The Centers for Medicare & Medicaid Services (CMS) August 3 released the calendar year (CY) 2021 Medicare Physician Fee Schedule (MPFS) proposed rule. This rule, which CMS issues annually, updates payment policies, reimbursement rates, and quality provisions for services furnished under the MPFS on or after January 1, 2021.
Increase in E/M payments, significant cuts to surgery reimbursement
In the rule, CMS describes previously finalized changes to its coding and billing policies for office/outpatient evaluation and management (E/M) visits. Beginning in CY 2021, CMS will eliminate history and physical exam as elements for E/M code selection and instead allow physicians to choose the E/M visit level based on the extent of their medical decision making or on time spent on the day of the encounter. CMS also will increase the value of most office/outpatient E/Ms, but these increases will not apply to global surgery codes.
To offset the increase in payment for E/Ms, CMS must cut reimbursement for other services, and therefore proposes to decrease the conversion factor from $36.09 to $32.26—a significant change of approximately 10.6 percent. CMS estimates a 7 percent reduction in total allowed charges for general surgery services relative to its proposals for CY 2021. The American College of Surgeons (ACS) will continue its advocacy efforts to oppose CMS’ failure to increase payment rates for the E/M portion of 10- and 90-day global surgical packages.
Additionally, the MPFS includes proposed changes to coverage for telehealth services after the COVID-19 public health emergency (PHE) ends. CMS proposes to add certain services to the Medicare telehealth list permanently, along with a series of services that may be added to the telehealth list temporarily and remain payable only through the calendar year in which the PHE expires. The agency also seeks stakeholder feedback on the development of permanent coding and payment for audio-only telephone E/M visits.
QPP and MIPS updates
CMS also released proposed updates for the calendar year (CY) 2021 Quality Payment Program (QPP) as part of the proposed rule. The proposed rule includes an increase of the overall Merit-based Incentive Payment System (MIPS) performance threshold, adjustments to the Cost and Quality performance category weights, and updates to Quality measure benchmarking policies to account for skewed quality reporting during the pandemic.
In CY 2021, surgeons participating in MIPS would need to meet CMS’ proposed 50-point performance threshold across the four categories to avoid a penalty in 2023. Within the proposed rule, CMS also reiterates that clinicians whose MIPS reporting has been disrupted as a result of the COVID-19 pandemic will be eligible to apply for reweighting of the MIPS performance categories through the MIPS extreme and uncontrollable circumstances exception for the 2020 performance year and extends this application to Alternative Payment Model (APM) entities, which were previously unable to apply. Additionally because of the pandemic, CMS delayed the implementation of the MIPS Value Pathways (MVP) framework until at least the 2022 performance year. The MVP framework was previously finalized as a new MIPS reporting pathway that would move away from reporting the siloed activities and measures in the current system to a framework that aims to align measures and activities across the four MIPS performance categories based on conditions and specialties.
In addition to proposed updates to the MIPS, CMS requests feedback on a new participation framework, the APM Performance Pathway (APP), that would be available to clinicians who participate in MIPS APMs.
Finally, to align with the newly proposed APP, CMS proposes to sunset the CMS Web Interface reporting option beginning with the 2021 performance year. If finalized, those who reported MIPS quality data using the CMS Web Interface in previous years will have to choose a new reporting mechanism such as the APP, direct submission via your electronic health record, Qualified Registry, Qualified Clinical Data Registry, or claims beginning in 2021.
The ACS is evaluating these and other proposals to determine the impact on surgery and will submit comments to CMS. The proposed rule is available for public review, along with a fact sheet on its payment provisions and a fact sheet on its QPP provisions. Contact firstname.lastname@example.org with questions.