2021 MPFS Proposed Rule

August 19, 2020

Kayley JaquetManager of Regulatory Affairs

Agenda

• AUC/CDS

• Fee Schedule

• Telehealth

• Supervision of Diagnostic Tests

• Quality Payment Program (QPP)

• Merit-Based Incentive Program (MIPs)

• Updates

• MVPs

• Alternative Payment Models (APMs)

• Updates

• APPs

Appropriate Use Criteria/Clinical Decision Support

Appropriate Use Criteria/Clinical Decision Support

AUC/CDS program not included in 2021 proposed rule

HOWEVER….

Appropriate Use Criteria/Clinical Decision Support

August 10th – CMS updated their website with the following

notice

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/Appropriate-Use-Criteria-Program

Appropriate Use Criteria/Clinical Decision Support

CMS is extending the testing year through 2021

January 1st, 2020 – December 31st, 2021

Operational Testing period

• AUC/CDS documentation required but no impact on claims if missing or

incorrect

January 1st, 2022 – Full Implementation

• CMS will not pay claims that are missing AUC/CDS documentation

Fee Schedule

Fee Schedule

Proposed Conversion Factor - $32.26

• Decrease of - $3.83 from 2020 CF of $36.09

• Anesthesia Factor - $19.96

• Decrease of - $2.05 from 2020 CF of $22.20

Fee Schedule - E/M Codes

• CMS decreased the number of levels for new patient (office or out patient) E/M visits to 4.

• Deletes Level 1 (99201) for new patients

• Established patient E/M visit levels remain at 5

• CMS will pay at each level of service rather an utilize a blended rate which was proposed/finalized in 2019 rule

• Coding for E/M visits revised to be based on time spent with patient and medical decision making

• History and exam only required when medically appropriate

Fee Schedule - E/M Codes

E&M Code 2020 RVUs 2021 RVUs

New Patients

99201 0.48 Removed

99202 0.93 0.93

99203 1.42 1.60

99204 2.43 2.60

99205 3.17 3.50

Established Patients

99211 0.18 0.18

99212 0.48 0.70

99213 0.97 1.30

99214 1.50 1.92

99215 2.11 2.80

In addition to moving forward with E/M code changes, CMS proposed reevaluation of the following code sets:

• End-Stage Renal Disease (ESRD) Monthly Capitation Payment (MCP)Services

• Transitional Care Management (TCM) Services

• Maternity Services

• Cognitive Impairment Assessment & Care Planning

• Initial Preventive Physical (IPPE) Examination & Initial & Subsequent Annual Wellness (AWV) Visits

• Emergency Department Visits

• Therapy Evaluations

• Psychiatric Diagnostic Evaluations & Psychotherapy Services

Fee Schedule – Impact by Specialty

Specialty ImpactNurse Anes. / Anes. Assistants -11%

Radiology -11%

Cardiac Surgery -9%

Interventional Radiology -9%

Pathology -9%

Physical/Occupational Therapy -9%

Anesthesiology -8%

Nuclear Medicine -8%

General Surgery -7%

Radiation Oncology -6%

Colon And Rectal Surgery -5%

Gastroenterology -5%

Orthopedic Surgery -5%

Hand Surgery -3%

Dermatology -2%

Podiatry -1%

Clinical Psychologist 0%

Physician Assistant 8%

Allergy/Immunology 9%

Family Practice 13%

Endocrinology 17%

CMS moving forward with

changes to E/M coding and

reimbursement as finalized in

the 2020 MPFS

Specialties that commonly bill

E/M codes may see increases of

up to 17%

Specialties that do not are

expected to see decreases of up

to -11%

FULL TABLE AVAILABLE HERE

Telehealth

Telehealth

The COVID-19 PHE rapidly expanded telehealth utilization and access for Medicare beneficiaries

• Pre-PHE - ~ 14,000 beneficiaries received telehealth care per week

• CMS estimates 10.1 million beneficiaries have utilized telehealth between March – July

Temporary waivers and flexibilities granted by CMS/HHS during the PHE allowed providers and beneficiaries to quickly shift to telemedicine services.

