Medicare Physician Fee Schedule Update
September 2, 2021
The AAAAI is sending a letter to the Centers for Medicare and Medicaid Services (CMS) regarding proposed Calendar Year 2022 Payment Policies Under the Physician Fee Schedule and other proposed regulations on behalf of its members. AAAAI comments emphasize the impact on physician payment and the proposed conversion factor, clinical labor pricing, telehealth and virtual care, MIPS Value Pathways (MVPs), Qualified Clinical Data Registry (QCDR) Policies, and other issues, including concerns raised by members of the AAAAI Committee on the Underserved. Read more here.
July 26, 2021
Hart Health Strategies, the AAAAI’s expert government relations consulting team, has provided extensive summaries of the CMS 2022 proposed fee schedule. Reflecting the rule itself, the summary is divided into parts: one focuses on payment and other policy provisions; the other focuses on the quality programs and alternative payment models. Please also see this list of items from the rule that are of particular interest to the allergy / immunology specialty.
The AAAAI will be preparing comments to provide feedback on a range of the proposed changes. The final rule is expected to be published on November 1.
July 23, 2021
The AAAAI has urged with others that Congress and the Administration make a critical investment in the nation’s health care delivery system by maintaining its 3.75% increase to the conversion factor through at least calendar years 2022 and 2023. Read the letter here.
July 13, 2021
The Centers for Medicare and Medicaid Services (CMS) released its CY 2022 Medicare Physician Fee Schedule (PFS) proposed rule. As is customary, CMS makes changes to the physician fee schedule (PFS) and other Medicare Part B payment policies. In addition, CMS updates the Quality Payment Program and makes changes to Medicare Shared Savings Program requirements. CMS also updates certain Medicare provider enrollment policies, makes requirements for pre-payment and post-payment medical review activities and for electronic prescribing for controlled substances for a covered Part D drug under a prescription drug plan, or a Medicare Advantage Prescription Drug (MA-PD) plan. CMS estimates the CY 2022 PFS CF to be $33.5848, a drop from the current (CY 2021) CF of $34.8931.
February 1, 2021
The AAAAI submitted comments on the CY 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, including its interim final policies on Coding and Payment for Virtual Check-in Services and for Personal Protective Equipment (PPE) (CPT code 99072). Read more.
January 14, 2021
On January 14, 2021, the Centers for Medicare and Medicaid Services (CMS) released a fact sheet, Physician Fee Schedule (PFS) Payment for Office/Outpatient Evaluation and Management (E/M) Visits that provides additional information and guidance on recent changes to E/M services as a result of the CY 2021 PFS final rule.
Complex Care Add-on Code
In the CY 2021 PFS, CMS finalized an “add-on” code for visit complexity, HCPCS G2211. However, payment for the code was delayed under the Consolidated Appropriations Act, 2021, until January 1, 2024 or later. According to the CMS notice, “Practitioners may report this code for qualifying visits furnished on or after January 1, 2021, although we assigned a PFS payment status indicator of ‘B’ (Bundled) until 2024.”
Implementation of this add-on codes is anticipated to increase reimbursement for Allergy/Immunology professionals and other cognitive specialties. Therefore, we encourage AAAAI members to report this code with their E/M services (i.e., CPT 99202 – 99215). This will help CMS understand how the code would be used, as well as revise its budget neutrality estimates when the code is able to be reimbursed in CY 2024.
Medical Review of E/M
CMS also discusses medical review when practitioners use time to select visit level, stating that, “Our reviewers will use the medical record documentation to objectively determine the medical necessity of the visit and accuracy of the documentation of the time spent (whether documented via a start/stop time or documentation of total time) if time is relied upon to support the E/M visit.”
It is necessary to appropriately document time in the medical record when it is used for E/M code selection. This may be supported through available audit tools as part of an electronic health record (EHR).
December 1, 2020
The Centers for Medicare and Medicaid Services (CMS) released its final CY 2021 Medicare physician fee schedule (PFS) rule, which includes changes to Medicare Part B payment policies, including payment for office/outpatient evaluation and management services, and the Quality Payment Program. CMS finalized its proposed essential changes for coding office visits and other related evaluation and management (E/M) services, including the G2211 code for complex visits, to be fully implemented as planned on January 1, 2021.
