On Dec. 1, the Centers for Medicare & Medicaid Services (CMS) released the final rule that includes final changes to the 2021 Medicare Physician Fee Schedule (PFS) and final policies for the Quality Payment Program (QPP).
The AASM has performed a complete analysis of the publication and provides the highlights below for sleep clinicians.
UPDATE: On Dec. 27, 2020, the Consolidated Appropriations Act was signed into law, offsetting almost all of the 10.2% budget neutrality adjustments that were to have taken effect on Jan. 1, 2021. CMS is implementing these revisions and has confirmed that claims will be paid on time at the rates reflected in this legislation. Refer to the summary, “Law modifies the 2021 Medicare Physician Fee Schedule,” for details about revisions in payment and RVUs.
The 2021 conversion factor was significantly decreased to 32.4085. This is approximately a $3.68 decrease from the 2020 conversion factor of 36.0896, which results in a significant decrease in payment for most procedures. The law requires that increases or decreases in relative value units (RVUs) may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes. If this threshold is exceeded, CMS makes adjustments to preserve budget neutrality. The increases for 2021 can largely be attributed to previously finalized policies for increases in valuation for office/outpatient evaluation and management (E/M) visits, which constitute nearly 20 percent of total spending under the fee schedule.
Changes in payment and RVUs are detailed in these documents:
The following codes have been added to the Medicare Telehealth Services list on a Category 1 Basis:
- G2211: Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)
- G2212: Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
- 90853: Group psychotherapy (other than of a multiple-family group)
CMS also clarified that a patient’s home cannot serve as an originating site for most Medicare Telehealth services. However, the SUPPORT for Patients and Communities Act was amended to remove geographic limitations and authorize the patient’s home to serve as a telehealth originating site for purposes of treating patients with substance use disorders or a co-occurring mental health disorder.
CMS is finalizing these relevant services to remain temporarily on the Medicare telehealth list through the end of the year in which the public health emergency for COVID-19 ends (Category 3 services), to allow for continued development of evidence to demonstrate clinical benefit and facilitate post-PHE care transitions:
- Critical Care Services (CPT 99291-99292)
Proposed Technical Amendment to Remove References to Specific Technology
In a previously published interim final rule with comment, a sentence was added that defines an interactive telecommunication system as “multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication.” CMS was concerned that the reference to “telephones” as impermissible technology could cause confusion in instances when otherwise eligible equipment, such as a smartphone, may also be used as a telephone. Because these concerns are not situation- or time-limited to the public health emergency for COVID-19, CMS removed the language that specified that telephones, fax machines, and email systems do not meet the definition of an interactive telecommunications system.
Communication Technology-Based Services (CTBS)
CMS finalized that G2061 – G2063, Healthcare Common Procedure Coding System (HCPCS) Level II codes, established to allow non-physician health care professionals to report online assessment and management services, are being replaced with the following CPT codes*:
- 98970: Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 5-10 minutes
- 98971: Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 11-20 minutes
- 98972: Qualified nonphysician health care professional online digital assessment and management, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes
*During the public health emergency, these codes are reportable by clinical psychologists.
CMS also finalized the creation of two additional G codes that can be billed by practitioners who cannot independently bill for E/M services:
- G2250: Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment
- G2251: Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion
G2250 and G2251 are billable by certain non-physician practitioners, consistent with the scope of these practitioners’ benefit categories. The values of these codes are identical to G2010 and G2012 and have been designated “sometimes therapy” codes to facilitate billing by therapists.
CMS also finalized that consent from the patient to receive communication technology-based services can be documented by auxiliary staff under general supervision, as well as by the billing practitioner.
Continuation of Payment for Audio-only Visits
CMS previously established payment for audio-only telephone E/M visits (99441 – 99443) during the public health emergency. CMS then established new RVUs for the codes and added them to the Medicare Telehealth List, given the understanding that these services were being furnished in place of the office/outpatient E/M codes. CMS established a waiver to allow these services to be furnished without the usual requirement to utilize both audio and video technology for Medicare telehealth services. However, after the end of the public health emergency, there will be no separate payment for the audio-only E/M visit codes. At the conclusion of the public health emergency, CMS will assign a status of “bundled” and post the RUC-recommended RVUs for these codes in accordance with their usual practice.
Clarifications of Current PFS Policies for Telehealth Services
- CMS reiterated the clarification that services that may be billed incident-to may be provided via telehealth incident to a physicians’ or non-physician health care professionals’ service and under the direct supervision of the billing professional.
- CMS, again, clarified, that if audio/video technology is used in furnishing a service when the beneficiary and the practitioner are in the same institutional or office setting, then the practitioner should bill for the service furnished as if it was furnished in person, and the service would not be subject to any of the telehealth requirements.
- CMS also noted that time should be counted for telehealth services furnished by auxiliary personnel incident to a billing professional’s services in the same way time is counted for other “incident to” services.
