services after the end of the PHE and will send CMS further comment on this inadequate interim final rule.

Quality Payment Program

Despite strong support from the AAFP, CMS reversed its proposal to reduce the Merit-based Incentive Payment System performance threshold to 50 points due to the PHE and is instead increasing the performance threshold to 60 points. Additionally,

the exceptional performance threshold will remain at 85 points;
the quality performance category weight is reduced to 40%, while the cost performance category will be weighted at 20% — adjustments the AAFP opposed; and
the implementation of MIPS Value Pathways is delayed until performance year 2022.

Medicare Shared Savings Program

Medicare Shared Savings Program accountable care organizations will be required in 2021 to report quality data via the APM Performance Pathway. ACOs will meet the quality performance standard for shared savings if the score is equal to or higher than the 30th percentile. In performance year 2023, this level will increase to the 40th percentile.

CMS is delaying the update to its extreme and uncontrollable circumstances policy until 2023.

Federally Qualified Health Centers

CMS is finalizing the proposal to rebase and revise the federally qualified health center market basket to reflect a 2017 base year. This will update the data that is used for payment to reflect more recent cost data.

Given these and other regulatory changes, the Academy has developed resources to help its members prepare for 2021. The 2021 Office Visit E/M Vignettes Module, the most recent addition to the AAFP’s diverse collection of information, resources and tools on E/M coding, walks users through four patient scenarios that illustrate how to apply the new guidelines to select the appropriate level of office visit using medical decision-making and time. It tracks closely with an article in the November/December issue of FPM that offers a detailed breakdown of how the new coding guidance works.