CMS Issues Proposed Physician Fee Schedule and Quality Payment Proposed Rules; Changes to Telehealth Services Included

The Centers for Medicare & Medicaid Services (CMS) released its Proposed Rule Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 202.

Included in the fee schedule were a number of telehealth provisions that either extended current waivers under the public health emergency or added new services. Of note, CMS is proposing to revise its long-standing policy on frequency of subsequent nursing facility visits via telehealth. They say:

“In response to stakeholders who have stated that the once every 30-day frequency limitation for subsequent nursing facility (NF) visits furnished via Medicare telehealth provides unnecessary burden and limits access to care for Medicare beneficiaries in this setting, we are proposing to revise the frequency limitation from one visit every 30 days to one visit every 3 days. We are also seeking comment on whether it would enhance patient access to care if we were to remove frequency limitations altogether, and how best to ensure that patients would continue to receive necessary in-person care.”

Here are some other highlights of the rule:

Telehealth

• Adding new services to telehealth (Category 1) including: Prolonged Services, Care Planning for Patients with Cognitive Impairment, Dom, Rest Home or Custodial Services (99334-99335, 99347), Home Visits.
  • New Category 3 services: Domiciliary, Rest Home, or Custodial Care services, Established patients (99336-99337, 99349), Home Visits, Nursing Facility Discharge Day Management (99315-99316).
• Telehealth services rules do not apply when the beneficiary and the practitioner are in the same location even if audio/video technology assists in furnishing a service.
• In the March 31 COVID-19 IFC, CMS established separate payment for audio-only telephone evaluation and management services. CMS is not proposing to continue to recognize these codes for payment under the PFS in the absence of the PHE for the COVID-19 pandemic. The need for audio-only interactions could remain as beneficiaries continue to try to avoid sources of potential infection, such as a doctor’s office. CMS is seeking comment on whether it should develop coding and payment for a service similar to the virtual check-in but for a longer unit of time and subsequently with a higher value.

Conversion Factor

• With the budget neutrality adjustment to account for changes in 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.
• Below are the nursing facility codes with the proposed new RVUs and conversion factor:

Payment for Office/Outpatient Evaluation and Management (E/M) and Analogous Visits

• As finalized in the CY 2020 PFS final rule, in 2021 CMS will be largely aligning the 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 are proposing to revise the times used for rate setting for this code set.

CMS is proposing to revalue the following code sets that include, rely upon, or are analogous to office/outpatient E/M visits commensurate with the increases in values CMS finalized for office/outpatient E/M visits for 2021:

• 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 (AWV) Visits
• Emergency Department Visits
• Therapy Evaluations
• Psychiatric Diagnostic Evaluations and Psychotherapy Services

Quality Payment Program Highlights

MIPS Value Pathways (MVPS): CMS is not proposing any MVP candidates for comment in this NPRM. As a result, MVPs will not be available for MIPS reporting until the 2022 performance period, or later.

New APM Performance Pathway (APP): This new Pathway is a complementary Pathway to the MVPs. The APP would be available only to participants in MIPS APMs and would be required for Medicare Shared Savings Program quality determinations for ACOs. It may be reported by the individual eligible clinician, group TIN, or APM Entity. The APP, like an MVP, would be comprised of a fixed set of measures for each performance category. In the APP, the Cost performance category would be weighted at 0%, as all MIPS APM participants are already responsible for cost containment under their APMs

MIPS Performance Category Weights:

• Quality: 40% (down from 45%)
• Cost: 20% (up from 15%)
• Promoting Interoperability: 25% (no change)
• Improvement Activities: 15% (no change)

Here are further summaries of both proposed rules:

• Physician Fee Schedule
• Quality Payment Program

CMS will host a Physician Fee Schedule Proposed Rule: Understanding 4 Key Topics Listening Session on Thursday, August 13, from 1:30 to 3:00 PM ET. Register for the session.

The Society continues to review the proposed rule and will make comments to CMS.