January 7, 2021 | By Grant Huang, CPC, CPMA
The 2021 Physician Fee Schedule (PFS) had included the largest one-year reduction to the Medicare conversion factor (CF) in more than 20 years, but it won’t actually take effect because the CF is being increased as a result of provisions in the recently passed stimulus legislation.
Originally, the 2021 CF was set to be $32.41, a decrease of $3.68 from the 2020 CF of $36.09. This would have been a 10.2% decrease. Instead, CMS has announced that the new CF for 2021 will be $34.8931, which is only a 3.3% decrease from 2020. The agency is making the change because of a provision in the $1.4 trillion Consolidated Appropriations Act of 2021 that orders CMS to implement a 3.75% positive adjustment to 2021 physician payments. This legislation, which combined stimulus provisions such as the $600 per-person economic impact payment with general budgetary provisions to fund the federal government, was signed into law by President Trump on December 27, 2020, which means the new CF of $34.8931 is what actually took effect on January 1, 2021.
The large cut to the CF was being made to mitigate the costs of the 2021 PFS’ increased work Relative Value Units (RVUs) for office/outpatient E/M codes, which will so impact the program’s budget that CMS is bound by the budget neutrality statute to make offsetting changes. The table below shows the net change in payments for the office/outpatient E/M codes between 2020 and 2021.
|CPT Code||Description||2020 RVU||2020 $||2021 RVU||2021 $||Net Change|
|99201||Deleted for 2021||1.29||$46.56||N/A||N/A||N/A|
|99202||Office o/p new sf 15-29 min||2.14||$77.23||2.12||$73.97||-$3.26|
|99203||Office o/p new low 30-44 min||3.03||$109.35||3.26||$113.75||$4.40|
|99204||Office o/p new mod 45-59 min||4.63||$167.09||4.87||$169.93||$2.84|
|99205||Office o/p new hi 60-74 min||5.85||$211.12||6.43||$224.36||$13.24|
|99211||Office o/p est minimal prob||0.65||$23.46||0.66||$23.03||-$0.43|
|99212||Office o/p est sf 10-19 min||1.28||$46.19||1.63||$56.88||$10.69|
|99213||Office o/p est low 20-29 min||2.11||$76.15||2.65||$92.47||$16.32|
|99214||Office o/p est mod 30-39 min||3.06||$110.43||3.76||$131.20||$20.77|
|99215||Office o/p est hi 40-54 min||4.11||$148.33||5.25||$183.19||$34.86|
‘Moratorium’ on implementing HCPCS code +G2211
The law also included a provision that instructs CMS to delay the implementation of the new interactive complexity add-on code +G2211 for a period of three years, until 2024. The code had confused many stakeholders and has a long and somewhat vague descriptor: “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition.”
CMS established +G2211 because, as it states in the 2021 PFS final rule, it believes that “the time, intensity, and [practice expense] involved in furnishing services to patients on an ongoing basis that result in a comprehensive, longitudinal, and continuous relationship with the patient and involves delivery of team-based care that is accessible, coordinated with other practitioners and providers, and integrated with the broader health care landscape, are not adequately described by the revised office/outpatient E/M visit code set.” The additional payment for +G2211 (which comes out to $15.88 using national par rates) “appropriately recognizes the resources involved when practitioners furnish services that are best-suited to patients’ ongoing care needs and potentially evolving illness,” CMS writes in the final rule. “We believe that [+G2211] captures the work by the reporting practitioner for many office/outpatient E/M visits that is not accounted for in the valuation of the primary office/outpatient E/M visit code.”
The agency gave several clinical examples where +G2211 would apply, such as a 68-year-old woman with multiple chronic conditions who presents to her primary physician for regular ongoing care. The physician addresses all ongoing problems and adjusts medications, then discusses age-appropriate preventive services, orders a flu shot that has come due, and schedules a screening colonoscopy. In this example +G2211 is supported, CMS says. Unfortunately, many providers and stakeholders commented to CMS that its definitions of +G2211 were simply too vague to make it a reliable service to bill, particularly for specialists who have patient encounters that do not readily fit the example given.
CMS had projected that +G2211 could be appended to as much as 90% of all E/M codes reported in 2021. Thus, the provision to delay its implementation means that the money allocated towards expected utilization of +G2211 is free to be allocated across all codes with RVUs in the 2021 PFS. This is also contributing to the increased 2021 CF.
Hopefully, CMS will use the additional three years’ time to better describe what documentation requirements would be necessary to support +G2211, as practices will be eager to receive the extra payment, though many were wary of billing for a new service in the absence of clear guidelines.