CMS estimates an 9% increase in allergy/immunology reimbursement, reflecting ongoing AAAAI advocacy work with the Cognitive Specialties Coalition and others on the E&M codes and increases in RVU values of key allergy/immunology codes. To compare 2021 reimbursement for allergy and asthma codes with 2020 reimbursement values, click here. To compare 2021 reimbursement for Evaluation and Management (E/M) click here. To review how reimbursement is calculated, click here.
November 20, 2020
The AAAAI has joined with many others to urge that the 116th Congress implement essential changes in Medicare payments for office visits and other related evaluation and management (E/M) services, including the GPC1X code for complex visits, as planned and scheduled on January 1, 2021. Read the letter here.
October 20, 2020
In coalition with others, the AAAAI urged Congress to:
• Move forward with fully implementing the increased payment for outpatient evaluation and management services and other improvements in the 2021 proposed and previously finalized Medicare Physician Fee Schedules, including:
o Increased Valuation and Payments for Outpatient Evaluation and Management (E/M) Services
o Proposed new billing code, known as the GPC1X code, which would provide increased payment for complex care inherent to some of the office visit codes
• Ensure that any proposed legislation to address the cuts for some services resulting from budget neutrality (BN) is fair to all services and specialties, does not distort relative values and actual payments as determined through the usual regulatory process with public comment and input from physicians, and does not disadvantage primary and comprehensive care services compared to other services.
o Avoid temporary legislative fix that would create a future “funding cliff.” The following approaches could achieve such an outcome.
Read more here.
October 1, 2020
The AAAAI and our professional governmental relations team, Hart Health Strategies, carefully reviewed the Centers for Medicare and Medicaid Services (CMS) proposed CY 2021 Medicare Physician Fee Schedule (PFS) and commented by letter to vigorously advance the practice of allergy, asthma and immunology for optimal patient care. Specifically, the AAAAI:
- Urged CMS to work with Congress to eliminate the negative impact, concurrent with prompt implementation of the aforementioned E/M policies.
- Urged CMS to proceed with implementation of the complexity add-on code, GPC1X.
- Urged CMS to make Telehealth and Virtual Care Services flexibilities permanent.
- Urged CMS to make audio-only E/M visits a permanent fixture in Medicare’s growing set of virtual care services codes, maintaining equal payment with in-person E/M visits.
In response to updates to its Quality Payment Program, the AAAAI
- Urged CMS to finalize the addition of multiple measures to the A/I Specialty Set for 2021
- Opposed the CMS proposal to increase the overall MIPS performance threshold in 2021
August 20, 2020
The Centers for Medicare and Medicaid Services (CMS) released its CY 2021 Medicare Physician Fee Schedule (PFS) proposed rule August 3, 2020. As is customary, CMS makes changes to Medicare Part B payment and other policies to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, and changes in the statute. CMS also makes changes to several other programs, including the Medicare Shared Savings Program (MSSP) and the Quality Payment Program (QPP). Of significance, and largely due to changes in RVUs for evaluation and management (E/M) services, CMS estimates the CY 2021 PFS conversion factor to be $32.2605, representing an almost -11% reduction from the CY 2020 conversion factor.
Click here for highlights impacting the Allergy Immunology specialty, and here to access a comprehensive summary prepared by the AAAAI's professional governmental relations team, Hart Health Strategies. See here for a brief summary from the American Medical Association. If you want to see the full posting, you can do so here.
November 13, 2019
On November 1, 2019 the Centers for Medicare and Medicaid Services (CMS) released the calendar year (CY) 2020 Medicare Physician Fee Schedule (MPFS) final rule. This major final rule addresses: changes to the physician fee schedule (PFS); other changes to Medicare Part B payment policies to ensure that payment systems are updated to reflect changes in medical practice, relative value of services, Medicare Shared Savings and more. To understand how CMS modified its proposals as related to AAAAI feedback, and to review expert analysis of the final rule, offered by the AAAAI with consultants Hart Health Strategies, click here.
