UPH Government & External Affairs

Physician Fee Schedule (PFS) Final Rule

by | Dec 17, 2020

On December 1, the Centers for Medicare & Medicaid Services (CMS) released the Physician Fee Schedule (PFS) 2021 Final Rule, which is the annual rule that dictates the majority of Medicare Part B reimbursement policies. The UnityPoint Health Government & External Affairs team has been actively monitoring this rule and, during the public comment period, submitted two formal comment letters on behalf of UnityPoint Clinic and UnityPoint Accountable Care. These comment letters reflect feedback from the organizations’ leadership and content experts. Key provisions of this lengthy final rule are below:

E/M Services

This continues a series of revisions from the Calendar Year (CY) 2020 rule. First, this is widely considered a “red tape win,” in that it allows the physician the option to use time or medical decision-making when selecting the E/M code level. Second, the rule revalued and ultimately increased E/M service reimbursement, a billing lifeline for primary care providers. Unfortunately, budget neutrality forced reimbursement offsets for other providers, namely specialists, whose reimbursement rates were negatively impacted. Reimbursement rates go into effect on January 1, 2021, and vary by code.

Telehealth and Other Remote Services

With the COVID pandemic as a backdrop and proving ground, CMS finalized many telehealth and related service expansions; however, most “new” services are authorized for Medicare reimbursement on a temporary basis only.

  • Traditional telehealth services grew by nine permanent services, including add-on codes for complexity as well as for prolonged visits. Additionally, CMS authorized 63 temporary telehealth services until the end of the calendar year in which the public health emergency (PHE) expires. New services identified for inclusion during the public comment period are:
Type of Service  Specific Services and CPT Codes 
 1. Permanent addition as Medicare Telehealth Services

 Group Psychotherapy (CPT code 90853)

Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes 99334-99335)

Home Visits, Established Patient (CPT codes 99347- 99348)

Cognitive Assessment and Care Planning Services (CPT code 99483)

Visit Complexity Inherent to Certain Office/Outpatient E/Ms (HCPCS code G2211)

Prolonged Services (HCPCS code g2212)

Psychological and Neuropsychological Testing (CPT code 96121)

 2. Temporary addition as Medicare Telehealth Services through the end of the year in which the Public Health Emergency (PHE) for COVID-19 ends.

 Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes 99336-99337)

Home Visits, Established Patient (CPT codes 99349-99350)

Emergency Department Visits, Levels 1-5 (CPT codes 99281-99285)

Nursing facilities discharge day management (CPT codes 99315-99316)

Psychological and Neuropsychological Testing (CPT codes 96130- 96133 and 96136- 96139)

Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161-97168, 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507)

Hospital discharge day management (CPT codes 99238- 99239)

Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT codes 99469, 99472, 99476)

Continuing Neonatal Intensive Care Services (CPT codes 99478-99480)

Critical Care Services (CPT codes 99291-99292)

End-Stage Renal Disease Monthly Capitation Payment codes (CPT codes 90952, 90953, 90956, 90959, and 90962)

Subsequent Observation and Observation Discharge Day

Management (CPT codes 99217 and 99224-99226)

  • Audio-only assessments or virtual check-ins were authorized temporarily at a lower reimbursement rate. These check-ins will be bundled with in-persons services if performed within 7 days of a previous E/M service or if an E/M service results within the following 24 hours. Virtual check-ins have been used successfully in rural areas and for behavioral health services.
  • Remote patient monitoring (RPM) services were finalized, although these services are limited to existing patient relationships after the PHE. RPM can be furnished to patients with acute conditions as well as chronic conditions and billing may include by non-physician practitioners. Home health agencies have championed this delivery tool.

Scope of Practice and Supervision

CMS finalized flexibilities to promote top of licensure practice. Flexibilities were granted in the areas of:

  • Supervision of diagnostic tests by nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs), certified nurse-midwives (CNMs) and certified registered nurse anesthetists (CRNAs) consistent with state law and scope of practice requirements.
  • Pharmacists providing services incident to physicians’ services, including medication management services, consistent with state law and scope of practice requirements.
  • Provision of maintenance therapy by therapy assistants, either physical therapist assistants (PTA) or occupational therapy assistants (OTA) in Part B settings and as clinically appropriate.
  • Medical record documentation entered by medical team members for PFS services may be reviewed and verified (signed and dated) by the billing physicians, non-physician practitioners or therapists. This similarly applies to documentation entered by therapy or other students.

Teaching physician and resident moonlighting policies were also revised to permit professional training at the top of licensure. Flexibilities include use of audio/visual real-time communication and permanent flexibilities for rural residency training sites.

Additional Requirements

  • Personal Protective Equipment (PPE) – Physicians and certain other practitioners may bill CPT code 99072 as a bundled service on an interim basis. This code is described as “additional supplies, materials, and clinical staff time and above those usually included in an office visit or other non-facility services, when performed during a PHE, as defined by law, due to respiratory-transmitted infectious disease.”
  • Substance Use Disorder Screening – Welcome to Medicare visit and Annual Wellness Visit (AWV) are mandated to include screening for potential substance use disorders and a review of any current opioid prescriptions. As appropriate, these screenings require referrals to treatment/specialists.
  • E-Prescribing of Controlled Substances (EPCS) – Aligning with Part D requirements, CMS mandated all prescribers to conduct e-Rx of Schedule II-V controlled substances using the NCPDP SCRIPT 2017071 standard. This requirement is effective on January 1, 2021, but has a compliance date of January 1, 2022, meaning that enforcement of non-compliance will be delayed until 2022.

Clinical Laboratory Fee Schedule (CLFS)

CMS delayed by one year (January through March 2022) the reporting period of private payer data by certain “applicable laboratories,” including hospital outreach laboratories. The baseline period remains January through June 2019. Additionally, the phase-in of payment cuts for CLFS was extended an additional year, resulting in a 0% reduction for CY 2021, and a 15% reduction cap for CYs 2022 through 2024.

Updates to Certified Electronic Health Record (EHR) Technology

Until December 31, 2022, Quality Payment Program (QPP) participants can use EHR technology certified to either the current 2015 Edition certification criteria OR the 2015 Edition Cures Update. After that date, technology must be certified to the 2015 Edition Cures Update. Additionally, the compliance date for information blocking was delayed and aligned with the Office of the National Coordinator for Health Information Technology (ONC) interim final rule issued on November 4, 2020.

Further Information from CMS on this Final Rule