Updated E&M Codes, Adjusting for COVID-19, 340B Provisions Shape 2021 Fee Schedule and Hospital Outpatient Final Rules

December 2, 2020

On December 1, the Centers for Medicare & Medicaid Services (CMS) released its final rule for the 2021 Medicare Physician Fee Schedule (PFS) and other changes to Medicare Part B reimbursement, including updates to the Quality Payment Program (QPP). On December 2, CMS released its Hospital Outpatient Prospective Payment System (OPPS) final rule for 2021. Details on the impact of the rules on cancer care are included below.

Notable Changes to the Medicare PFS

Estimated Impact on OncologyTo account for changes in Relative Value Units (RVUs), including increases to Current Procedural Terminology (CPT ®) codes for Evaluation and Management (E&M) visits, the final 2021 PFS conversion factor is $32.41, a decrease of $3.68 from the 2020 PFS conversion factor of $36.09. Despite this decrease, the estimated overall impact of the 2021 PFS final rule is +14% on reimbursement for the hematology/oncology specialty and -5% on reimbursement for the radiation oncology specialty. However, the actual impact on individual physician practices will depend on the mix of services the practice provides.

Evaluation and ManagementAs finalized in the 2020 PFS final rule, CMS will largely 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 finalized revisions to the times used for rate-setting for the office/outpatient E&M visit code set, clarified the definition of the E&M visit complexity code (HCPCS add-on code G2211), and finalized separate payment for prolonged office/outpatient E&M visits (HCPCS code G2212).

TelehealthCMS is permanently adding approximately 10 codes to the Medicare Telehealth list, including the complex patient add-on code (HCPCS code G2211) and the prolonged services code (HCPCS code G2212). Another set of services will be added to the telehealth list temporarily through the end of the calendar year during which the COVID-19 Public Health Emergency (PHE) ends. CMS states it does not have the authority to pay for audio-only E&M services after expiration of the PHE. In response to the Association for Clinical Oncology (ASCO) and other stakeholder’s comments, CMS established new coding and payment, outside of the PHE, for an extended audio-only virtual check-in service (HCPCS code G2252) for 11-20 minutes of medical discussion. CMS did not propose or finalize any changes to the originating site requirement. When the PHE expires, telehealth services will again only be available to beneficiaries in rural areas who travel to an originating site to receive the telehealth service, with some exceptions.

Electronic Prescribing of Controlled Substances (EPCS)Section 2003 of the SUPPORT Act requires prescribers to use the National Council for Prescription Drug Programs’ (NCPDP) SCRIPT 2017071 standard for EPCS prescription transmissions, the same standard Part D plans are already required to support. CMS is finalizing the provision with an effective date of January 1, 2021 and a compliance date of January 1, 2022 to encourage prescribers to implement EPCS as soon as possible, while helping to ensure that CMS’ compliance process is conducted thoughtfully.

Part B Payments for Drugs Approved under Section 505(b)(2) of the Food, Drug, and Cosmetic Act—In response to ASCO’s comments asking for more detail about its proposed approach, CMS will not finalize the proposal to continue assigning certain section 505(b)(2) drug products to existing multiple source drug codes. This proposal had the potential to lower reimbursement for Part B drugs approved under this pathway.

Coding and Payment for Personal Protective Equipment (PPE)—Following the publication of the 2021 PFS proposed rule, the CPT Editorial Panel approved the creation of CPT code 99072 (Additional PPE during the PHE). CMS is finalizing CPT code 99072 as a bundled service on an interim basis stating that payment for the services are always bundled into payment for the services to which they are incident. CMS does recognize the increased costs for certain types of PPE, and they are finalizing several supply price increases and adding the N95 mask to the supply database.

National Coverage Determinations—CMS is finalizing the removal of six outdated or obsolete National Coverage Determinations (NCDs). Removing outdated NCDs means that Medicare Administrative Contractors are no longer required to follow those outdated coverage policies when it comes to covering beneficiary services.

HCPCS Code G2211—CMS finalized the implementation of add on complexity code GG211 (formerly GPC1X). HCPCS code G2211 describes "visit complexity inherent to evaluation and management associated with medical care services... part of ongoing care related to a patient's single, serious condition or complex condition." The agency’s goal is to capture the practitioner work that may not be included in the valuation of the primary office/outpatient E&M service as the patient's condition requires the expertise of a clinician who has specialized skills, knowledge, and expertise. The service accounts for the time, intensity, and resources involved in a practitioner's collaboration and continuous care planning with the patient in addition to an E&M service.

