Advocacy Alert: CMS Releases 2021 Physician Fee Schedule and Hospital Outpatient Prospective Payment System Proposed Rules

The Centers for Medicare & Medicaid Services (CMS) has released the 2021 Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS) proposed rules.
CMS Maintains Contractor Pricing for PET Codes

CMS was persuaded by ASNC and its sister societies and has proposed to 
maintain contractor pricing for the technical component of Myocardial PET services (CPT codes 78432, 78459, 78491, and 78492) for 2021. Additionally, in response to new information provided to CMS by ASNC, the American College of Cardiology and the Society of Nuclear Medical and Molecular Imaging, CMS is proposing to update the price for the nuclide rod source set (ER044) equipment from $1977.2497 to $2,081.17.

CMS is also proposing to:
  • add the ER044 equipment to CPT codes 78432, 78459, 78491, and 78492 as requested, assigning the same equipment time utilized by the “PET Refurbished Imaging Cardiac Configuration” (ER110) equipment in each service;
  • update the useful life of the ER044 equipment to one year instead of 5 years as previously finalized; and
  • remove the “PET Generator (Rubidium)” (ER114) equipment from its database.
ASNC's top-line analysis of other components of the proposed rules is as follows: 

Conversion Factor

For CY 2021, CMS estimates the PFS conversion factor will decrease by $3.83 to $32.26 to maintain budget neutrality arising out of changes associated with the new evaluation and management (E/M) coding and payment structure. The overall impact on cardiology is +1%, although the effect of this significant drop in the conversion factor will vary depending on a practice's mix of services. ASNC is on record asking Congress and HHS to waive budget neutrality and prevent this 11% cut in the conversion factor, and will continue to advocate to prevent this cut.
CMS is proposing to increase payment rates under the Hospital OPPS by a factor of 2.6 percent. 

AUC Mandate 

The Medicare PFS proposed rule is silent on continued implementation of the Medicare Appropriate Use Criteria (AUC) Program for advanced diagnostic imaging, which indicates CMS intends to move forward with the Jan. 1, 2021 program start date. The program is currently in an Educational and Operations Testing Period during which there are no payment consequences associated with the program. ASNC will continue to lead efforts to stop implementation of the program and instead encourage policymakers to support the use of AUC through other quality improvement mechanisms. 

CMS is proposing to create a new category of criteria for adding services to the list of Medicare telehealth services on a temporary basis. Included in this category are services added to the telehealth list during the public health emergency (PHE), but for which there is not yet sufficient evidence available to consider the services as permanent additions. Any service added under the new proposed category would remain on the Medicare telehealth services list through the calendar year in which the PHE ends.

The rule also states that while CMS established during the PHE separate payment for audio-only telephone (E/M) services, it is not proposing to continue to recognize these codes for payment under the PFS in the absence of the PHE for the COVID-19 pandemic. Recognizing the need for audio-only interactions could remain as beneficiaries avoid sources of potential infection, such as a doctor's office, CMS is seeking comment on whether the Agency should develop coding and payment for a service similar to the virtual check-in but for a longer unit of time and subsequently with a higher value, and whether separate payment for such telephone-only services should be a provisional policy to remain in effect for a period after the PHE ends, or if it should be a permanent PFS payment policy.
Office and Outpatient Evaluation and Management Payments

As finalized in the CY 2020 PFS final rule, CMS will largely align its E/M visit coding and documentation policies with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits, beginning Jan. 1, 2021. CMS is proposing a refinement to clarify the times for which prolonged office/outpatient E/M visits can be reported and is proposing to revise the times used for rate setting for this code set.
Scope of Practice

CMS is proposing to make permanent following the COVID-19 PHE the ability of nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs) and certified nurse-midwives (CNMs) to supervise the performance of diagnostic tests in addition to physicians. If finalized on a permanent basis effective Jan. 1, 2021, NPs, CNSs, PAs and CNMs would be allowed under the Medicare Part B program to supervise the performance of diagnostic tests within their state scope of practice and applicable state law, provided they maintain the required statutory relationships with supervising or collaborating physicians.

Continuation of Q9969 (Non-heu tc-99m add-on/dose)

CMS intends to continue the policy that provides an additional $10 add-on payment for radioisotopes produced by non-HEU sources.

More Details to Come

CMS anticipates release of the final rules will be delayed as a result of the agency's COVID-related efforts, but the effective date for policy changes will remain Jan. 1, 2021.

ASNC will release further analysis of the proposed rules in the days ahead and will work with ASNC leaders to develop comments in response to these and other proposals.

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