Direct Supervision by Interactive Telecommunications Technology
CMS finalized the proposal to allow direct supervision to be provided using real-time, interactive audio and video technology through the later of the end of the calendar year in which the public health emergency for COVID-19 ends or Dec. 31, 2021. Due to the wide range of responses received in support and opposition of making the policy permanent, CMS will continue to consider whether it would be feasible to make this policy permanent while prioritizing patient safety and program integrity.
Remote physiologic monitoring (RPM) involves the collection and analysis of patient physiologic data that are used to develop and manage a treatment plan related to a chronic and/or acute health illness or condition. CPT codes 99453, 99454, 99091, 99457, and 99458, can be ordered and billed only by physicians or nonphysician practitioners (NPPs) who are eligible to bill Medicare for E/M services. Practitioners may furnish these services to remotely collect and analyze physiologic data from patients with acute conditions and from patients with chronic conditions.
Appropriate Medical Devices for RPM
The device must be a medical device as defined by the FDA and should digitally (automatically)
upload patient physiologic data (that is, data are not patient self-recorded and/or self-reported). Additionally, use of the medical devices that digitally collect and transmit patients’ physiologic data must be reasonable and necessary for the diagnosis and treatment of the patient’s illness or injury or to improve the functioning of a malformed body member. The device must also be used to collect and transmit reliable and valid physiologic data that allow understanding of a patient’s health status in order to develop and manage a plan of treatment.
The RPM process begins with two practice expense (PE) only codes, CPT codes 99453 and 99454. As PE only codes, they are valued to include clinical staff time, supplies, and equipment, including the medical device for the typical case of remote monitoring.
- 99453 (Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment) is valued to reflect clinical staff time that includes instructing a patient and/or caregiver about using one or more medical devices. 99453 can be billed only once per episode of care where an episode of care is defined as “beginning when the remote physiologic monitoring service is initiated and ends with attainment of targeted treatment goals.”
- 99454 (Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days) is valued to include the medical device or devices supplied to the patient and the programming of the medical device for repeated monitoring.
After the data collection period for CPT codes 99453 and 99454, the physiologic data that are collected and transmitted may be analyzed and interpreted as described by CPT code 99091 (Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days). This code only includes professional work, as there are no PE inputs.
After analyzing and interpreting a patient’s remotely collected physiologic data, CMS noted that the next step in the process of RPM is the development of a treatment plan that is informed by the analysis and interpretation of the patient’s data. It is at this point that the physician or non-physician health care professional develops a treatment plan with the patient and/or caregiver and then manages the plan until the targeted goals of the treatment plan are attained, which signals the end of the episode of care. CPT code 99457 (Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes) and its add-on code, CPT code 99458 (Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes (list separately in addition to code for primary procedure)) describe the treatment and management services associated with RPM. CPT codes 99457 and 99458 can be furnished by clinical staff under the general supervision of the physician or non-physician health care professional. The services described by CPT codes 99457 and 99458 are services that are typically furnished remotely using communications technologies that allow “interactive communication,” which for the purposes of these codes, CMS defines as a real-time synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission.
CMS finalized several policies:
- While CMS is allowing the provision of RPM services to new and established patients, on an interim basis for the duration of the public health emergency for COVID-19, RPM services will be reportable for established patients only, once the public health emergency ends.
- During the public health emergency, CMS is allowing consent to be obtained at the time 99453 and 99454 services are furnished. This policy has been made permanent and will continue after the public health emergency ends.
- CMS finalized an interim policy to allow reporting of 99453 and 99454 for fewer than 16 days during the public health emergency. However, upon conclusion of the public health emergency, the original requirement for 16 days of data to be collected and transmitted each 30 days will resume.
- CMS finalized that auxiliary personnel can furnish services of 99453 and 99454 under the general supervision of the billing physician or practitioner.
Summary of changes for the office/outpatient E/M codes:
- History and exam no longer used for code selection
- 99201 (Level 1, new patient) deleted
- Medical Decision Making or Total Time used for code selection
- Establishment of two add-on codes
- G2211 (Formerly GCP1X): Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)
- G2212 (In lieu of 99417): Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)
CMS finalized that beginning in calendar year (CY) 2021, it will adopt the actual total times (defined as the sum of the component times) rather than the total times recommended by the RUC for CPT codes 99202 through 99215.
Revaluing Services that are similar to office/outpatient E/M visits
Therapy and Behavioral health care services
There are a number of services paid under the physician fee schedule that are similar in many respects to the office/outpatient E/M visit code set, but do not specifically include, were not valued to include, and were not necessarily valued relative to, office/outpatient E/M visits. These services include therapy evaluation services and psychiatric diagnostic evaluation services. The practitioners who furnish these services are prohibited by CMS from billing E/M services due to the limitations of their Medicare benefit categories, and separate codes were created to capture these services. Although these services are billed using specific, distinct codes relating to therapy evaluations and psychiatric diagnostic evaluations, CMS believes that a significant portion of the overall work in the codes is for assessment and management of patients, as it is for the office/outpatient E/M visit codes.
