2021 Physician Fee Schedule Proposal - Medicare - Texas Orthopaedic Association

The Centers for Medicare and Medicaid Services (CMS) released the Medicare Physician Fee Schedule proposed payment rule for calendar year (CY) 2021 on August 3.

AAOS will provide a full summary and stakeholder comments on behalf of orthopaedic surgeons. Comments are due by October 5, 2020.

The following is TOA’s initial summary of the proposed rule. Click here to view CMS’s proposal.

New E/M Payment Proposals

CMS proposed dramatic changes for E/M codes in the past few payment proposals. As a result of CMS’s new E/M policy, some specialties could witness pay increases as high as 17 percent (endocrinologists) in 2021. Meanwhile, some could experience pay cuts as large as 11 percent (radiology and nurse anesthetists). Pathology, cardiac surgery, and physical/occupational therapy could witness 9 percent cuts.

Orthopaedic surgery would witness a 5 percent cut under the proposal. The table can be found on page 898.

The redistribution is due to the result of higher budget neutrality requirements linked to the 2020 rule’s increase in pay for E/M. CMS indicated that “the changes in the practice of medicine, recognizing that additional resources are required of clinicians to take care of the Medicare patients, of which two-thirds have multiple chronic conditions.”

CMS did indicate that these are averages, and “may not necessarily be representative of what is happening to the particular services furnished by a single practitioner within any given specialty.”

Physicians would experience a reduced conversion factor from $36.09 to $32,26 in 2021. The is a result of the adjustment that is necessary for the new E/M payments in the budget neutral system.

E/M Changes in the 2020 Rule: A Review

After a dramatic 2019 proposal that received widespread criticism, CMS finalized policies in the 2020 proposed payment rule that are now reflected in the 2021 proposal. Changes to the E/M code set from the 2020 final rule include:

Four levels of E&M codes for new patients (99202-99205) and deleting code 99201.
Five levels for established patients (99211-99215).
An add-on code (99XXX) for prolonged visits billed with level 5 codes only.
Modifications to the time and usage of this code were proposed in this rule.
99XXX will discontinue the usage of CPT codes 99358 and 99359.
A G code (GPCIX) to be billed with complex visits.
Adopting the AMA RUC recommendations to reduce administrative burden and increase reimbursement for the majority of these E/M codes in 2021.

Global Surgical Packages

CMS moved to eliminate the 10- and 90-day global surgical packages in a rule several years ago. However, Congress restored the packages in legislation. The legislation included a provision that CMS must continue to study the future of the surgical packages in the future.

While CMS dedicated past payment proposals to lengthy discussions about surgical packages and their relation to orthopaedics, CMS did not do so this time.

Telehealth

President Trump signed an executive order on August 3 calling on CMS to make permanent some of the COVID-19-related telehealth provisions.

CMS does address telehealth in the 2021 PFS Payment proposal. Some of the permanent additions that CMS is seeking in this payment proposal include:

Prolonged office visits.
Diagnostic codes for group psychotherapy, neurobehavioral status exams, care planning for patients with cognitive impairments, and domiciliary home care.
Diagnostic codes through the end of the year in which the public health emergency ends for home visits of established patients, emergency department visits, and psychological testing.

The PFS contains proposals that would put in place some of the telehealth flexibilities created as a result of the COVID-19 public health emergency through December 31, 2021, or the end of the calendar year in which the public health emergency ends (whichever is longer). Some of the additions to that telehealth proposal include:

GPC1X – Visit Complexity Associated with Certain Office/Outpatient E/Ms
99XXX – Prolonged Services
99334, 99335 – Domiciliary, Rest Home, or Custodial Care Services
99347, 99248 – Home Visits

The PFS would create a temporary category of criteria for adding services to the list of the Medicare telehealth services to be used until the public health emergency ends (through the end of the calendar year):

99336, 99337 – Domiciliary, Rest Home, or Custodial Care Services
99349, 99350 – Home Visits, Established Patient
99281, 99282, 99283 – Emergency Department Visits
99315, 99316 – Nursing Facilities Discharge Day Management
96130, 96131, 96132, 96133 – Psychological and Neuropsychological Testing

Of note, CMS is not proposing to continue separate payments beyond the public health emergency for the audio-only telephone service that was created on March 31 during the COVID-19 interim rule. However, CMS is seeking feedback on the creation of a code and payment for this service in the future.