CMS proposes to adopt some flexibilities on a permanent or semi-permanent basis

Telehealth

Permanent additions to the CMS Telehealth list

During the PHE, CMS added 135 CPTs to their list of payable services

that can be delivered via telehealth

• CMS proposes to make 9 CPTs permanent additions

Temporary additions to the CMS Telehealth list

CMS proposing a third category of criteria to add services to the

telehealth list on a temporary basis

• CMS proposing to add 13 CPTs to the list if the “Category 3” criteria is finalized

• Allows temporary codes to stay on list until the end of the calendar year when a

PHE occurs

https://www.cms.gov/Medicare/Medicare-General-

Information/Telehealth/Telehealth-Codes

Telehealth

Proposed Permanent Additions Proposed Temporary ‘Category 3’ Additions

99483 Care Planning for Patients with

Cognitive Impairment

99336, 99337 Domiciliary, Rest Home, or Custodial

Care services, Established Patients

99334, 99335 Domiciliary, Rest Home, or

Custodial Care

99281, 99282,

99283

Emergency Department Visits

90853 Group Psychotherapy 99349, 99350 Home Visits, Established Patient

99347, 99348 Home Visits 99315, 99316 Nursing facilities discharge day

management

96121 Neurobehavioral Status Exam 96130, 96131

96132, 96133

Psychological and

Neuropsychological Testing

99XXX New E/M prolonged service add-

on code

GPC1X New E/M visit complexity add-on

code

Telehealth

Direct Supervision via Telehealth

• CMS is proposing to continue this flexibility outside of waiver

authority until December 31, 2021 or the end of the PHE

CMS is NOT proposing:

• Continue to pay for ‘audio only’ telehealth codes – but is

seeking suggestions for an alternative to ‘virtual check in’

codes

• Change the originating site restrictions

• Permanent changes require Congressional legislation

Supervision of Diagnostic Tests

Physician Supervision

CMS is proposing to permanently allow NPs, CNSs, PAs, and

CNMs to supervise the performance of diagnostic tests

• Currently permitted under PHE waiver

• If finalized, these non-physician practitioners would be

permitted to supervise diagnostic tests within their state

scope of practice

• Provided statutory relationships with supervising or collaborating

physicians is maintained

Quality Payment Program

MIPS Program Updates

2021 Performance Year Proposals

• Penalty threshold – 50 pts

• Currently set at 60 pts by the 2020 final rule

Performance Category Weights

• Quality – 40% (- 5%)

• Cost – 25% (+ 5%)

• Improvement Activities – 15%

• Promoting Interoperability – 20%

***CMS is required to weight Quality and Cost equally by 2022***

No changes to program eligibility or maximum payment adjustments

MIPS Program Updates

Performance Year Payment Year Max Payment

Adjustments

Performance

Threshold

Exceptional

Performance Threshold

Payment

Adjustments

2017 2019 (+/ - ) 4% 3 pts 70 pts 1.88%

2018 2020 (+/ - ) 5% 15 pts 70 pts 1.68%

2019 2021 (+/ - ) 7% 30 pts 75 pts (1.79%)

4.67% **

2020 2022 (+/ - ) 9% 45 pts 85 pts 6.25% **

2021 2023 (+/ - ) 9% 50 or 60 pts 85 pts 6 – 8 % **

2022 2024 (+/ - ) 9% 74 – 86 ** 90 – 95 ** 8+%**

Historical Performance Year Thresholds

**CMS forecast

CMS is required to set performance thresholds to mean or

median performance rates by 2022

MIPS Program Updates

2020 and 2021 Program Flexibilities

• 2020 PY

• Complex Patient Bonus

• Max of 10 pts towards total score

• COVID-19 hardship application

• Adding option for APMs to apply

• 2021 PY

• Using current year performance benchmarks for quality scoring

OR

• Using 2020 PY benchmarks instead of historical benchmarks

MIPS Program UpdatesProposed Quality Measure Updates

• Substantive changes to 112 existing MIPS quality measures

• Telehealth and eCQM instructions – common theme

• Removal of 14 quality measures

• Adding 2 new administrative claims outcome quality

measures

• Unique case-minimums for claims-based measures

MIPS Program Updates

Quality Measure Proposed for Removal

24Communication with the Physician or Other Clinician Managing On-Going Care Post-Fracture for Men and Women