September 26, 2019
AAAAI leadership recently submitted comments to the Centers for Medicare and Medicaid (CMS) in response to the Proposed 2020 Physician Fee Schedule and related revisions to the Quality Payment Program. Read more here.
July 29, 2019
On July 29, the Centers for Medicare & Medicaid Services (CMS) released the DRAFT CY 2020 Medicare Physician Fee Schedule (MPFS). Overall, the A/I specialty is not expected to see a decrease in its total Medicare revenues, and the conversion factor – the value used to calculate total relative value units (RVUs) into payment rates - is up slightly at $36.0896. The AAAAI, with our expert consultants at Hart Health Strategies, continues to analyze the proposals. We will be sharing additional information soon, and will post our comments to be submitted to CMS in September.
Click here to compare 2020 proposed reimbursement for allergy codes with 2019 reimbursement values. To review how CMS converts RVUs into compensation, click here. To review CMS’ draft Evaluation and Management (E/M) code proposal from the 2020 proposed rule, click here.
Key provisions of interest to the A/I community are highlighted below.
Evaluation and Management (E/M) Coding and Payment. Stepping back from its previously announced policies, CMS proposes to align its E/M coding policies consistent with recommendations by the AMA CPT Editorial Panel, and accept the associated AMA RUC recommended values. If finalized and implemented in CY 2021, CMS anticipates a 7% increase to A/I. To review the proposed new Evaluation and Management (E/M) codes click here.
Review and Verification of Medical Record Documentation. Last year, CMS finalized that a teaching physician could review and verify (sign/date) notes made by a medical student in a patient’s medical record for E/M services, rather than having to redocument the information. Given concerns raised by non-physician practitioners, CMS proposes to establish a general principle to allow the physician, the PA, or the APRN who furnishes and bills for their professional services to review and verify, rather than re-document, information included in the medical record by physicians, residents, nurses, students or other members of the medical team.
Care Management Services. CMS proposes to revise its billing requirements for transitional care management (TCM) services by allowing TCM codes to be billed concurrently with other key services, including prolong services without direct patient contact, complex chronic care management (CCM) services, and care plan oversight services. CMS also proposed to increase the work RVUs for certain TCM services, resulting in higher reimbursement when these services are delivered. CMS anticipates that this will lead to increased access to TCM services by Medicare beneficiaries. With regard to CMM services, CMS proposes to adopt two new G-codes for complex CCM services, as well as two new G-codes for non-complex CCM. These codes are anticipated to be replaced once the AMA CPT Editorial Panel completes revisions associated with these services. Last, CMS proposes two new codes for principal care management (PCM) services, which describe care management services for one serious chronic condition, and would be predominantly billed by specialists who are focused on managing patients with a single complex chronic condition requiring substantial care management.
Communication Technology-Based Services (CTBS). Last year, CMS finalized new codes and payment for CTBS (i.e., virtual check-in, evaluation of store and forward images, and interprofessional internet consultation). Hearing concerns that obtaining beneficiary consent for each discrete service is burdensome, CMS proposes that practices could use a single advance beneficiary consent.
Merit-based Incentive Payment System (MIPS). CMS proposes significant changes in the MIPS program, including an increase in the Cost performance category weight (from 15% to 20%) with a corresponding decrease in the Quality performance category weight (from 45% to 40%). With regard to quality measures, CMS is proposing to add a new quality measure – Adult Immunization Status – to the A/I specialty set, and remove the following measures – Influenza Immunization, Pneumococcal Vaccination Status for Older Adults, and Pneumocystis Jiroveci Pneumonia (PCP) Prophylaxis. AAAAI has advocated for the removal of other HIV/AIDS measures from the specialty set, and will continue to press for this revision in our formal comments. As a reminder, the AAAAI QCDR contains the most relevant measures for A/I practices, and captures other key data helpful to our efforts in demonstrating the safety of in-office compounding of allergenic extracts.
