By Betty Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC- Compliant Health Care Solutions |



Date Posted: Tuesday, December 08, 2020


CMS issued a final rule on the Medicare Physician Fee Schedule and some other policies that are slated to start on or after January 1, 2021.  The 1,994 page document has a lot of information on many different policies, so a few important ones will be highlighted here, but you can find the full Final Rule at https://public-inspection.federalregister.gov/2020-26815.pdf.

Conversion Factor
Due to raising the RVUs on E/M services and rate-setting refinements to update premium data for malpractice expense and geographic practice cost indices, or GPCIs, the conversion factor will decrease to $32.41 from its current conversion factor of $36.09.   Your practice will want to run some calculations to see how that will affect the bottom line.  There is currently a bill in Congress trying to freeze the Medicare payment rate for 2 years, named the "Holding Providers Harmless from Medicare Cuts During COVID-19 Act of 2020,” so be sure to watch for updates as the year comes to a close.

The Final Rule affirms that CMS is accepting most of the changes for the new Office/Other outpatient E/M (O/O E/M) services.  In the Rule, it states that E/M visits account for about 40% of allowed charges, with O/O E/M account for about 20% of allowed charges.  CMS agreed that the current system for "counting" body areas and organ systems is outdated. 

The Final Rule confirms the following regarding the O/O E/M codes:
  • 99201 will be deleted
  • Levels may be chosen by either medical decision-making (MDM) or time
  • Only the medically appropriate history and examination for the encounter need to be documented
  • When coding by time, the entire time spent by the physician/OQHCP on the day of the visit (whether face-to-face or non-face-to-face) should be used to choose a level of E/M service

The area that CMS does not agree with the AMA is on prolonged services for O/O E/M.  CMS disagrees with CPT's view of when the counting of prolonged service time should start.  Due to this, CMS has created a HCPCS II code, G2212, to use in place of 99417.  Be sure to watch for more on this from CMS to ensure that you are reporting prolonged services correctly for Medicare patients.

There were many changes finalized for telehealth.  CMS discussed the new Categories of telehealth services and how they would be used.  If you need a more in-depth look at this new change, see my article that will be included in BC Advantage Issue 16.1-January/February 2021.  

Basically, here are the categories:
  • Category 1: These codes are permanently added as covered under Medicare Telehealth Services as they are considered to be similar to services currently on the list
  • Category 2: These codes are permanently added as covered under Medicare Telehealth Services but are not similar to services currently on the list.  In order to be considered, CMS requires that clinical studies demonstrating the service furnished via telehealth improves the patient's diagnosis or treatment of an illness or injury; and copies of published peer-reviewed articles relevant to the service when performed via telehealth
  • Category 3: These codes are temporarily covered on the Medicare Telehealth List through the end of the year in which the PHE for COVID-19 ends, allowing CMS to evaluate whether it should become a Category 1 or Category 2 code.

All thirteen (13) codes in the Proposed Final Rule have been accepted and some codes were deleted.  

Here is a complete list of Category 3 telehealth services for 2021:
  • End-stage Renal Disease Codes: 90952, 90953, 90956, 90959, 90962
  • Emergency Department Visits: 99281, 99282, 99283, 99284, 99285
  • Domiciliary/Rest Home/Custodial Care Services: 99336, 99337
  • Home Visits, Established Patients: 99349, 99350
  • Nursing Facility Discharge Day Management: 99315, 99316
  • Psychological and Neuropsychological Testing: 96121, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139
  • Therapy Services: 97161, 97162, 97163, 97164, 97165, 97166, 97167, 97168, 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521, 92522, 92523, 92524, 92507
  • Subsequent OBS/OBS discharge Day Management: 99217, 99224, 99225, 99226
  • Initial Hospital Care/Discharge Day Management: 99221, 99222, 99223, 99238, 99239
  • Critical Care Services: 99291, 99292
  • Inpatient Neonatal/Pediatric Subsequent Critical Care: 99469, 99472, 99476
  • Continuing Neonatal Intensive Care: 99478, 99479,99480

There are also final rules documented for Remote Physiologic Monitoring Services, Immunization Services, Policies Regarding Professional Scope of Practice and Related Issues, and the Medicare Shared Savings Plan just to name a few.  So, there is a lot to digest, and more to watch for (time thresholds for prolonged services) from CMS prior to January or 2021.  It's going to be a busy time to ready the practice for all the coming changes.

Betty Hovey, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, is a nationally recognized healthcare consultant and speaker. She is an expert auditor and loves to help practices stay compliant and profitable. Betty states, "Physicians work hard for their practices and they should be paid properly for what they do."
Betty brings over thirty years of healthcare experience. She has worked for practices both large and small with the same intensity and attention. She has spent years on the "front lines" for practices handling medical billing, coding, claims, and denials.  She has also managed practices and directed healthcare system departments. Her areas of expertise include Evaluation and Management, Primary Care, Dermatology, Plastic Surgery, Cardiology, Cardiothoracic Surgery, General Surgery, GI, E/M and procedural auditing, and ICD-10-CM.
As a speaker and trainer, Betty brings a welcoming mannerism that her attendees relate to and enjoy. She brings humor and real life experience to her educational sessions that allow her to ensure that everyone understands the training and has a good time. Betty has educated medical coders, managers, health plans, administrators, physicians and non-physician practitioners all across the country. She has co-written manuals on ICD-10-CM, ICD-10-PCS, and CPT specialty areas.  She most recently authored a chapter for the soon to be released book, Telemedicine in Orthopedics and Sports Medicine: Development and Implementation in Practice.
Betty is a Certified Coding Specialist-Physician based (CCS-P) and a Certified Documentation Improvement Practitioner (CDIP) through the American Health Information Management Association (AHIMA). Through AAPC she holds certifications as a Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Professional Medical Auditor (CPMA), Certified Professional Coder for Dermatology (CPCD), Certified Professional Biller (CPB), and a Certified Professional Coder Instructor (CPC-I).  Betty is also a member of Sigma Beta Delta-an International Honor Society for Business, Management, and Administration.

CMS.gov. (December 1, 2020).  Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021. https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1
Centers for Medicare and Medicaid Services. (December 1, 2020).  42 CFR Parts 400, 410, 414, 415, 423, 424, and 425.  https://public-inspection.federalregister.gov/2020-26815.pdf

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