Evaluation & Management Coding Changes in the 2021 Physician Fee Schedule Final Rule

On Dec. 1, the Centers for Medicare & Medicaid Services (CMS) released the calendar year (CY) 2021 Medicare Physician Fee Schedule (PFS). One of the key takeaways is the implementation of the American Medical Association (AMA) Relative Value Update Committee’s (RUC) recommended increases in the values of outpatient evaluation and management (E/M) services. This finalized policy marks the most significant update to the E/M Current Procedural Terminology (CPT) codes in approximately 30 years. The agency believes these key changes will reduce the burden on physicians who are required to follow the current coding point system and reward providers for time spent evaluating and managing patients.

CY 2021 Conversion Factor
Although the payment increase for office and outpatient face-to-face E/M visits will go into effect on Jan. 1, 2021, as required by law to account for changes in the relative value updates, the final CY 2021 physician fee schedule conversion factor will be $32.41, a $3.68 decrease from $36.09 in CY 2020.

Telehealth & Other Services/Communications Technology
The CMS finalized on a permanent basis some additional telehealth provisions included in the CY 2021 PFS as a result of the COVID-19 public health emergency (PHE), as well as other provisional services through the end of the PHE. Unfortunately, in the absence of the COVID-19 PHE declaration, the CMS will not continue to recognize audio-only codes that were added in response to the COVID-19 PHE. However, based on comments received, it is establishing a new Healthcare Common Procedure Coding System (HCPCS) code, G2252, describing 11-20 minutes of extended medical discussion. Additionally, the CMS also specifies that the telehealth restrictions will not apply when a beneficiary and practitioner are in the same location, even if conducted via audio/video technology.

The final rule also kept the provision that licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists and speech-language pathologists can deliver brief online assessment and management services, as well as virtual check-ins and remote evaluation services. The final rule includes two new HCPCS codes, G2010 and G2012, to support billing for these telehealth services.

Direct Supervision by Interactive Telecommunications
In the CY 2021 PFS rule, the CMS will continue to cover services that meet incident-to guidelines via telehealth under direct supervision of the billing practitioner. The agency will allow direct supervision to be provided using real-time, interactive audio and video technology through the end of the calendar year in which the PHE ends or Dec. 31, 2021, whichever is later. This provision will allow beneficiaries to receive care by allowing direct supervision through virtual presence while adhering to patient safety and clinical appropriateness. The CMS also indicated it will continue to monitor increased utilization, fraud, waste and abuse and it encourages continued education on incident-to guidelines for providers.

Office/Outpatient E/M Payments & Guidelines
Beginning Jan. 1, 2021, the CMS will align the E/M visit coding and documentation policies with changes created by the AMA CPT Editorial Panel for office/outpatient E/M visits. This includes finalizing key revisions to provider times used for rate-setting for the office/outpatient E/M visit code set.

Under the new CPT outline of office/outpatient E/M services adopted by the CMS, providers will no longer have to use history and examination to select the level of an E/M visit. Rather, documentation guidelines for office services levels 2 through 5 will be based on either the redefined medical decision-making or total time spent by the provider. Recording the history and exam are still necessary components and should be included for the medical record when reasonable, necessary and clinically appropriate, but will not be used to determine the visit level code submitted for reimbursement. These changes to the E/M codes were designed to make documenting office visits simpler and more flexible by reducing documentation burden through a more streamlined reporting process for E/M levels, improve payment accuracy and better reflect the current practice of medicine.

The CMS also finalized separate payments for two new add-on HCPCS codes, G2211 (which replaces temporary HCPCS add-on code GPC1X) and G2212 (replaces the temporary CPT code 99XXX). G2211 was created to capture the work for office/outpatient E/M visits not accounted for in the valuation of the primary office/outpatient E/M visit code. G2212 is for prolonged services and can only be reported when time is used to select the visit level.

Summary of Codes and Work RVUs Finalized for CY 2021

The ACR has applauded the CMS for making these long-awaited updates to cognitive care reimbursement in its CY 2021 Medicare PFS final rule. These much-needed Medicare rate increases for E/M services provided by rheumatologists and other cognitive care specialties to Medicare beneficiaries are crucial to the future of the rheumatology specialty and the continued delivery of high-quality rheumatology care.  To ensure these long overdue E/M rate increases do not lead to rate cuts to other medical specialties including physical and occupational therapists, the ACR is also leading advocacy efforts in support of H.R. 8505, legislation that would provide for a one-year waiver of budget neutrality adjustments. In November, the ACR led more than 60 groups in sending a letter to Congressional leaders urging them to support the bipartisan legislation, which was introduced by Reps. Michael Burgess (R-TX) and Bobby Rush (D-IL).

For additional questions on the PFS final rule or ACR advocacy work, contact Amanda Grimm Wiegrefe at [email protected]. For questions on the new E/M guidelines or RVUs, contact Antanya Chung at [email protected].