Orthopedic Coding Alert

… but there’s good news about the covered telehealth list.

If you haven’t had enough upheaval in 2020, Medicare is closing out this most unusual of years with a flurry of major changes to how your practice will perform services, code, and get paid in 2021.

In a nutshell: So far this autumn, Medicare has published a controversial proposed rule, and the White House has made a decision about expanding telehealth into next year. That’s in addition to the changes regarding office/outpatient evaluation and management (E/M) coding that you’ve had to digest in preparation for 2021.

Read on for more information on all the splashy Medicare payment news you need to know.

Final Rule Proposal Cuts 10 Percent Off CF

The Centers for Medicare & Medicaid Services (CMS) recently issued its Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) proposed rule. Unfortunately, CMS has proposed to cut the conversion factor (CF) by 10.61 percent. Other newsworthy items of note include COVID-19-inspired policies related to telehealth and virtual care options and the highly anticipated evaluation and management (E/M) changes.

In one of the more surprising CY 2021 proposals, CMS aims to cut the conversion factor (CF) by 10.61 percent. According to the proposed rule, Section 101(a) of MACRA changed the way the CF is calculated; plus, the office/outpatient E/M payment rate changes influenced the agency’s decision to reduce the CF.

“With the budget neutrality adjustment to account for changes in [relative value units] RVUs, as required by law, the proposed CY 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09,” CMS indicates.

As expected, industry organizations are rattled by the major CF dip, especially in the midst of COVID-19 spikes. Backing up cash-strapped providers, the American Medical Association (AMA) urged Congress to get involved before the final rule is released later this year.

“The AMA appreciates that CMS will implement significant increases to the payment for office visits, based on recommendations on resource costs from the AMA/Specialty Society RVS Update Committee (RUC),” acknowledged AMA President Susan R. Bailey, MD in a statement. “Unfortunately, these office visit payment increases, and a multitude of other new CMS proposed payment increases, are required by statute to be offset by payment reductions to other services, through an unsustainable reduction of nearly 11 percent to the Medicare conversion factor.”

Bailey added “For this reason, the AMA strongly urges Congress to waive Medicare’s budget neutrality requirement for the office visit and other payment increases. Physicians are already experiencing substantial economic hardships due to COVID-19, so these pay cuts could not come at a worse time.”

One more thing: “CMS also indicated that it will waive the 60-day publication requirement for the final rule and replace it with a 30-day notification. This means that the final rule will be effective January 1, 2021, even though it may not be published until December 1, 2020, instead of the typical November 1 target publication date,” according to www.policymed.com.

Expect a Telehealth Services Expansion

On a brighter note, it looks as if telehealth will be even more widely accepted moving forward. In mid-October, the Centers for Medicare & Medicaid Services (CMS) expanded the list of telehealth services that Medicare will pay for during the coronavirus disease COVID-19 public health emergency (PHE).

“CMS is taking action to increase telehealth adoption across the country,” said CMS Administrator Seema Verma.

Nuts and bolts: CMS is adding 11 new services to the Medicare telehealth services list that it published in May to cope with the COVID PHE. “Medicare will begin paying eligible practitioners who furnish these newly added telehealth services effective immediately, and for the duration of the PHE,” according to a CMS release.

Check out the list of new services covered by telehealth at: https://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/Telehealth-Codes.

Get Ready for 2021 E/M Changes

In the CY 2020 final rule, CMS solidified long-awaited changes to office/outpatient evaluation and management (E/M) policies and payment rates. The CY 2021 proposed rule explains the final steps and the rollout.

Policies: “As finalized in the CY 2020 PFS final rule, in 2021 we will be largely aligning our E/M visit coding and documentation policies with changes laid out by the CPT^® Editorial Panel for office/outpatient E/M visits, beginning January 1, 2021,” says CMS in a fact sheet on the rule. “We are proposing a refinement to clarify the times for which prolonged office/outpatient E/M visits can be reported and are proposing to revise the times used for rate setting for this code set,” the agency adds.

Direct Supervision Updates Extended

CMS adopted an interim final policy for the duration of the PHE related to the COVID-19 pandemic that revised the definition of “direct supervision.” The new definition included virtual presence of the supervising physician or practitioner using interactive audio/video real-time communications (85 FR 19245). The update was made because CMS realized that in some cases, the physical proximity of the provider might increase infection exposure risk to the patient and/or provider.

Update: The CY 2021 MPFS proposed rule allows direct supervision to be provided using real-time, interactive audio/ video technology through December 31, 2021 (excluding telephone calls that do not also include video).

The proposed rule also includes interim policy changes for supervision services of teaching physicians: Teaching physicians may use audio/video real-time communications technology to interact with a resident through virtual means, to meet the requirement of being present for the key portion of the service.

An excerpt of the proposed rule reads: “While flexibility to provide direct supervision through audio/video real-time communications technology was adopted to be responsive to critical needs during the PHE to ensure beneficiary access to care, reduce exposure risk and to increase the capacity of practitioners and physicians to respond to COVID-19, we are concerned that direct supervision through virtual presence may not be sufficient to support PFS payment on a permanent basis, beyond the PHE, due to issues of patient safety. In complex, high-risk, surgical, interventional, or endoscopic procedures, or anesthesia procedures, a patient’s clinical status can quickly change. To permit payment under the PFS for these teaching physician services, we believe the services must be furnished with a certain level of personal oversight and involvement of the teaching physician who has the experience and judgment that is necessary for rapid on-site decision-making during these procedures.”

Editor’s note: You can review the MPFS proposals at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2020-17127.pdf.