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CMS announces proposed Medicare rates and policies for 2021

| August 10, 2020

CMS announces proposed Medicare rates and policies for 2021

The Centers for Medicare and Medicaid Services (CMS) has announced a number of proposed policy and payment changes which will impact allergists beginning in 2021. Overall, the proposed rule appears to be good news for allergy. Medicare estimates an overall increase of 9% in Medicare allowed charges for the allergy/immunology specialty – higher than most specialties. Following are the highlights along with a table showing 2021 proposed rates compared to 2020.

  • E&M Increases: Outpatient evaluation and management (E&M) services such as office visits will go up. As an example, payment for 99213 will increase from approximately $76 to $86 and 99214 from approximately $110 to $122, not accounting for geographic adjustments.
  • E&M Complexity Add-On: Medicare will begin making an extra payment – as an add-on to E/M codes – to reflect the added time and intensity of providing holistic care, to build longitudinal relationships with patients and to ensure consistency of care over the long-term. The new code, GPC1X, adds an additional $15.80 to E&M reimbursement. CMS is still developing guidance on use of this code.
  • Allergy Immunotherapy Increases: Reimbursement will increase for allergy immunotherapy ranging from 4.7% to 10.6% compared to 2020 rates.Also increasing is reimbursement for the venom extracts – 2021 is year three of a four-year phase-in program; overall a 12-36% increase.
  • Medicare Conversion Factor: The conversion factor (the dollar figure multiplied by the RVUs to get the payment amount) goes down by about 10.6%. The new conversion factor is set at $32.26. This decrease is deemed necessary by CMS to maintain budget neutrality given the increases in the E/M codes as well as other adjustments. The AMA, Advocacy Council, as well as many surgical specialties, are urging that the E/M increases be implemented outside of budget neutrality to avoid the drop in the conversion factor especially given the hardship already imposed on physician practices as a result of the pandemic.
  • Immunization Administration: CMS is proposing to substantially increase payment for immunization administration to about $28, in an effort to increase access.
  • Test Supervision: CMS is proposing that nurse practitioners and physician assistants can supervise performance of diagnostic tests within their scope of practice. Current rules require supervision by a physician only. This would allow NPs and PAs to supervise skin testing performed by other clinical staff and could free up the allergist to provide other services.
  • Telehealth: CMS is proposing to add several new services to the telehealth list. CMS does not have authority to extend the waiver of the telehealth geographic and site-of- service restrictions in place during the PHE. However, there are several bills in Congress that would, if passed, permanently expand telehealth benefits.
  • Virtual Supervision: Through the end of 2021, CMS is proposing to allow physicians to provide direct supervision of clinical staff through interactive audio and video technology – to limit exposure to infection.
  • Pharmacists: CMS is clarifying that pharmacists can provide services incident to the physician’s service, under appropriate supervision.
  • Teaching Physicians:  CMS is proposing to expand the services that can be furnished by residents to include visit levels 4-5 as well as care management and communication technology-based services. Teaching physicians would be permitted to provide required direction and management of the resident using real time audio/video communications technology.
  • Appropriate Use Criteria: Updated 8/12/20: The Centers for Medicare and Medicaid Services announced the Appropriate Use Criteria (AUC) Program testing period has been extended through CY 2021. Clinicians will not be required to use AUC until 2022. The program requires physicians consult AUC when ordering advanced imaging services such as MRIs, PET, and CT Scans. Beginning in 2022, physicians will be required to consult clinical decision criteria support tools prior to ordering and append the criteria to the claims for those services.

The Advocacy Council will submit comments on some of the above proposals before the due date of Oct. 5, 2020. The Advocacy Council – we have you covered.

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