This is the second installment in our three-part series covering physician-focused proposals in recent Centers for Medicare & Medicaid Services (CMS) proposed regulations. Next week, we will discuss relevant proposals in the Calendar Year (CY) 2021 Hospital Outpatient Prospective Payment System proposed rule.  

Through its CY 2021 Physician Fee Schedule (PFS) proposed rule, CMS proposes to implement several sweeping changes to the current framework and reimbursement for evaluation and management (E/M) CPT codes. These changes originally were finalized in the CY 2020 PFS final rule.

Key Changes Finalized in the CY 2020 PFS Final Rule

Currently, there are five levels of office/outpatient E/M visits (CPT codes 99201–99205 for new patients and CPT codes 99211–99215 for established patients). These codes historically have included three key components to determine the level selection: (1) history of present illness, (2) physical examination and (3) medical decision making.

In the CY 2020 PFS final rule, CMS finalized a new framework (based on the AMA’s CPT Editorial Panel recommendations) that would:

  • Delete CPT code 99201
  • Change the E/M level selection to be based on:
    • Medical decision making (straightforward, low complexity, moderate complexity or high complexity) or
    • Total time personally spent by the practitioner on the day of the visit (including face-to-face and non-face-to-face time)
  • Create a new add-on code (CPT code 99XXX) for prolonged visits
  • Create a new code (HCPCS code GPC1X) for visit complexity inherent to E/M services
  • Establish new values for CPT codes 99202-99215, 99XXX and GPC1X

Key Changes in the CY 2021 PFS Proposed Rule

CMS proposes to largely maintain the policies finalized in the prior year, with a few revisions and clarifications. Of note, CMS proposes to revise the total pre-, intra- and post-service times for CPT codes 99202-99215 as follows:

As proposed, the final relative value units (RVUs) for the codes would be as follows:

“The change in RVUs, both related to the E/M codes and other proposed changes, would result in a significant shift in reimbursement across specialties within the PFS. Specifically, CMS anticipates that the payment to family medicine practitioners would increase by 13 percent.”

Impact on Family Medicine

The change in RVUs, both related to the E/M codes and other proposed changes, would result in a significant shift in reimbursement across specialties within the PFS. Specifically, CMS anticipates that the payment to family medicine practitioners would increase by 13 percent.

Other “winners” under this proposal include endocrinology (17 percent increase), rheumatology (16 percent increase) and hematology/oncology (14 percent increase). The “loser” specialties include radiology (11 percent decrease), nurse anesthetists (11 percent decrease), chiropractors (10 percent decrease) and surgeons (varying decreases by specialty type).

Conversion Factor Reduction

Due to the expected shift in reimbursement within the PFS, as well as the statutorily required “budget neutrality,” CMS proposes to address the expected increased payments associated with E/M services and other RVU changes by applying a reduced conversion factor of 32.2605. This is a 10.61 percent reduction from the prior year’s conversion factor (36.0896). Thus, while family medicine is expected to experience an overall increase, the upside is somewhat capped by CMS’s proposal to reduce the overall conversion factor.

Outlook

In general, ACOFP supports policy changes that ensure payment for primary care services more closely reflect the value of these services, including E/M. Several specialty societies are seeking congressional intervention to prevent the Conversion Factor reduction from going into effect. ACOFP will work with members of Congress to protect the E/M changes while they consider ways to protect against the expected decreases.

We believe this is a good first step to protect Medicare beneficiary access to critically important primary care services, but there is more work to do. ACOFP will submit a comment letter to CMS in support of these and other proposals and continue to seek opportunities to protect and support family medicine.

Although ACOFP will be submitting comments, we encourage individual physicians to submit their own comments as well. Comments from family medicine physicians can help CMS craft policies that best fit your practice’s needs. Submit your comments to CMS regarding the PFS proposed rule by October 5, 2020.  

Stay tuned for additional updates and advocacy opportunities.

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