Medicare Compliance & Reimbursement

Hint: Endocrinologists can expect some big gains next year.

There’s no denying that 2020 was a tough year for providers of all types and sizes, and many were hoping for a boost in 2021. Unfortunately, Medicare’s significant conversion factor cut, which starts on Jan. 1, capsized many specialists’ forecasts for smooth sailing next year.

Details: According to the calendar year (CY) 2021 Medicare Physician Fee Schedule (MPFS) final rule — dropped on Nov. 30 and slated for publication in the Federal Register on Dec. 28 — the Centers for Medicare & Medicaid Services (CMS) couldn’t deliver on a conversion factor (CF) boost for next year. Instead, the agency decided to impose a 10.2 percent decrease, dropping the CF from the 2020 rate of $36.0896 to $32.4085 for CY 2021.

Why? This historic cut was due to CMS’ decision to increase reimbursement for the office/outpatient E/M visit codes (99202-99215) — a boon for some specialists who utilize the services often and a fiscal liability for those who don’t. Moreover, this increased spending triggered a significant budget neutrality adjustment, as required by law and was “necessary to account for changes in relative value units [RVUs] and expenditures that would result from finalized policies,” notes a CMS fact sheet on the final rule.

Consider This Conversion Factor Refresh

Though it’s impossible to determine what the overall impact of the office/outpatient E/M code revamp will be next year, it’s a good idea to review what RVUs entails and how they are established.

The MPFS determines various values for codes depending on the setting/site (facility or non-facility) where a clinician performs the service or procedure. For some services, the total RVUs for a given procedure are the same in a facility or a non-facility setting. However, in some circumstances, the two totals differ.

The facility and non-facility totals for RVUs are the combined impact or sum of three different components. They include the following:

• Physician work RVUs: These cover the cost of the provider’s work. Work RVUs deal with the “relative time and intensity associated with furnishing a Medicare PFS service,” explains the “How to Use the Searchable MPFS” booklet.
• Practice expense RVUs: These concern the cost of supplies, equipment, and staff salaries.
• Malpractice expense RVUs: These have to do with the cost of professional liability expenses.

Geography: RVUs also vary geographically. “These adjustments are called GPCIs [Geographic Practice Cost Indices], and each kind of RVU component has a corresponding GPCI adjustment,” the agency guidance says. Thus, each component RVU (physician work, practice expense, and malpractice) is multiplied by its own GPCI for the payment locality where the service is rendered. After that, the RVU components are added together then multiplied by the CF; this total translates to the MPFS payment rate for an individual service, according to CMS.

Important: Remember, private payers and other public payers may use different conversion factors for setting their fees — even if they use the same RVUs as Medicare.

Find the MPFS booklet at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/How_to_MPFS_Booklet_ICN901344.pdf.

Who Came Out Ahead and Who Fell Behind

Endocrinologists and rheumatologists are expected to see some major gains in 2021 due to the E/M changes while feds estimate that radiologists’ and nurse anesthetists’ bottom lines will be negatively impacted.

“Unfortunately cutting the conversion factor means that a lot of services other than E/M are cut severely,” says Stephanie A. Thebarge, CPC, CPMA, CPPM, CEMC, CHONC, PESC, AAPC National Advisory Board member and compliance manager at New England Cancer Specialists in Scarborough, Maine. “If specialists provide imaging or surgeries, it will definitely be felt by these practices. The best thing will be to look at the loss of revenue in the other services and make sure the providers are not underwater in those categories — meaning paying more for having the radiology equipment than getting reimbursed.”

Reminder: The CARES Act temporarily suspended the 2-percent sequestration payment adjustment for FFS claims back in May, but the suspension is scheduled to end on Dec. 31. “Let’s not forget in 2021 the 2-percent sequestration will also be coming back, so all and all this negatively impacts providers,” Thebarge warns.

Thebarge points out that it’s not all bad news. “Keep in mind that there will be new codes and new services to bill for in 2021, including the visit complexity code G2211 [Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)]. This may create additional reimbursement for specialists who feel the crunch,” she acknowledges.

Here’s a glance at the specialties that CMS anticipates will experience the biggest increases and decreases in CY 2021:

(Source: TABLE 106: CY 2021 MPFS Estimated Impact on Total Allowed Charges by Specialty)

Rule Comments Highlight Providers’ Reimbursement Woes

Several commenters asked the Department of Health and Human Services (HHS) Secretary to intercede with a waiver to stop the budget neutrality cut as part of the COVID-19 public health emergency (PHE). Many questioned why CMS couldn’t just “implement the revaluations to the office/outpatient E/M visits, analogous services, and HCPCS code G2211” without the CF decrease, mentions the final rule.

Commenters also urged the agency to “exempt specialties that do not predominantly bill for office/outpatient E/M services from the budget neutrality adjustment,” the rule states. Additional analysis requests on the finalized policies also fell on deaf ears.

“While we understand the concerns articulated by the commenters, we reiterate that section 1848(c)(2)(B)(ii)(II) of the [Social Security] Act requires that increases or decreases in RVUs may not cause the amount of expenditures for the year to differ by more than $20 million from what expenditures would have been in the absence of these changes,” CMS maintains. “If this threshold is exceeded, we make adjustments to preserve budget neutrality.”

According to the final rule, “the Secretary’s waiver authority pursuant to the public health emergency declaration for COVID-19 does not extend to authorize changes to the PFS outside of budget neutrality. Additionally, section 1848 of the Act does not grant the Secretary the authority to exempt categories of physicians or practitioners from the budget neutrality adjustments.”

On the horizon: Two separate Congressional bills with bipartisan sponsorship suggest that the House of Representatives is looking at the possibility of offering Medicare providers some relief in 2021. “Reps. Michael Burgess (R-Texas) and Bobby Rush (D-Ill.) introduced H.R. 8505, which would provide a one-year waiver of budget neutrality adjustments in the physician fee schedule,” notes

Miranda Franco, senior policy advisor with Holland & Knight LLP in Washington D.C., in online analysis.

“Reps. Ami Bera (D-Calif.) and Larry Bucshon (R-Ind.) introduced H.R. 8702, which would hold providers harmless for cuts by giving them an additional payment that would bring their overall reimbursement up to the 2020 physician fee schedule levels for two years,” Franco mentions. “The Senate is also exploring a phase-in approach,” she adds.

Resource: Review the final rule at https://public-inspection.federalregister.gov/2020-26815.pdf.