Neurosurgery Coding Alert

In one of the more surprising CY 2021 proposals, CMS aims to cut the conversion factor (CF) by 10.61 percent. According to the proposed rule, Section 101(a) of MACRA changed the way the CF is calculated; plus, the office/outpatient E/M payment rate changes influenced the agency’s decision to reduce the CF.

“With the budget neutrality adjustment to account for changes in [relative value units] 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,” CMS indicates.

Public outcry: As expected, industry organizations are rattled by the major CF dip, especially in the midst of COVID-19 spikes. Backing up cash-strapped providers, the American Medical Association (AMA) urged Congress to get involved before the final rule is released later this year.

“The AMA appreciates that CMS will implement significant increases to the payment for office visits, based on recommendations on resource costs from the AMA/Specialty Society RVS Update Committee (RUC),” acknowledged AMA President Susan R. Bailey, MD in a statement. “Unfortunately, these office visit payment increases, and a multitude of other new CMS proposed payment increases, are required by statute to be offset by payment reductions to other services, through an unsustainable reduction of nearly 11 percent to the Medicare conversion factor.”

Bailey added “For this reason, the AMA strongly urges Congress to waive Medicare’s budget neutrality requirement for the office visit and other payment increases. Physicians are already experiencing substantial economic hardships due to COVID-19, so these pay cuts could not come at a worse time.”

Get Ready for 2021 E/M Changes

In the CY 2020 final rule, CMS solidified long-awaited changes to office/outpatient evaluation and management (E/M) policies and payment rates. The CY 2021 proposed rule explains the final steps and the rollout.

Policies: “As finalized in the CY 2020 PFS final rule, in 2021 we will be largely aligning our 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,” says CMS in a fact sheet on the rule. “We are proposing a refinement to clarify the times for which prolonged office/outpatient E/M visits can be reported and are proposing to revise the times used for rate setting for this code set,” the agency adds.

Expect a Post-COVID Telehealth Expansion

The Medicare telehealth expansion has been a real benefit to many providers hit hard by the pandemic. CMS published interim final rules in March and May that streamlined telehealth and gave clinicians more care options with a plethora of 1135 waivers in place as part of the public health emergency (PHE).

“Most of these regulatory flexibilities are set to sunset upon the expiration or termination of the PHE,” warns international law firm Dentons in online analysis.

Now: “The CY 2021 PFS proposed rule includes proposals to maintain an expanded list of Medicare-covered telehealth services and remote service flexibilities until the end of the CY in which the COVID-19 PHE ends, or in some cases beyond, and to clarify existing policies for remote services,” the Dentons’ attorneys note.

“Several types of services would be permanently approved for delivery via telehealth, including traditional home visits for evaluating and managing patient treatment and certain provider visits for patients with cognitive impairments,” counsels New York-based attorney Ada Kozicz with Rivkin Radler in the Rivkin Rounds blog.

Kozicz adds, “CMS believes that this expansion will provide enough time for CMS and key stakeholders to consider whether such services should be permanently approved for delivery via telehealth.”

A few of the telehealth-related proposed rule highlights include:

• Permanently add some services from the Medicare telehealth list.
• Create a temporary addition list through the PHE called “Category 3.”
• Cut frequency limits for skilled nursing facilities (SNFs).
• Permit direct supervision using real-time, interactive audio and video technology (excluding telephone that does not also include video) through Dec. 31, 2021.

Reminder: The CARES Act temporarily removed geographic and originating site barriers for Medicare telehealth services. “The proposed rule does not address these provisions because CMS is limited by statute and cannot permanently expand the list of telehealth providers. CMS notes that making these flexibilities permanent requires an act of Congress,” explains Miranda Franco, senior policy advisor with Holland & Knight LLP in Washington D.C., in a blog post.

Direct Supervision Updates Extended

CMS adopted an interim final policy for the duration of the public health emergency (PHE) related to the COVID-19 pandemic that revised the definition of “direct supervision.” The new definition included virtual presence of the supervising physician or practitioner using interactive audio/video real-time communications (85 FR 19245). The update was made because CMS realized that, in some cases, the physical proximity of the provider might increase infection exposure risk to the patient and/or provider.

Update: The CY 2021 MPFS proposed rule allows direct supervision to be provided using real-time, interactive audio/video technology through Dec. 31, 2021 (excluding telephone calls that do not also include video).

The proposed rule also includes interim policy changes for supervision services of teaching physicians: Teaching physicians may use audio/video real-time communications technology to interact with a resident through virtual means, to meet the requirement of being present for the key portion of the service.

An excerpt of the proposed rule reads: “While flexibility to provide direct supervision through audio/video real-time communications technology was adopted to be responsive to critical needs during the PHE to ensure beneficiary access to care, reduce exposure risk and to increase the capacity of practitioners and physicians to respond to COVID-19, we are concerned that direct supervision through virtual presence may not be sufficient to support PFS payment on a permanent basis, beyond the PHE, due to issues of patient safety. In complex, high-risk, surgical, interventional, or endoscopic procedures, or anesthesia procedures, a patient’s clinical status can quickly change. To permit payment under the PFS for these teaching physician services, we believe the services must be furnished with a certain level of personal oversight and involvement of the teaching physician who has the experience and judgment that is necessary for rapid on-site decision-making during these procedures.”

Editor’s note: You can review the MPFS proposals at https://s3.amazonaws.com/public-inspection.federalregister.gov/2020-17127.pdf.