Health Law Daily CMS expands telehealth, lowers conversion factor with 2021 PFS proposal
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Wednesday, August 5, 2020

CMS expands telehealth, lowers conversion factor with 2021 PFS proposal

By Bryant Storm, J.D.

The 2021 physician fee schedule proposed rule focuses on the reduction of practitioner burdens as a means to address COVID-19.

Expanded scope of practice rules and an increase in the number of telehealth services are among the changes proposed in an advance release of CMS’ Physician Fee schedule (PFS) proposed rule for calendar year (CY) 2021. CMS is also proposing a CY 2021 conversion factor of $32.26—a significant decrease from the CY 2020 PFS conversion factor of $36.09. The proposed rule, which is slated to publish in the Federal Register on August 17, 2020, includes proposed program changes designed to address health care challenges amidst the COVID-19 pandemic. CMS is accepting comments on the proposals through October 5, 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 implementing the budget neutrality adjustment to account for changes in relative value units (RVUs), CMS is proposing a CY 2021 PFS conversion factor of $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09.

MIPS. Due to the impact of COVID-19 on providers, CMS is proposing to continue to grant hardship exemptions for the Merit-based Incentive Payment System (MIPS) program on a case-by-case basis. Eligible clinicians who meet the criteria for a significant hardship or other type of exception may submit an application requesting a zero percent weighting for all four performance categories. A provider awarded an exemption will not receive a bonus or a penalty based upon their 2020 MIPS performance.

Telehealth. CMS is proposing to add a number of services to the Medicare telehealth list on a Category 1 basis. Category 1 services include services that are similar to professional consultations, office visits, and office psychiatry services—the kinds of services that are already on Medicare telehealth services list. Some of the proposed new services include: prolonged services, group psychotherapy, care planning for patients with cognitive impairment, and home visits.

CMS is also proposing a third temporary category of criteria for adding services to the list of Medicare telehealth services. Under the proposal, these Category 3 services would be added to the Medicare telehealth list during the public health emergency (PHE) for the COVID-19 pandemic that will remain on the list through the calendar year in which the PHE ends. Some Category 3 services include: emergency department visits, psychological and neurological testing, and home visits for established patients.

In response to concerns that the limitation is burdensome and limits access to care, CMS is also proposing to shorten the frequency limitations for telehealth nursing facility visits from 30 days to 3 days.

The proposal also clarifies CMS’ positon that the telehealth rules do not apply when individual physician or practitioner furnishing the service is in the same location as the beneficiary, even if audio/video technology assists the furnishing of the service.

COVID-19. Although CMS is not planning to continue separate payment for audio-only telephone evaluation and management services which were established in response the COVID-19 pandemic, the agency is seeking input on whether CMS should develop coding and payment for a service similar to the virtual check-in but for a longer unit of time and at a higher value.

In response to the COVID-19 pandemic, CMS is proposing to allow direct supervision to be provided using real-time, interactive audio and video technology (excluding telephone that does not also include video) through December 31, 2021. CMS is seeking input on "guardrails" which might be necessary for this policy and whether the policy should be considered to extend beyond December 31, 2021.

RPM codes. The proposed rule clarifies CMS’ payment policies related to the seven remote physiologic monitoring (RPM) codes. For example, the rule explains that, in order for RPM services to be furnished, an established patient-physician relationship must exist. Additionally, CMS RPM services to be evaluation and management (E/M) services and only physicians and NPPs who are eligible to furnish E/M services may bill RPM services.

E/M. CMS is continuing with its proposal to align 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. CMS is proposing a refinement to clarify the times for which prolonged office/outpatient E/M visits can be reported, and is proposing to revise the times used for ratesetting for the code set.

Scope of practice. CMS is proposing to make permanent an earlier COVID-19 proposal which would 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. If finalized, effective January 1, 2021, NPs, CNSs, PAs and CNMs would be allowed under the Medicare Part B program to supervise the performance of diagnostic tests on a permanent basis.

CMS is also proposing to make permanent a COVID-19 policy that grants a physical therapist (PT) and occupational therapist (OT) the discretion to delegate the performance of maintenance therapy services, as clinically appropriate, to a therapy assistant—including a physical therapist assistant (PTA) or an occupational therapy assistant (OTA).

Additionally, CMS is clarifying In the CY 2021 PFS proposed rule that physicians and NPPs, including therapists can review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the PFS.

Opioids. CMS is proposing to expand the Medicare Part B benefit for opioid use disorder (OUD) treatment services by creating two new add-on codes, one add-on code for nasal naloxone and another add-on code for auto-injector naloxone. CMS is also proposing to provide enrollment flexibilities requested by some OTPs that would allow submission on institutional claims and to provide clarification regarding what activities qualify for billing the periodic assessment add-on code.

SUPPORT Act. CMS is proposing to implement section 2003 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act by requiring that prescribing of a Schedule II, III, IV, or V controlled substance under Medicare Part D be done electronically in accordance with an electronic prescription drug program.

RHCs and FQHCs. CMS is proposing to add two Principal Care Management (PCM) service codes for Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs). CMS is also proposing to update the FQHC market basket. The proposed CY 2021 FQHC payment update is 1.9 percent.

MSSP. CMS is proposing to make changes to the quality performance standards and quality reporting requirements for the Medicare Shared Savings Program (Shared Savings Program) for performance years beginning on January 1, 2021. CMS is also putting out a call for comments on an alternative scoring methodology approach under the extreme and uncontrollable circumstances for performance year 2020.

NCDs. CMS is asking stakeholders to provide feedback on the removal of nine outdated National Coverage Determinations (NCDs).

MDPP. CMS is proposing to revise certain Medicare Diabetes Prevention Program Expanded Model (MDPP) policies during the remainder of the COVID-19 Public Health Emergency (PHE) and for any future applicable 1135 waiver event. Some of the proposals include: (1) allowing MDPP suppliers to either deliver MDPP services virtually or suspend in-person services and resume services at a later date; (2) permitting certain MDPP beneficiaries to obtain the set of MDPP services more than once per lifetime; and (3) amending the definition of "engagement incentive period" to further qualify when the period ends in the case of the COVID-19 PHE or an applicable 1135 waiver event. Additionally, CMS is proposing that the limit placed on the number of virtual make-up sessions 79 would not apply during the remainder of the COVID-19 PHE.

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