CMS also proposes modifications to the Qualified Clinical Data Registry (QCDR) measure standards for MIPS, which will require measure testing, harmonization, and clinician feedback. Given AAAAI’s considerable investment, we will work diligently to ensure requirements are reasonable, that our QCDR is compliant, and will continue to be available for A/I practices to use for MIPS and other research activities.
Finally, CMS requests information on a proposed framework for new MIPS Value Pathways (MVP), aimed at streamlining the MIPS program and making it more clinically relevant. While a potentially positive development that could assist A/I practices, CMS intends to employ administrative claims-based measures focused on population health, which may not be relevant to A/I practices and patients. AAAAI will work with the medical community on a coordinated response to ensure the new MVP can be a success.
Open Payments. As required by law, CMS proposes to include non-physician practitioners as “covered recipients” in its Open Payments program. This means PAs, NPs, CNSs, CRNAs, and CNMs would have data reported about their payments from industry in the Open Payments system. CMS also proposes to modify the nature of payment categories by consolidating separate distinctions for payments made to faculty at accredited/certified and unaccredited/non-certified continuing education programs into one “medical education programs” category, and establishing categories for debt forgiveness, long-term medical supply or device loan, and acquisitions.
AAAAI will continue to analyze the proposals and provide additional information soon. If you have questions or would like to flag key concerns about these proposals as they relate to your practice, we welcome your feedback at firstname.lastname@example.org.
November 15, 2018
Expert Analysis of 2019 Physician Fee Schedule Now Posted
Hart Health Services has completed their expert analysis of the Final 2019 Physician Fee Schedule. Read a high level summary of key points here. To compare the Final 2019 Physician Fee Schedule with the earlier fee schedule proposed by the Centers for Medicare and Medicaid Services (CMS), click here. To review and compare 2018 and 2019 CMS reimbursement rates for relevant Current Procedural Terminology® (CPT) codes, click here.
For the practicing allergist/immunologists, highlights of the Final 2019 Physician Fee Schedule include:
• For Calendar Year (CY) 2021, CMS is collapsing the payment variation for E/M office/outpatient visit levels by paying a single rate for E/M office/outpatient visit levels 2 through 4 for established and new patients, and is maintaining the payment rate for E/M office/outpatient visit level 5 to better account for the care and needs of complex patients. CMS estimates that the impact of the cumulative finalized policies will, on the whole, be cost-neutral.
• The national reimbursement rate for CPT 95165 (Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens) increased from $13.31 in CY 2018 to $14.41 in CY 2019.
• The CY Physician Fee Schedule conversion factor is 36.0391, a +0.11 percent increase over CY 2018.
For more information on how conversion factor, practice expense and RVU factors combine to determine reimbursement rates, click here.
September 20, 2018
A bi-partisan group of Senators sent a letter today to CMS regarding the proposal to collapse E & M codes in the Medicare Physician Fee Schedule. The letter expresses concern about the impact on vulnerable patients with complex conditions and urges CMS to work collaboratively and with transparency with other stakeholders to explore alternatives to reduce physician burden while improving healthcare quality. The AAAAI is part of the coalition that secured this letter.
September 10, 2018
In response to the 2019 Proposed Medicare Physician Fee Schedule, the AAAAI expressed deep concern regarding the CMS’ proposed collapse of E/M services (Level 2-5); and urged CMS to reconsider Venom Immunotherapy and Antigen Costs, while also commenting upon the Quality Payment Program, and other aspects of the proposal.
To review the AAAAI letter, click here.
To review the letter co-signed with the American College of Allergy, Asthma & Immunology, the Advocacy Council of the American College of Allergy, Asthma & Immunology and American Academy of Otolaryngic Allergy, click here.
The Patient-Centered Evaluation and Management Services Coalition (Coalition), of which the AAAAI is a part, wrote to share concerns with the new evaluation and management (E/M) coding and payment proposals included in the Medicare Physician Fee Schedule Proposed Rule for Calendar Year 2019 (Rule). Read the letter to Members of Congress here. Read the letter to the Administration here.
September 7, 2018
Read the “Dear Colleague” letter written with the support of a coalition of specialty societies concerned about the implications of the E&M proposal on both patient access and physician reimbursement. The AAAAI is a member of the coalition that secured this letter.