Health Law Daily CMS adds permanent telehealth services, focuses on COVID-19 changes with 2021 PFS rule
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Wednesday, December 2, 2020

CMS adds permanent telehealth services, focuses on COVID-19 changes with 2021 PFS rule

By Bryant Storm, J.D.

The 2021 physician fee schedule final rule decreases the conversion factor, widens scope of practice rules, and updates the MDPP.

Wider scope of practice for non-physician practitioners, permanent additions of a number of services to the telehealth list, increased payments for evaluation and management (E/M) services, and other program updates designed to ease burdens related to the COVID-19 public health emergency (PHE) are among the finalized changes in an advance release of CMS’ Physician Fee schedule (PFS) final rule for calendar year (CY) 2021. The final rule sets a conversion factor of $32.41 for 2021, a $3.68 drop from 2020.

Payment update. The PFS is based upon national relative value units (RVUs)—a measure of the relative resources typically used to furnish the service. These values are multiplied by a conversion factor (CF) to convert the RVUs into payment rates. After applying the budget neutrality adjustment required by law, the final CY 2021 PFS conversion factor is $32.41, a decrease of $3.68 from the CY 2020 PFS conversion factor of $36.09. This is a slightly smaller decrease than projected in the August proposal (see CMS expands telehealth, lowers conversion factor with 2021 PFS proposal, August 17, 2020).

QPP. Although CMS intended to begin transitioning to the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) in the 2021 MIPS performance year, due to the PHE for COVID-19, CMS is delaying the proposal until at least the 2022 performance year. In addition, CMS is providing burden relief via extreme and uncontrollable circumstances policy exceptions for 2019, 2020, and 2021. The rule also finalizes the Alternative Payment Model (APM) Performance Pathway (APP), a new reporting framework which will begin in 2021.

Telehealth. Prior to the PHE, 15,000 fee-for-service beneficiaries each week received a Medicare telemedicine service. As a result of additional telehealth coverage and the pressures of the PHE, between mid-March and mid-October 2020, over 24.5 million (out of 63 million total) beneficiaries received a Medicare telemedicine service.

Due to the increased need and utilization, CMS is adding over 60 services to the Medicare telehealth list which Medicare will continue to cover even after the end of the PHE. The added services remain focused on traditionally-covered telehealth care and populations—specifically, care for beneficiaries in rural areas who are in a medical facility (like a nursing home) for certain types of emergency department visits, therapy services, and critical care services. The final rule indicates, for the most part, CMS lacks the statutory authority to authorize broader use of telehealth, for example, to pay for telehealth to beneficiaries outside of rural areas or to allow beneficiaries to receive telehealth in their home. However, CMS says it is gathering data to determine if even more additional services can be added to the 60 which are being permanently included in the coverage list.

E/M. The care needs of Medicare beneficiaries are becoming more complex—more than two-thirds of Medicare beneficiaries having two or more chronic conditions. Accordingly, the final rule includes an increase in payment for E/M office visits to accurately compensate providers for coordinating care for patients, especially those with chronic conditions. The payment update focuses on care for End-Stage Renal Disease (ESRD) Monthly Capitation Payment (MCP) Services, Transitional Care Management (TCM) Services, Maternity Services, Cognitive Impairment Assessment and Care Planning, Initial Preventive Physical Examination (IPPE) and Initial and Subsequent Annual Wellness Visits (AWV), Emergency Department Visits, Therapy Evaluations, and Psychiatric Diagnostic Evaluations and Psychotherapy Services.

Alongside the payment increase are changes designed to simplify coding and documentation for E/M services. The changes, which will go live January 1, 2021 allow providers greater discretion in choosing a "visit level" and are estimated to save to save clinicians a total of 2.3 million hours per year.

Scope of practice. CMS is also expanding scope of practice rules to allow nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs) and certified nurse-midwives (CNMs) to supervise the performance of diagnostic tests in addition to physicians. Additionally, under the new rules, physical and occupational therapists will be able to delegate "maintenance therapy" to a therapy assistant. Also, physical and occupational therapists, speech-language pathologists, and other clinicians who directly bill Medicare can review and verify, rather than re-document, information already entered into a patient’s medical record.

MDPP. The PFS final rule also updates the Medicare Diabetes Prevention Program (MDPP) for calendar year 2021. The final rule revises MDPP program rules for the 1135 waiver event that is the PHE and for any future 1135 waiver event. Among the changes are allowing MDPP suppliers to either deliver MDPP services virtually or suspend in-person MDPP services and resume MDPP services later. The rule also extends the flexibilities finalized in the March 31st COVID-19 IFC to all beneficiaries who were receiving MDPP services as of March 31, 2020, instead of March 1, 2020.

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