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Physician Fee Schedule (PFS) Final Rule CY 2021

Issue Brief

December 3, 2020


This final rule makes changes to the Physician Fee Schedule (PFS), which governs payment policy in Medicare Part B for ambulatory care practice. The final rule also encompasses changes to related programs, including the Quality Payment Program, the Diabetes Prevention Program, and the Medicare Shared Savings Program among others. CMS updates these rules annually, so many of the policy changes outlined for 2021 build on existing policies.

Below, we outline ASHP’s comments on the proposed PFS rule, and CMS’s responses in the final PFS rule. CMS’s clarification of incident-to billing of evaluation and management (E/M) codes for pharmacist services is of particular concern. CMS believes that it does not have the statutory authority to reimburse pharmacist-provided incident-to services above 99211 because pharmacists are not Medicare providers, and E/M codes 2 -5 (including time-based coding) are reserved for those clinicians who are Medicare-eligible. However, the agency expressed an openness to creating new pharmacist-specific codes. ASHP, with member input, will develop a slate of codes to present to CMS. We will also pursue all other potential regulatory and legislative solutions to ensure that pharmacists’ services are reimbursed at level commensurate with the complexity and duration of the services provided.

Major Changes for CY 2021

  • Incident-To Billing by Pharmacists:

ASHP Comments on the Proposed Rule: In the proposed rule, 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, questions have remained regarding the codes that may be billed for pharmacist-provided services. Specifically, ASHP has repeatedly requested that CMS clarify, in writing, that physicians can bill the highest level evaluation and management (E/M) codes for services provided by pharmacists if all incident to requirements are met. In the 2015 PFS rule, CMS did explicitly state that E/M codes could be billed just this way. However, since 2015, some Medicare Administrative Contactors have independently interpreted CMS requirements to allow physicians to bill only the lowest level E/M code (99211) for pharmacist-provided incident to services. These conflicting MAC interpretations have made it difficult to implement innovative pharmacist care models and to ensure patient access.

CMS Response in the Final Rule: CMS responded to our requested for E/M coding clarification, stating that because pharmacists are not “qualified health professionals”, meaning that they are not independently eligible for Medicare payment, they cannot be paid at a level higher than 99211 of the E/M code. Although this is extremely frustrating, CMS did express support for pharmacist services and new codes, stating: "We understand and appreciate the expanding, beneficial roles certain pharmacists play, particularly by specially trained pharmacists with broadened scopes of practice in certain states, commonly referred to as collaborative practice agreements. We note that new coding might be useful to specifically identify these particular models of care.” ASHP will begin working immediately to address coding to ensure that pharmacists’ services are reimbursed at a level commensurate with their complexity and duration. We anticipate asking CMS to adopt a new slate of codes for pharmacists, which will require input from members. Additionally, we will advocate directly to the American Medical Association, which drafted the CPT codebook, to try to identify a solution to the coding problem.

  • Telehealth Services:

ASHP Comments on Proposed Rule: CMS proposed to add new services to the telehealth list, including a new add-on code for prolonged E/M services and new home visit codes, and provided new clarifications regarding virtual supervision of incident-to services. Virtual supervision is critical to creating and sustaining care models that fully integrate pharmacists.

CMS Response in Final Rule: CMS finalized its proposal to extend virtual supervision until December 31, 2021 or the year in which the public health emergency (PHE) ends, whichever is later. Although we are very supportive of the extension, ASHP will continue to advocate aggressively to make virtual supervision a permanent option for services reimbursed under the PFS. ASHP recently spearheaded a sign-on letter to CMS and the Administration advocating permanent virtual supervision, which included nearly 100 health system, pharmacy association, and provider association signatories.

CMS is also finalizing changes to its telehealth coding list. It’s adding a number of codes to its existing list, but also creating a new category (Category 3) for those codes that were added during the PHE. Category 3 codes will remain in effect through the later of December 31, 2021 or the calendar year in which the PHE ends. It is possible that CMS could decide in next year’s PFS rule to permanently retain some Category 3 codes.

Permanent Codes Added:

Group Psychotherapy (CPT code 90853)
Psychological and Neuropsychological Testing (CPT code 96121)
Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes 99334-99335)
Home Visits, Established Patient (CPT codes 99347-99348)
Cognitive Assessment and Care Planning Services (CPT code 99483)
Visit Complexity Inherent to Certain Office/Outpatient Evaluation and Management (E/M) (HCPCS code G2211)
Prolonged Services (HCPCS code G2212)

Category 3 Codes:

Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes 99336-99337)
Home Visits, Established Patient (CPT codes 99349-99350)
Emergency Department Visits, Levels 1-5 (CPT codes 99281-99285)
Nursing facilities discharge day management (CPT codes 99315-99316)
Psychological and Neuropsychological Testing (CPT codes 96130-96133; CPT codes 96136-96139)
Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161-97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507)
Hospital discharge day management (CPT codes 99238-99239)
Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT codes 99469, 99472, 99476)
Continuing Neonatal Intensive Care Services (CPT codes 99478-99480)
Critical Care Services (CPT codes 99291-99292)
End-Stage Renal Disease Monthly Capitation Payment codes (CPT codes 90952, 90953, 90956, 90959, 90962)
Subsequent Observation and Observation Discharge Day Management (CPT codes 99217; CPT codes 99224-99226)

  • Payment Changes for E/M Codes and Analogous Visits: CMS finalized changes to E/M codes in order to implement site neutral payment and recognize the challenges of taking care of Medicare patients, particularly those with chronic conditions.