Appropriate Use Criteria (AUC) for Imaging

CMS is not proposing changes for the AUC mandate when ordering advanced imaging services. Requirements are summarized in this MLN Matters article:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM11268.pdf

Quality Payment Program (QPP) – 2021 Proposal

CMS is proposing changes to the QPP program for 2021, and it will be important to look at AAOS’s analysis of the proposal. Click here to read CMS’s fact sheet, which was just released:
2021 QPP Proposed Rule Fact Sheet

The following is a look at the QPP highlights:

Delayed implementation of the MIPS Value Pathways (MVP) until at least 2022.
Alignment of the Alternative Payment Model (APM) with the MVP framework.
An increase in the performance threshold to 50 points in 2021 (from 45 points in 2020). The exceptional performance would increase from 80 points in 2020 to 85 points in 2021.
The Quality performance category weights would a five-point decrease to 40 percent in 2021.
Promoting Interoperability (25 percent) and Improvement Activities (15 percent) would remain at their current levels under the proposal.
The proposal contains a measure that would award a one-time bonus (doubling he complex patient bonus) for the additional complexity of having to deal with COVID-19.
CMS is asking for comments related to a lower performance threshold of 50 points (60 points in CY 2020).
Several proposals related to Advanced Payment Models.
A proposal would rely on the performance period (instead of the historical period) for benchmarks to score quality measures in 2021.
Quality measures are addressed. See below for information related to orthopaedic measures.
New requirements for Qualified Clinical Data Registry (QCDR) measures and the services that third-party intermediaries must provide for the 2021 performance period.

Physical Therapy Services – RVUs

Proposed RVUs for therapy can be found on page 172. Again, physical therapy would receive a payment decrease under the new E/M system.

Physical Therapy – Delegate Performance of Maintenance Therapy to a PTA

Per CMS on page 212:

Given that we already make payment for rehabilitative services requiring improvement in the patient’s functional status when they are furnished by PTAs and OTAs at the discretion of the supervising therapist treating the patient in accordance with the therapist-established plan of care, we believe that it would be appropriate for the therapist to use that same judgement in deciding whether to delegate to the PTA or OTA the performance of maintenance therapy services under the associated plan of care. We believe that there is little difference between the rehabilitative therapy services furnished to improve a patient’s functional status and those for maintenance therapy services other than the goals set by the therapist in the therapy plan that are aimed to maintain, slow or prevent further decline of a patient’s condition. We do not believe that the therapist-only maintenance therapy requirement is needed in the case of outpatient physical or occupational therapy services, and instead believe that it would be appropriate for an OT or PT to be permitted to use their professional judgement to assign the performance of maintenance therapy services to an OTA or PTA when it is clinically appropriate to do so.

As such, we propose to allow, on a permanent basis, therapists to delegate performance of maintenance therapy services to an OTA or PTA for outpatient occupational and physical therapy services in Part B settings beginning January 1, 2021. This proposal would better align our Part B policy with that in SNFs and HH paid under Part A where maintenance therapy services may be performed by a therapist or a therapy assistant.

Physical Therapy – Medical Documentation

Per CMS on page 214:

We note that although there are currently no documentation requirements that would impact payment for PTs, OTs, or SLPs when documentation is added to the medical record by persons other than the therapist, we are responding in this proposed rule to stakeholder requests for clarification. Specifically, we are clarifying that the broad policy principle that allows billing clinicians to review and verify documentation added to the medical record for their services by other members of the medical team also applies to therapists. This will help ensure that therapists are able to spend more time furnishing therapy services, including pain management therapies to patients that may minimize the use of opioids and other medications, rather than spending time documenting in the medical record. We emphasize that, while any member of the medical team may enter information into the medical record, only the reporting clinician may review and verify notes made in the record by others for the services the reporting clinician furnishes and bills. We also emphasize that information entered into the medical record should document that the furnished services are reasonable and necessary.

Hip-Knee Arthroplasty Codes 27130 and 27447

CMS’s discussion on these values related to work values begins on page 240.

CMS made the following proposal and comments for 2021:

We are proposing the RUC-recommended work RVU of 19.60 for CPT code 27130 and the RUC-recommended work RVU of 19.60 for CPT code 27447. We are also proposing the RUC-recommended direct PE inputs for both codes. Additionally, we are seeking comment

from the medical community on how to consider and/or include pre-optimization time (preservice work and/or activities to improve surgical outcomes) going forward. We are also

interested in stakeholders’ thoughts on what codes could be used to capture these preoptimization activities that could be billed in conjunction with the services discussed previously. Overall, we are interested in continuing our ongoing dialog with stakeholders about how CMS might pay more accurately for improved clinical outcomes that may result from increased efficiency in furnishing care through activities, such as pre-optimization and are appreciative of information provided by the medical community. We invite the medical community to continue to engage with CMS on this and other topics.

Toe Amputation Codes 28820 and 28825

CMS’s commentary on these proposed work values can be found on page 241.

Shoulder Code 29823

The table can be found on page 312.

New 2023 MIPS Payment Quality Measure: RSCR Following THA/TKA

More can be found on page 1038.

Previously Finalized Measures: Orthopaedics

A list of the previously finalized measures for orthopaedics can be found on page 1153.

Proposal of Removal of MSK Measures

Communication of fracture management can be found on page 1223. CMS’s rationale for the proposed removal:

We propose the removal of this measure (finalized in 81 FR 77558 through 77675) as a quality measure from the MIPS program because the measure supports communication between the physician treating the fracture and the clinician managing the patient’s ongoing care, but does not ensure that the patient receives the appropriate treatment or testing for osteoporosis. We believe measure Q418: Osteoporosis Management in Women Who Had a Fracture represents a more robust quality outcome in the management of patients with osteoporosis who experience a fracture since the clinical focus of this measure is the care of the patient rather than just the communication of the care plan for on-going post fracture care.