Aged 50 Years and Older

48 Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older

69 Hematology: Multiple Myeloma: Treatment with Bisphosphonates

146 Radiology: Inappropriate Use of “Probably Benign” Assessment Category in Screening Mammograms

333 Adult Sinusitis: Computerized Tomography (CT) for Acute Sinusitis (Overuse)

337Psoriasis: Tuberculosis (TB) Prevention for Patients with Psoriasis, Psoriatic Arthritis and Rheumatoid Arthritis on a

Biological Immune Response Modifier

348 Implantable Cardioverter-Defibrillator (ICD) Complications Rate

390 Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options

408 Opioid Therapy Follow-up Evaluation

412 Documentation of Signed Opioid Treatment Agreement

414 Evaluation or Interview for Risk of Opioid Misuse

437 Rate of Surgical Conversion from Lower Extremity Endovascular Revascularization Procedure

458 All-Cause Hospital Readmission

MIPs Value Pathways (MVPs)

MIPS Value Pathways

• CMS is proposing to delay the start of MIPs Value Pathways

(MVPs) until 2022

• MVPs – condition or specialty-specific groups of cost,

quality and improvement measures with a foundation of the

promoting interoperability category.

MIPS Value Pathways

CMS aims to reduce clinician burden and streamline reporting

requirements

• How are MVPs different than MIPS?

• Clinicians no longer have to select measures from large pool

• CMS will assign MVPs to groups or clinicians based on provider

specialty or clinical condition

• All measures within an MVP are required

• Examples from CMS show reduced number of measures

• 3 Quality measures

• 1 to 2 Improvement Activities

• 2 Cost measures

Alternative Payment Models (APMS)

APM QPP UpdatesProposed Removal of the MIPs ‘APM’ Scoring Standard

• Participants in a ‘MIPs APM’ are subject to different category

weights:

• Quality: 50 %

• Improvement Activities: 20 %

• Promoting Interoperability: 30 %

• Cost: 0 %

• APM Entities would become a ‘submitter type’

• Allowing participants to continue to submit through their APMs

APM QPP UpdatesDiscontinuing CMS Web Interface Submission

• Web Interface most commonly used by Accountable

Care Organizations (ACO)

• Web Interface measures are duplicative of existing MIPs

CQM or eCQM measures

CMS believes removing this option will better align with future

‘value pathway’ framework

APM Performance Pathway (APP)

APM Performance Pathway

CMS is proposing a similar framework as MVPs but

for APM and ACO participants for 2022

• APPs would be optional for APMs but mandatory for ACO’s who

participate in the Medicare Shared Savings Program (MSSP)

• Same concept as an MVP but not specific to

specialties/conditions

APM Performance Pathway

APP for APM participants

QualityPromoting

Interoperability

Improvement

ActivitiesCost

CAHPS for MIPS

All standard

measures in the PI

category

Automatic score

of 100%None

Diabetes: Hemoglobin A1c (HbA1c) Poor Control

Preventive Care and Screening: Screening for

Depression and Follow-up Plan

Controlling High Blood Pressure

(New) Hospital-Wide, 30-day, All-Cause

Unplanned Readmission (HWR) Rate

(New) Risk Standardized, All Cause Unplanned

Admissions for Multiple Chronic Conditions for

ACOs

APM Performance Pathway

APP for ACO (MSSP) participants

QualityPromoting

Interoperability

Improvement

ActivitiesCost

CAHPS for MIPS

Not required to participate in the remaining MIPs

categories

Diabetes: Hemoglobin A1c (HbA1c) Poor Control

Preventive Care and Screening: Screening for

Depression and Follow-up Plan

Controlling High Blood Pressure

(New) Hospital-Wide, 30-day, All-Cause

Unplanned Readmission (HWR) Rate

(New) Risk Standardized, All Cause Unplanned

Admissions for Multiple Chronic Conditions for

ACOs

Comment Period and Final Rule

Comments on the proposed rule are open until

October 5th

CLICK HERE for the 2021 Proposed Rule on the Federal Register

Final rule is anticipated early December

Questions?Kayley.Jaquet@radadvocate.com

Thank you!