CMS Issues Proposed Rule on Draft Policy Changes for Medicare Payments  

Telehealth and immunizations are two of numerous services targeted for revision.

Federal officials are seeking public comments from providers on an expansive set of sweeping revisions to policies governing Medicare payments.

The Centers for Medicare & Medicaid Services (CMS) announced the recommended revisions via a proposed rule issued late last week, with all changes connected to Medicare payments made under the Physician Fee Schedule (PFS) and Medicare Part B, for services rendered on or after Jan. 1, 2021.  

“The calendar year (CY) 2021 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation,” the agency said in a press release.

Since 1992, Medicare has paid for the services of physicians and other billing professionals under the PFS; services covered this way are furnished in a variety of settings, CMS noted, including physician offices, hospitals, ambulatory surgical centers, skilled nursing facilities and other post-acute care settings, hospices, outpatient dialysis facilities, clinical laboratories, and even beneficiaries’ homes. Payment under the PFS is also made to several types of suppliers for technical services, often in settings for which no institutional payment is made. 

For most services furnished in a physician’s office, Medicare makes payments to physicians and other professionals at a single rate, based on the full range of resources involved in furnishing the service. However, PFS rates paid to physicians and other billing practitioners in facility settings, such as a hospital outpatient department (HOPD) or an ambulatory surgical center, reflect only the portion of the resources typically incurred by the practitioner in the course of furnishing the service. 

For many diagnostic tests and a limited number of other services under the PFS, separate payment can be made for the professional and technical components of services; the technical component is frequently billed by suppliers like independent diagnostic testing facilities and radiation treatment centers, while the professional component is billed by the physician or practitioner.

Two key proposals announced by CMS involve services rendered particularly relevant amid the global COVID-19 pandemic: telehealth and immunization.

First, for the 2021 calendar year, CMS is proposing to add the following list of services to the Medicare telehealth list on a Category 1 basis:

• Visits complexity associated with certain office/outpatient evaluation and management (E&M) services
• Prolonged services
• Group psychotherapy
• Neurobehavioral status exam
• Care planning for patients with cognitive impairment
• Domiciliary, rest, home, or custodial care services
• Home visits

Additionally, CMS said, it is proposing to create a third temporary category of criteria for Medicare telehealth services; Category 3 will describe services added to the Medicare telehealth list during the public health emergency (PHE) for the COVID-19 pandemic that will remain on the list through the calendar year in which the PHE ends. These include the following:

• Domiciliary, rest, home, or custodial care services for established patients
• Home visits for established patients
• Emergency department visits
• Nursing facility discharge day management
• Psychological and neuropsychological testing

CMS said it is also soliciting comment on services added to the Medicare telehealth list during the COVID-19 PHE that CMS is not proposing to add to the Medicare telehealth list permanently – or proposing to add temporarily on a Category 3 basis.

“In response to stakeholders who have stated that the once every 30-day frequency limitation for subsequent nursing facility (NF) visits furnished via Medicare telehealth provides unnecessary burden and limits access to care for Medicare beneficiaries in this setting, we are proposing to revise the frequency limitation from one visit every 30 days to one visit every three days,” officials noted. “We are also seeking comment on whether it would enhance patient access to care if we were to remove frequency limitations altogether, and how best to ensure that patients would continue to receive necessary in-person care.”

Furthermore, CMS said, it is also clarifying that licensed clinical social workers, clinical psychologists, physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) can furnish the brief online assessment and management services for telehealth, as well as virtual check-ins and remote evaluation services. In order to facilitate billing by these practitioners for the remote evaluation of patient-submitted video or images and virtual check-ins (HCPCS codes G2010 and G2012), CMS is proposing to use two new HCPCS G codes.

“We have also received questions as to whether services should be reported as telehealth when the individual physician or practitioner furnishing the service is in the same location as the beneficiary; for example, if the physician or practitioner furnishing the service is in the same institutional setting, but is utilizing telecommunications technology to furnish the service due to exposure risks,” CMS said. “We are, therefore, reiterating in this proposed rule that telehealth rules do not apply when the beneficiary and the practitioner are in the same location, even if audio/video technology assists in furnishing a service.”

As for immunizations, CMS appears to be readying for the advent of a COVID-19 vaccine – for which dozens of trials are currently ongoing, in various stages, around the world.

“In the CY 2021 PFS proposed rule, we are proposing to establish new payment rates for immunization administration services described by CPT codes 90460, 90461, 90471, 90472, 90473, and 90474 and HCPCS codes G0008, G0009, and G0010, that better reflect the relative resources involved in furnishing all of these services, in consideration of payment stability for stakeholders, public health concerns, and the import of these services for Medicare beneficiaries,” officials said.

Other areas for which CMS is proposing changes to payment policies include the following:

• Remote Physiologic Monitoring Services
• Direct Supervision by Interactive Telecommunications Technology
• Payment for Office/Outpatient Evaluation and Management (E&M) and Analogous Visits
• Proposals Regarding Professional Scope of Practice and Related Issues
• Supervision of Diagnostic tests by Certain Non-Physician Practitioners (NPPs)
• Pharmacists Providing Services Incident to Physicians’ Services
• Therapy Assistants Furnishing Maintenance Therapy
• Medical Record Documentation
• PFS Payment for Services of Teaching Physicians
• Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs)
• Clinical Laboratory Fee Schedule: Revised Data Reporting Period and Phase-in of Payment Reductions
• Principal Care Management Services in Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs)
• Medicare Shared Savings Program
• Part B Drug Payment for Drugs Approved under Section 505(b)(2) of the Food, Drug, and Cosmetic Act
• Removal of Outdated National Coverage Determinations (NCDs)

To review all of the proposed policy changes in their entirety, go online to: https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-4