HCPCS Code G2212—CMS introduced HCPCS code G2212 to describe a 15-minute prolonged service (with or without direct patient contact) beyond the maximum total time of E&M services 99205 or 99215. This code should be reported to CMS instead of CPT ® code 99417 (prolonged E&M service of 15 minutes beyond the total time of 99205 or 99215). Private payers’ policies on this service may differ, so it will be important to check whether 99417 or G2212 should be reported. The guidelines for G2212 are similar to CPT code 99417, except CMS made clarifications to the language in the code description that it found unclear (such as the terms “total time” and “usual service.”)

More information about G2211 and G2212 can be found on ASCO Practice Central.

Notable Changes to the QPP

Scoring and Performance Category Weights in the Merit-based Incentive Payment System (MIPS)—The MIPS performance threshold for 2021 will be 60 points, increased from 50 points in the 2021 proposed rule and the exceptional performance threshold was finalized at 85 points as proposed. The performance category weights for traditional MIPS reporting (individual, group, or virtual group) will be as follows: Quality = 40%, Cost = 20%, Promoting Interoperability = 25%, and Improvement Activities = 15%. CMS will implement MIPS Value Pathways (MVPs) in 2022. Scoring for MVPs has yet to be described in detail.

Alternative Payment Model (APM) Scoring Standard—CMS will sunset the APM Scoring Standard in the 2021 performance period and allow MIPS eligible clinicians (ECs) in APMs to participate in traditional MIPS and submit data at the individual, group, virtual group, or APM Entity level. The MIPS performance category weights for APM entities reporting in traditional MIPS will be: Quality = 50%, Cost = 0%, Promoting Interoperability = 30%, and Improvement Activities = 20%.

New APM Performance Pathway (APP)—CMS finalized a new APM Performance Pathway (APP) for 2021. The APP will be composed of a fixed set of measures for each performance category, available as an option only for MIPS ECs in MIPS APMs, and will be reported by individual ECs, groups, or APM Entities. The Improvement Activities performance category score will be automatically assigned based on the requirements of the MIPS APM in which the MIPS EC participates. In 2021, all APM participants reporting through the APP will earn a score of 100%. Medicare Shared Savings Program ACOs will be required to report quality data for the Shared Savings Program via the APP.

Complex Patient Bonus—CMS finalized the complex patient bonus for 2020 only at a 10-point maximum (an increase from a 5-point maximum) for clinicians, groups, virtual groups, and APM Entities to offset the additional complexity of patient populations due to COVID-19.

Extreme and Uncontrollable Circumstances—CMS finalized the proposal to allow APM Entities to submit applications to reweight MIPS performance categories as a result of extreme and uncontrollable circumstances, such as the public health emergency resulting from the COVID-19 pandemic. This policy will apply beginning with the 2020 performance period.

Medicare Shared Savings Program—For the 2020 performance year, all Accountable Care Organizations (ACOs) are considered affected by the COVID-19 PHE, and the Shared Savings Program extreme and uncontrollable circumstances policy applies. ACOs will also receive automatic full credit for the patient experience of care measures.

CMS Web Interface—ASCO objected to CMS’ proposal to abruptly sunset its web interface in 2021. CMS agreed in the final rule to delay sunsetting this reporting option until 2022.

Notable Changes to the Hospital OPPS

CMS is continuing the current 340B Drug Pricing Program reimbursement policy of paying ASP -22.5% for 340B-acquired drugs, despite many stakeholder objections. CMS also finalized its proposal to continue adding services to the list of those requiring prior authorization for dates of services on or after July 2021, despite very little experience with the initial list and concerns expressed by stakeholders that this policy will impact beneficiary access.

The agency is also finalizing its proposal to eliminate the Inpatient Only (IPO) list over a three-year transitional period, beginning with the removal of approximately 300 primarily musculoskeletal-related services, with the list completely phased out by 2024.

CMS will update OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.4%. This update is based on the projected hospital market basket increase of 2.4% with a 0.0% adjustment for multi-factor productivity (MFP).

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