CMS finalized applying this approximately 28 percent increase to the work RVUs for the therapy evaluation and psychiatric diagnostic evaluation services codes. CMS has finalized increases in work RVUs for the following Psychiatric diagnostic evaluation and Psychotherapy services:
|CPT code||Code Descriptor||CY 2020 Work RVU||CY 2021 Work RVU|
|90791||Psychiatric diagnostic evaluation||3.00||3.84|
|90792||Psychiatric diagnostic evaluation with medical services||3.25||4.16|
|90832||Psychotherapy, 30 minutes with patient||1.50||1.70|
|90834||Psychotherapy, 45 minutes with patient||2.00||2.24|
|90837||Psychotherapy, 60 minutes with patient||3.00||3.31|
CMS finalized interim final rule with comment period provisions related to the application of teaching physician and moonlighting regulations during the public health emergency for the COVID-19 pandemic:
- The interim policy allowing virtual presence of a teaching physician using audio/video real-time communications, during the public health emergency for COVID-19, will be extended for the duration of the public health emergency.
- Interim policy allowing virtual presence of a teaching physician during Medicare Telehealth Services, adopted during the public health emergency for COVID-19, to allow payment under the physician fee schedule when residents furnish telehealth services to beneficiaries with the teaching physician present using interactive, audio/video real-time communications technology (excluding audio-only) have been finalized for the duration of the public health emergency.
- The policy adopted on an interim basis during the public health emergency for COVID-19, to allow physician fee schedule payment for services provided by fully licensed residents that are not related to their approved GME program in the inpatient setting of a hospital in which they are training, under specific conditions, have been finalized for the duration of the public health emergency.
- The interim policy, to permit physician fee schedule payment for teaching physician services that do not require face-to face patient care when the resident is furnishing such services while in quarantine when the teaching physician is present through audio/video real-time communications technology has been finalized for the duration of the public health emergency.
CMS is also finalizing a permanent policy to permit teaching physicians to meet the requirements to bill for their services involving residents through virtual presence, but only for services furnished in residency training sites that are located outside of an Office of Management and Budget (OMB) defined metropolitan statistical area (MSA).
In order to ensure that the teaching physician renders sufficient personal and identifiable physicians’ services to the patient to exercise full, personal control over the management of the portion of the case for which the payment is sought, CMS is clarifying the existing documentation requirements to specify that, when a teaching physician, through virtual presence, furnishes services involving residents in a residency training site located outside of an MSA, the patient’s medical record must clearly reflect how and when the teaching physician was present for the service in accordance with CMS regulations. For all other settings, CMS is not permanently finalizing the teaching physician virtual presence policies; however, the policies will remain in place for the duration of the public health emergency to provide flexibility for communities that may experience resurgences in COVID-19 infections.
Virtual Teaching Physician Presence during Medicare Telehealth Services
CMS is permanently finalizing the policy that Medicare may make payment under the physician fee schedule for teaching physician services when a resident furnishes Medicare telehealth services in a residency training site located outside of an MSA to a beneficiary who is in a separate location outside the same MSA (that is, in the same rural area) as the residency training site or is within a rural area outside of a different MSA, while a teaching physician is present, through interactive, audio/video real-time communications technology (excluding audio-only), in a third location, either within the same rural training site as the resident or outside of that rural training site.
For all other settings, CMS is not permanently finalizing this policy; however, the policy will remain in place for the duration of the public health emergency for COVID-19 to provide flexibility for communities that may experience resurgences in COVID-19 infections.
Resident Moonlighting in the Inpatient Setting
CMS finalized the interim policy for the services of moonlighting residents on a permanent basis. Services of residents that are not related to their approved GME programs and are performed in the outpatient department, emergency department, or inpatient setting of a hospital in which they have their training program are separately billable physicians’ services for which payment can be made under the physician fee schedule provided that the services are identifiable physicians’ services and meet the conditions of payment for physicians’ services to beneficiaries, the resident is fully licensed to practice medicine, osteopathy, dentistry, or podiatry by the state in which the services are performed, and the services are not performed as part of the approved GME program.
Supervision of Diagnostic Tests by Certain NPPs
- CMS finalized amending the basic rule to allow nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs), certified registered nurse anesthetists (CRNAs), or certified nurse-midwifes (CNMs) to supervise diagnostic tests on a permanent basis as allowed by state law and scope of practice.
- CMS finalized specifying that supervision of diagnostic psychological and neuropsychological testing services can be done by NPs, CNS’s, PAs, CRNAs, or CNMs to the extent that they are authorized to perform the tests under applicable state law and scope of practice, in addition to physicians and clinical psychologists (CPs) who are currently authorized to supervise these tests, on a permanent basis.
- CMS also finalized, on a permanent basis, specifying that diagnostic tests performed by a PA in accordance with their scope of practice and state law do not require the specified level of supervision assigned to individual tests, because the relationship of PAs with physicians would continue to apply. They also finalized making permanent the removal of the parenthetical, previously made as part of the May 8 COVID-19 interim final rule with comment that required a general level of physician supervision for diagnostic tests performed by a PA.
AASM analyses of the two interim final rules for virtual check-ins and personal protective equipment (PPE), included in the final rule document, are forthcoming. A separate analysis of the Quality Payment Program final rule also will be posted separately.
Updated Jan. 15, 2021