    • Coding Changes: Effective January 1, 2021, CMS is implementing its proposal from last year to implement new payment and documentation requirements based on the American Medical Association’s CPT Editorial Panel. Specifically, CMS will allow clinicians to report E/M codes using either the current 1995/1997 documentation guidelines, by medical decision making alone, or by time alone. These documentation requirements should reduce administrative burden for physicians and practices.

    • E/M Reimbursement Changes: Due to the changes to E/M coding levels described above, some providers, such as primary care physicians, will see substantial pay bumps of up to 17%. Other specialties, including radiology, orthopedics, occupational therapy, physical therapy, and speech language pathology, will see reimbursement decrease anywhere from 5 – 11%. CMS finalized these changes and now providers facing cuts are asking Congress to step in and legislate to restore previous payment rates.

    • Increased Payment for AWVs and TCM: CMS will increase payments for a number of related services, including transitional care management (TCM) and annual wellness visits (AWVs). Further, to improve and streamline uptake of TCM, CMS will remove 14 End-Stage Renal Diseased related HCPCS codes and the chronic care management (CCM) code from the list of codes that cannot be billed concurrently with TCM.

  • Opioid Treatment Program (OTP) Changes: CMS finalized a number of enhancements to OTPs, including payment for overdose education services and a new add-on code for nasal naloxone. CMS did not fully commit to finalizing a proposal to allow OTPs to submit institutional claims, stating that the agency is “continuing to explore how best to implement these flexibilities” and stating that it “will provide notice of any relevant changes through claims processing instructions.” This language suggests that a change may be made outside of the rulemaking process. CMS did not finalize a proposed add-on code for auto-injector naloxone as the both the generic and brand products have been discontinued.

  • Medicare Diabetes Prevention Program (DPP): CMS finalized new policy for DPP patients during emergency periods, including the current PHE. Patients currently enrolled in DPP and who cannot attend in-person sessions can either opt to restart the DPP services at a later date or continue their course virtually. Patients who opt for virtual DPP services are prohibited from retaking in-person sessions at a later date. For patients who opt to resume sessions only once in-person services are available, patients in the first 12 months of the DPP course may restart the course from the beginning or pick up from their most recently-attended session. After the first year of DPP, patients cannot restart the program and must resume sessions from where they left off when the emergency began.

CMS also finalized a requirement that beneficiaries receiving DPP services can only stop and restart services once during a declared emergency to allow for better tracking, given that Medicare covers the full set of DPP services only once per beneficiary. CMS clarified that during an emergency period, virtual sessions will be treated as in-person sessions for billing and documentation purposes and that providers may obtain weight measurements remotely via digital technology (e.g., Bluetooth) or through an audio-visual feed of the patients home scale.

  • Electronic Prescribing of Controlled Substances (CIIs) in Medicare Part D: In the proposed rule, CMS offered a detailed overview of the evolution of e-prescribing in Part D and the new SUPPORT Act requirements of e-prescribing of CIIs in Medicare Part D. The agency set out a number of statutory exemptions of the e-prescribing of CIIs, including when the practitioner and the dispensing pharmacy are the same entity and when the prescription cannot be sent using the most recent NCPDP Script. In order to offer providers flexibility during the PHE, CMS will not mandate compliance with EPCS until January 1, 2022, although the agency urges providers to begin implementation of the EPCS requirements as soon as possible.

Applicability and Timing

Policy proposals adopted in a PFS final rule generally become effective on January 1, 2021 (with the exception of the EPCS requirement, which will not take full effect until January 1, 2022). Although agencies are somewhat insulated from abrupt political changes that accompany new Presidential Administrations, it is possible that, following the transition, CMS will rethink some of the policies outlined above.

ASHP will continue to advocate directly with CMS and legislators to address the E/M clarification and ensure that pharmacists’ services are reimbursed appropriately. Advocacy will also continue on other PFS-related topics, including the need to change X-waiver requirements to ensure pharmacists can fully engage in OTPs. We urge members to submit any comments, questions, or feedback on these issues to Jillanne Schulte Wall, ASHP Senior Director, Health & Regulatory Policy, at [email protected].