Documentation of signed opioid agreement proposed for removal can be found on page 1226. CMS’s rationale:

We propose the removal of this measure (finalized in 81 FR 77558 through 77675) as a quality measure from the MIPS program at the request of the measure steward because this measure does not align with the most recent guidelines. The measure steward will not be further reviewing or updating the measure specifications, citing the measure is topped out and there are newer opioid measures to report that are not topped out.

CMS is also proposing to remove the evaluation or interview for risk of opioid misuse. Per CMS:

Changes Proposed for Current Measures

Documentation of current medications in the medical record can be found on page 1257:

We propose to update the measure description to remove language that is more appropriate for the guidance/notes sections of the measure specification. This will help with measure intent, clarity, and readability. The guidance for the eCQM Specifications collection type has been updated to clarify the intent of the measure. The intent is to document all known prescriptions, since the measure steward believes that MIPS eligible clinician should not be held accountable for information that is not available utilizing all immediate resources. The denominator exception was updated in all collection types to add clarity regarding use of the denominator exception and to align the language throughout the specification. The numerator notes for the Medicare Part B Claims Measure Specifications and the MIPS CQMs Specifications collection types was updated with information removed from the description. This information outlines what is necessary for numerator compliance and is better suited for the numerator notes section for ease of use.

Exposure dose indices or exposure time and number of images reported for procedures using fluoroscopy. Per CMS on page 1265:

We propose to update the denominator criteria encounter coding to ensure that all of the codes are associated with fluoroscopy and to create a more complete patient population. Additionally, we propose to add numerator instructions to further clarify how the fluoroscopy information should be recorded in the final report to be numerator compliant and meet the intent of the measure.

Nuclear medicine – Correlation with existing imaging studies for all patients undergoing bone scintigraphy. Per CMS on page 1266:

We propose to update the denominator to account for encounter codes that can be utilized for imaging other than bone scintigraphy. This will narrow the eligible patient population to those using bone imaging agents and only assess MIPS eligible clinicians that are relevant to this measure’s intent.

Functional status change for patients with knee impairments. Per CMS on page 1274:

We propose to update the description, denominator exclusion, numerator statement, and numerator options to reflect the change in functional assessment tool, Knee FS PROM to the LEPF PROM. The assessment is being revised to address scientific updates and maintenance necessary for item-response theory based outcome measures. We propose to update the denominator exception language to add clarity and better align with measure’s intent.

Functional status change for patients with hip impairments. Per CMS on page 1275:

Functional status change for patients with lower leg, foot or ankle impairments. Per CMS on page 1276:

We propose to update the description, denominator exclusion, numerator statement, and numerator options to reflect the change in functional assessment tool, Hip FS PROM to the LEPF PROM. The assessment is being revised to address scientific updates and maintenance necessary for item-response theory based outcome measures. We propose to update the denominator exception language to add clarity and better align with measure’s intent. Additionally, we propose to update the ICD-10 coding related to the denominator criteria statement, ‘With a lower leg, foot, or ankle impairment and/or diagnosis pertaining to a functional deficit affecting lower leg, foot, or ankle,’ to align with current coding.

Functional status change for patients with low back impairments. Per CMS on page 1277:

We propose to refine the description for easier readability. We propose to update the denominator exception language to add clarity and better align and communicate the measure’s intent.

Functional status change for patients with shoulder impairments. Per CMS on page 1278:

We propose to refine the description for easier readability. We propose to update the denominator exception language to add clarity and better align and communicate the measure’s intent.

Functional status change for patients with elbow, wrist or hand impairments. Per CMS on page 1279:

We propose to refine the description for easier readability. We propose to update the denominator exception language to add clarity and better align and communicate the measure’s intent.

Osteoporosis management in women who had a fracture. Per CMS on page 1325:

We propose to expand the eligible encounter coding for Option 1 to include all relevant encounters and create a more complete eligible patient population. We propose that the denominator exclusion language and logic be updated in all collection types to clarify that, for the measure, long-term care will be defined as patients staying 90 consecutive days at the long-term care facility versus any 90 days within the performance period. A denominator exclusion was added to remove patient 81 years of age and older with a frailty encounter during the measurement period as patients within this age stratification are more appropriately assessed less stringently when determine if they should be excluded from the eligible patient population. Additionally, we propose adding applicable coding to better define the advanced illness and frailty patient population for the purposes of this measure. We propose to update the definition for pharmacologic therapy to align with the current U.S. Food and Drug Administration approved pharmacologic options for osteoporosis prevention and/or treatment of postmenopausal osteoporosis.

Back pain/leg pain after lumbar discectomy/laminectomy and lumbar fusion can be found beginning on page 1339.

Functional status after lumbar fusion, primary TKA, lumbar discectomy/laminectomy, leg pain after lumbar fusion can be found beginning on page 1345.

Functional status change for patients with neck impairments can be found beginning on page 1350.

2021 Physician Fee Schedule Proposal – Medicare