Next year promises interesting changes for the Medicare Physician Fee Schedule — many of which will help medical billers and medical coders adapt to a world that has heavily shifted to telehealth and that is still responding to a pandemic. To prepare for next year, it’s critical to familiarize yourself with what’s coming down the pipeline. Major highlights of the proposal include:
- Addressing potentially mis-valued codes along with other policies that affect payment rate calculations.
- Adding services to the telehealth list, which includes a third temporary category for services added under the public health emergency (PHE), along with other revisions.
- Regulatory actions regarding the scope of practice for non-physician practitioners.
- Clarification of the implementation of Section 2005 of the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, creating a new Medicare Part B benefit for Opioid Treatment Programs.
The CY 2021 Medicare Physician Fee Schedule Proposed Rule was posted on the Federal Register on August 4, 2020.
Concerns
At the same time, there are still concerns being expressed across the industry [1].
Provider groups in particular are concerned that the rule might worsen the financial challenges that physicians are already dealing with during COVID-19 — specifically the lack of telehealth reimbursement and maintaining sustainable revenue for their practices. AMGA President and CEO, Jerry Penso, MD, MBA stresses the importance of certainty during a time when their members are dealing with upheaval across the board.
Another concern is the reduction in the conversion factor from $36.09 to $32.26 — a change that was implemented to offset an increase in the relative value units (RVUs) and associated reimbursement to providers for chronic disease management and primary care services. The result is a 5.5% reduction to physician payment next year, bumping the total cuts to 11% along with other proposals, according to the American Medical Association (AMA). The American Hospital Association believes the cut would potentially impact some specialties more than others, including anesthesiologists, respiratory specialists, radiologists, and critical care and emergency medicine providers.
The rule also addresses telehealth coverage, including the expansion of the Category 1 list of telehealth services with the addition of eight codes, along with the introduction of a Category 3, providing temporary coverage expansions. While most in the industry agree that the steps are positive, providers are reportedly looking for flexibility that’s more permanent in light of telehealth services increasing as a result of the PHE. In terms of access, AMGA has highlighted the fact that many patients don’t have broadband to receive video-telehealth services, stressing the importance of support for audio-only interactions.
How to Prepare Your Billing and Coding Services
Besides familiarity with the changes above and other updates, medical billing and coding leaders will need to keep several points in mind as they wait for finalization of the rule. Keep an eye out for a few key issues [2].
Codes Are Changing
It’s reported that utilization rates of code 99201 were very low, leading to many indications that its absence will be finalized in CY2021. There will also be a shift in the coding framework in which CMS is projected to modify coding and required documentation so it’s either based on time or Medical Decision Making (MDM).
Other code modifications include:
- Adding 99XXX for prolonged services
- Removing history and exam elements in scoring CPT levels
- Removing 99441-99443 audio only CPT codes
- Permanently adding telehealth CPT codes including group psychotherapy 90853 and home visits 99347-99348
Reimbursement Challenges Persist
As mentioned before, in an effort to maintain budget neutrality, increases in Work RVU evaluations and Physician Expense RVUs are taking place and triggering decreases in other areas.
Medical coding and billing leaders should keep a close eye on how this impacts revenue by watching key KPIs.
Telehealth is Shifting
Of course, telehealth is seeing big expansions.
Nine services are becoming permanent, thirteen others will be added until the end of the calendar year of the PHE, and frequency limitations on nursing facility visits will be changed. Additionally, leaders should be prepared for the discontinuation of remote physiological monitoring (RPM) or wearables monitoring.
As we move into 2021, leaders should take a few, key steps including:
- Reviewing the rule in depth to understand how the changes will affect the specific billing and coding environment at their organizations.
- Creating an action plan that will address changes in regulatory compliance, care delivery, coding, and reimbursement.
- Brushing up on time-based and MDM coding principles.
- Staying in touch with MAC for regional updates.
- Downloading and analyzing the 2021 MPFS when available.
As medical billing and medical coding become more complex in 2021, additionally consider working with an outside vendor who is specialized in these changes and who can serve as a resource and support into next year.
References
[1] J. LaPointe, “Top 3 Concerns with the 2021 Medicare Physician Fee Schedule Rule,” RevCycleIntelligence, 13 October 2020. Available: https://revcycleintelligence.com/news/top-3-concerns-with-the-2021-medicare-physician-fee-schedule-rule.
[2] A. W. Pecci, “3 Ways To Prepare For The 2021 Physician Fee Schedule,” HealthLeaders, 11 November 2020. Available: https://www.healthleadersmedia.com/welcome-ad?toURL=/revenue-cycle/3-ways-prepare-2021-physician-fee-schedule.
