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CMS proposes a controversial Medicare Physician Fee Schedule for 2021

August 05, 2020


On August 3, 2020, the Centers for Medicare and Medicaid Services (CMS) published its proposed 2021 Medicare Physician Fee Schedule. Most notably, CMS is moving forward with the overhaul of the Evaluation and Management (E/M) office visit coding, documentation and payment system. While the California Medical Association (CMA) appreciates that CMS is proposing to implement long overdue and substantial payment increases for office visits, we are opposed to the corresponding payment cuts to the non-primary care specialties

Overall, there is an unsustainable 11% reduction in the Medicare conversion factor. CMA is extremely concerned that CMS did not adopt the entirety of the American Medical Association (AMA) Specialty Society RVS Update Committee (RUC) recommendations for the E/M overhaul that includes the E/M office visit payment increases in the global surgery payment bundles.  

In early July, AMA, CMA, all specialty societies and state associations urged CMS to avoid the pending payment cuts to non-primary care physicians by waiving the budget neutrality requirements in the Medicare Fee Schedule at least during the COVID-19 pandemic. California physician Congressman Ami Bera, M.D., is introducing legislation at CMA’s urging to authorize CMS to waive the budget neutrality requirements that would allow the payment increases for primary care to move forward while precluding any cuts to the specialists, particularly during the COVID-19 pandemic when physician practices cannot sustain additional revenue losses. 

Additional proposals in the fee schedule include: 

Telehealth: CMA has been urging Congress to make the current telehealth waivers permanent so that patients can continue to receive care in their homes. Under the proposed rule, CMS is proposing to make several codes permanent, including the prolonged office or outpatient E/M visit code and certain home visit services. The proposal would also maintain certain services, including emergency department visits in the telehealth waiver until at least the end of the year. 

Appropriate Use Criteria: Despite overwhelming opposition from organized medicine, CMS is implementing the Appropriate Use Criteria (AUC) which requires physicians to consult the AUC prior to ordering advanced imaging services. 

MIPS Quality Payment Program: CMS will continue to allow physicians to opt out of Medicare Quality Payment Program (QPP) Merit-Based Incentive Payment System (MIPS) for the 2020 performance year without penalties because of the pandemic. CMS is also proposing a new MIPS pathway for participants in alternative payment models (APM) called the APM Performance Pathway (APP). The performance threshold would increase from 45 points in 2020 to 50 points in 2021, instead of the 60 points as had been previously proposed. CMS also proposes to reduce the weight of the Quality Category score from 45 to 40% of the final score, and increase the weight of the Cost Category from 15 to 20%. CMS is adding telehealth services to the existing cost measures and applying performance period benchmarks rather than historical benchmarks for quality measures, as the 2020 data may not be accurate due to the pandemic. 

Accountable Care Organizations (ACOs): CMS is reducing many of the reporting requirements, including allowing ACOs to only report one set of quality metrics for both MIPS and the Medicare Shared Savings Program (MSSP)and reducing the quality measure set from 23 to 6 measures. However, CMS has raised the quality performance standard for ACOs to receive shared savings. For the 2020 performance year, ACOs will continue to be allowed to opt out of reporting because of the COVID-19 pandemic and will waive the patient surveys but provide full credit. 

California GPCI Updates: CMA is analyzing the final year of the California transition to new localities and updated payments.  More information to come.

Finally, President Trump issued a simultaneous Executive Order calling on CMS to develop innovative payments systems for rural health care within 30 days. These innovations must include more predictable payments for rural physicians. 

CMA and AMA are analyzing the 1300-page rule and will provide additional details. Comments are due to CMS by October 5, 2020. 

For additional information:

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