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CMS Releases PFS and OPPS Proposed Rules for CY 2021 (Full Issue Briefs to Come)

Centers for Medicare & Medicaid Services

August 4, 2020

On August 4, the Centers for Medicare & Medicaid Services (CMS) released two of its largest annual payment proposed rules – the Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (OPPS) for CY 2021. ASHP is in the process of reviewing the proposed rules, which are well over 500 pages each, and anticipate that full issue briefs for each proposed rule will be available later this week. In the interim, we have provided some highlights below.

Physician Fee Schedule Proposed Rule

  • Incident-To Billing by Pharmacists: ASHP was pleased to see that CMS explicitly states that pharmacists can provide incident-to services, including medication management services under Part B. CMS noted that it hopes the clarifications “encourage pharmacists to work with physicians and [non-physicians practitioners] in new ways where pharmacists are working at the top of their training, licensure and scope of practice.” However, CMS did not address ASHP’s question regarding evaluation and management (E/M) billing levels for services provided by pharmacists incident to physicians. ASHP will continue to seek this information from the agency.

  • Telehealth Services: CMS is proposing to add new services to the telehealth list and provides new clarifications regarding virtual supervision of incident-to services. CMS is proposing to extend virtual supervision until December 31, 2021. ASHP will continue to advocate for making this flexibility permanent.

  • Payment Changes for E/M Codes and Analogous Visits: CMS is proposing changes to E/M codes to reflect the challenges of taking care of Medicare patients, particularly those with chronic conditions. Some providers, like primary care physicians, will see substantial pay bumps, while others, such as radiologists will see a decrease in payment. Additionally, CMS is proposing to increase payments for related services, including transitional care management and annual wellness visits.

  • Opioid Treatment Program (OTP) Changes: CMS is proposing a number of enhancements to OTPs, including new add-on codes for nasal naloxone and auto-injector naloxone, as well as new enrollment flexibilities to allow submission of institutional claims.  

Hospital Outpatient Prospective Payment System Proposed Rule

  • 340B: CMS is proposing two options for reimbursing drugs purchased under the 340B drug discount program – maintaining the current average sales prices (ASP) minus 22.5% that was imposed last year, or a new rate based on this year’s hospital survey of ASP minus 34.7% plus an overhead payment set at 6% of ASP for a net rate of ASP – 28.7%. CMS is proposing to exempt rural sole community hospitals, certain cancer hospitals, and children’s hospitals from the changes, but will still require them to report the informational TB modifier. ASHP remains firmly opposed to these cuts and will to continue to advocate for immediate restoration of the previous ASP + 6% rate.

  • Elimination of Inpatient Only List: CMS is proposing to eliminate the inpatient only list over three years in order to allow the services to be provided in the hospital outpatient setting when appropriate.

  • Star Rating Changes: CMS is proposing a number of significant Star Ratings changes, designed to “update and simplify how the ratings are calculated, reduce the total number of measure groups, and stratify the Readmission measure group based on the proportion of dual-eligible patients.”

In addition to posting full issue briefs on the PFS and OPPS proposed rules, ASHP will be submitting written comments to CMS on each rule by the October 5 deadline. Member feedback is vital to ensuring that we provide CMS with the most relevant and robust feedback possible. Please send any questions or feedback that you would like ASHP to consider for inclusion in our comment letter to Jillanne Schulte Wall, ASHP Senior Director for Health & Regulatory Policy, at [email protected] by September 21, 2020.