3 Ways to Prepare For The 2021 Physician Fee Schedule

2021 Physician Fee Schedule

Spiking COVID-19 cases and the presidential election may have diverted attention away from the 2021 Physician Fee Schedule, but that doesn’t mean that revenue cycle leaders can afford to drop the ball as they wait for CMS to release its final rule.

And even though CMS was late to release the proposed rule—which in turn pushed back the public comment period and the final rule’s publication—don’t count on other delays.

“There is, however, no indication that this will delay the effective date of the rule,” say revenue cycle experts Taya Moheiser, CMPE, CMOM, and Kem Tolliver, BS, CMPE, CPC, CMOM.

Moheiser is owner of ITS Healthcare LLC, as well as president of HIMSS Nebraska and an MGMA Government Affairs Council member. Tolliver is president of Medical Revenue Cycle Specialists, and president of the Hyattsville/PG County chapter of AAPC. They’re also the authors of Revenue Cycle Management: Don’t Get Lost in the Financial Maze.

With less than 60 days until 2021, we asked Moheiser and Tolliver about three key issues to watch for.

HealthLeadersCan you tell us about the big E/M changes to pay attention to?

Moheiser and Tolliver: Though this has been on deck for a while now, it’s important to remember that 99201 is projected to disappear in 2021. The utilization rate was extremely low, and all indications are that this will be finalized in the CY2021 rule. The bigger shift for many is the coding framework. CMS has projected to modify coding and required documentation to be based upon either time or MDM (Medical Decision Making).

It is worth noting that Medicare Advantage plans are required to follow Medicare guidelines; however other payers are not. Organizations should check with commercial, state, and other payers to determine their policies related to E/M code use and reimbursement for 2021.

Key 2021 E/M modifications include:

  • Leveraging CPT Editorial Panel’s new time range descriptions for affected CPT Codes
  • Deletion of 99201 for Level 1 New Patients
  • Addition of 99XXX for prolonged services
  • Addition of GPC1X add on code for single serious, or complex chronic condition
  • Removal of history and exam elements in scoring CPT levels
    • Use of Medical Decision Making or time spent for scoring CPT levels
  • Removing 99441-99443 audio only CPT codes
  • Direct supervision policy extension through 12/31/21; allowing a supervising provider to utilize interactive real-time audio/video communication technology platform
  • Remote Physiologic Monitoring (RPM) may be billed for both new and established patients during the Public Health Emergency (PHE) 99453-99454; 99091
  • Permanently adding the following Telehealth CPT codes:
    • Group Psychotherapy 90853
    • Home visits 99347-99348

HL: What about the reimbursement impacts?

TM and KT: CMS’ reimbursement changes, as always, have a net neutral goal. This means some specialties will see an increase as others will see a decrease.

The confirmation is of course dependent upon the finalization of this proposed rule and is primarily due to the large increases in Work RVU evaluations (up 9%) and Physician Expense RVUs (up 5%).

wRVU Changes

New Pt CPT Work RVU 2019 Time 2021 Time MDM
99201 Deletion of CPT code
99202 0.93 20 min 15-29 min Straight-Forward
99203 1.60 30 min 30-44 min Low Complexity
99204 2.60 45 min 45-59 min Moderate Complexity
99205 3.50 60 min 60-74 min High Complexity


Estab. Pt CPT Work RVU 2019 Time 2021 Time MDM
99211 0.18 5 min 7-14 min None
99212 0.70 10 min 15-29 min Straight-Forward
99213 1.30 15 min 30-44 min Low Complexity
99214 1.92 25 min 45-59 min Moderate Complexity
99215 2.80 40 min 60-74 min High Complexity

Another notable item related to reimbursement? The conversion factor (CF) is proposed to decrease to $32.26. The proposed 2021 CF is a $3.83 decrease from the current 2020 CF. This change equates to roughly an 11% decrease. The proposed 2021 anaesthesia CF is $2.24 decrease from the 2020 CF.

Conversion Factor Changes Over Time

2016 2017 2018 2019 2020 2021
$35.80 $35.89 $35.99 $36.04 $36.09 $32.26
Increase Increase Increase Increase Increase DECREASE

The CF is a major component of the overall Medicare Physician payment methodology and significantly impacts reimbursement rates across the fee schedule.

Also, make note of the delay in lab payment reductions. According to the proposal, CMS will not implement the previously planned reductions to the Clinical Laboratory Fee Schedule (CLFS) in 2021. This is not projected to amend the dates being reported on, it is only projected to amend the dates that reporting will be performed.

HLFinally, how might the rule impact telehealth?

TM and KT: If the proposed rule is finalized, telehealth will see significant expansion, including adding permanency to nine services, adding thirteen services temporarily (until the end of the calendar year in which the public health emergency ends), changes to frequency limitations on nursing facility visits. Also proposed is the discontinuation of audio-only visits (99441-99443) and clarification on remote physiological monitoring (RPM) or wearables monitoring.

HLWhat are some of your thoughts on next steps?

TM and KT: There are three things to keep in mind now as we eagerly await the CY 2021 final rule:

First, this is not finalized, expect to see the final rule released sometime around early December 2020. Review and analyze the changes that will impact your organization. Create an action plan to address potential changes in care delivery, regulatory compliance, coding, and reimbursement.

Second, this article does not represent all of the details included in the proposed rule.  Dig into areas that will impact your practice and keep in mind that the period to submit comments to CMS in regard to this rule has passed (October 5, 2020).

Finally, consider using these steps to get started on your 2021 action plan:

  • Prioritize the management of chronic illnesses
  • Work with EMR/PM software to customize template removing H & P
  • Brush up on time-based coding principles
  • Brush up on MDM coding principles
  • Stay in touch with your MAC on regional updates
  • Download and analyze the 2021 MPFS as it’s available

For more information: https://www.healthleadersmedia.com/revenue-cycle/3-ways-prepare-2021-physician-fee-schedule