Article - CMS: Proposed Physician Fee Schedule for CY 2021

The law which establish a physician fee schedule:

The Social Security Act requires the CMS to set up payments under the Medicare Physician Payment Schedule based on nationally uniform relative value units (RVUs) that account for the relative resources utilized in furnishing a service.

The Centers of Medicare and Medicaid Services (CMS) released the proposed physicians fee schedule for CY 2021 on Aug 3, 2020. Due to this proposal physicians will see a reduced conversion factor from $36.09 to $32.26, effective Jan. 1, 2021. 

Comment Period for CY 2021 Physician Fee Schedule

Aug 4, 2020, the CY 2021 Medicare Physician Fee Schedule Proposed Rule with comment period was placed on display at the Federal Register. This proposed PFS rule updates payment policies, payment rates, and other provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after Jan. 1, 2021.


CY 2021 PFS Rate setting and Conversion Factor

CMS is proposing a series of standard technical proposals involving practice expense, including the implementation of the third year of the market-based supply and equipment pricing update, and standard rate-setting refinements to update premium data involving malpractice expense and geographic practice cost indices (GPCIs).

With the budget neutrality adjustment to account for changes in RVUs, as required by law, the proposed CY 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09.

New Telehealth Codes

CMS added new 9 CPT codes to the 2021 list, covering a variety of services:

Code 99347 and 99348 (Home Visits)

Code 99334 and 99335 (Domiciliary, Rest Home or Custodial Care Services)

99483 (Care Planning for Patients with Cognitive Impairment)

96121 (Neurobehavioral Status Exam)

90853 (Group Psychotherapy)

99XXX (Prolonged Services)

GPC1X (Visit Complexity Associated with Certain Office/Outpatient E/Ms)

One notable service omitted from this list is proposed CPT 96040, which would have allowed genetic counselors to bill for telehealth services.

In addition, CMS has proposed creating a separate category for codes added to the list to cover telehealth services during the COVID-19 emergency. Some 50 codes have been created during the pandemic are included in this Category 3, along with 13 new codes, covering Domiciliary, rest Home or Custodial Care Services – Established Patients (99336, 99337 and 99349), Home Visits – Established Patients (99350), Emergency Department Visits (99281, 99282 and 99283), Nursing Facilities Discharge Day Management (99315 and 99316), Psychological and Neuropsychological Testing (96130, 96131, 96132 and 96133).

Direct Supervision via Telehealth and Incident-to-Billing

CMS is expanding the telehealth platform to allow supervising physicians – who previously had to be in the building and immediately able to assist in a clinical procedure – to supervise via real-time, interactive, audio-visual telemedicine.

CMS is limiting the time frame of this change to the 2021 year and asking for comments on whether additional “guardrails” are needed to make the change permanent.

Emergency Limitations for Nursing Facility and Hospital Inpatient Services

CMS is proposing to increase the frequency of nursing facility care services provided via telehealth from once every 30 days to once every three days. The agency is also asking for comments on a proposal that the frequency limitation be eliminated, and how best to balance virtual and in-person care in that case.

Communications Technology-Based Services (CTBS)

CMS is proposing to expand the list of providers able to bill for telehealth services through HCPCS codes G2061-G2063 to include licensed clinical social workers, clinical psychologists, physical and occupational therapists, and speech-language pathologists who bill Medicare directly for their services. This would make permanent coverage now allowed under an emergency waiver.

In addition, the agency proposes to create two additional codes – G20X0 and G20X2 - for billing by non-physician practitioners who can’t independently bill for E/M services.

To help therapists bill for their service, the agency is proposing that HCPCS codes G20X0, G20X2, G2061, G2062, and G2063 be designated “sometimes therapy” services.


Trump’s Executive Order, meanwhile, sets out timetables for certain goals. Within 30 days, he says:

The Health and Human Services Department must develop an “innovative payment model to enable rural healthcare transformation;”

The HHS Secretary and Secretary of Agriculture must “develop and implement a strategy to improve rural health by improving the physical and communications healthcare infrastructure available to all Americans;” and

The HHS Secretary must report on existing and future policy initiatives to increase access to healthcare by removing regulatory burdens, “prevent disease and mortality” by developing incentives to improve rural outcomes, “reduce maternal mortality and morbidity” and improve mental health services in rural areas.

Trump gives the HHS Secretary 60 days, meanwhile, to review the emergency measures enacted during the pandemic to improve telehealth coverage and access and “propose a regulation to extend these measures, as appropriate, beyond the duration” of the public health emergency.

Published By - Medical Billers and Coders
Published Date - Aug-17-2020 Back

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