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).

While the AASM is performing a complete analysis of the publication, several highlights are included below.

2021 Physician Fee Schedule Conversion Factor

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 decrease in the conversion factor is due to the budget neutrality adjustment, which was implemented to account for significant increases in relative value units (RVUs) for the evaluation and management (E/M) office/outpatient visit codes, which will be implemented in 2021.

Changes to Evaluation and Management Documentation Guidelines and Codes

The changes to the evaluation and management codes finalized in the 2020 PFS final rule will be implemented in 2021. A webinar recording summarizing the changes to the new and established patient outpatient office visit codes and describing how they may be applied to sleep medicine visits can be accessed as a free member resource in the AASM online store. CMS finalized revisions to the times used for rate-setting for the codes, but this will not impact the work RVUs.

In the 2021 PFS final rule, CMS also finalized two office/outpatient E/M visit Healthcare Common Procedure Coding System (HCPCS) add-on codes for visit complexity (G2211) and prolonged services (G2212).

CMS also finalized revaluation of several code sets that include, rely upon, or are analogous to office/outpatient E/M visits, commensurate with the increases in values finalized for new values for office/outpatient E/M visits for 2021, including psychiatric diagnostic evaluations and psychotherapy services

Coding and Payment for Virtual Check-in Services

CMS issued an interim final rule with comment period to establish coding and payment for virtual check-in services to support the continuing need for coding and payment to reflect the provision of lengthier audio-only services outside of the public health emergency for COVID-19, if not as substitutes for in-person services, then as a tool to determine whether an in-person visit is needed, particularly as beneficiaries may still be cautious about exposure risks associated with in-person services.

Coding and Payment for Personal Protective Equipment (PPE)

CMS also issued an interim final rule with comment period to establish coding and payment for PPE as a bundled service and certain supply pricing increases in recognition of the increased market-based costs for certain types of PPE.

Medicare Telehealth and Other Services Involving Communications Technology

CMS finalized several changes to Medicare Telehealth including:

  • The addition of several codes to the Medicare telehealth list on a Category 1 basis, including psychological and neuropsychological testing (96121) and the aforementioned E/M outpatient office visit HCPCS add-on codes (G2211 and G2212)
  • The creation of a Category 3 Medicare telehealth list, for codes added to the telehealth list during the COVID-19 public health emergency, which will remain on the list until the calendar year in which the PHE ends
  • Clarification that telehealth 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
  • Establishment of payment, on an interim final basis, for a new HCPCS G-code describing 11-20 minutes of medical discussion to determine the necessity of an in-person visit
  • Direct supervision by interactive telecommunications technology may be provided using real-time, interactive audio and video technology until the later of the end of the calendar year in which the public health emergency for COVID-19 ends or Dec. 31, 2021.

The final rule also includes much more information, including clarifications on requirements for billing Remote Physiologic Monitoring codes and scope of practice issues, such as medical record documentation and payment for services of teaching physicians and resident “moonlighting” services.

The AASM will perform a full analysis of the final rule and will develop communications and resources to inform members of revisions relevant to sleep medicine in the 2021 PFS and QPP programs.

For more details, review the CMS final rule fact sheet. Find more resources on the Medicare Resources page of the AASM website.

Please send any questions about the final rule to coding@aasm.org.