The Centers for Medicare & Medicaid Services (CMS) has released the 2021 Physician Fee Schedule, which will impact emergency medicine reimbursement significantly. The final rule was released Dec. 1, 2020, a month later than usual due to the public health emergency. More analysis will be included in a future issue, but here are points you need to know now to prepare for the rule, which took effect Jan. 1, 2021.
2021 RVUs Increase for ED E/M Services
Acting to protect the safety net, ACEP asked CMS to recognize the intensity of ED services and maintain the relativity between the ED evaluation and management (E/M) codes and the new patient office codes, which received increased values in 2021. Even though the ED codes received increases of about 5 percent for levels 1–4 in 2020, CMS has accepted our arguments and agreed to increase the ED relative value units (RVUs) for 99283–99285 again in 2021 (see Table 1).
Table 1: 2021 Increases to ED E/M Code Work RVUs
| Code | 2020 Work RVUs | 2021 Proposed Work RVUs | % Increase in Work RVUs in 2020 |
|---|---|---|---|
| 99281 | 0.48 | 0.48 | 0% |
| 99282 | 0.93 | 0.93 | 0% |
| 99283 | 1.42 | 1.60 | 12.68% |
| 99284 | 2.60 | 2.74 | 5.38% |
| 99285 | 3.80 | 4.00 | 5.26% |
In addition to increasing the work RVUs, each year CMS tweaks the practice expense and professional liability insurance components of our RVUs, with the three components together making up our total RVUs for the year (see Table 2).
Table 2: 2021 ED E/M Code Total RVUs and Components
| Code | 2020 Work RVUs | 2021 Work RVUs | 2020 PE RVUs | 2021 PE RVUs | 2020 PLI RVUs | 2021 PLI RVUs | 2020 Total RVUs | 2021 Total RVUs |
|---|---|---|---|---|---|---|---|---|
| 99281 | 0.48 | 0.48 | 0.11 | 0.11 | 0.05 | 0.05 | 0.64 | 0.64 |
| 99282 | 0.93 | 0.93 | 0.21 | 0.21 | 0.09 | 0.10 | 1.23 | 1.24 |
| 99283 | 1.42 | 1.60 | 0.29 | 0.33 | 0.13 | 0.17 | 1.84 | 2.10 |
| 99284 | 2.60 | 2.74 | 0.51 | 0.54 | 0.27 | 0.29 | 3.38 | 3.57 |
| 99285 | 3.80 | 4.00 | 0.71 | 0.74 | 0.40 | 0.42 | 4.91 | 5.16 |
2021 Conversion Factor Decrease
On Dec. 2, 2020, the 2021 Physician Fee Schedule published a conversion factor (payment per RVU) of $32.4085, a 10.2 percent decrease from the 2020 conversion factor of $36.0896. This significant decrease was due to the CMS decision to increase reimbursement for the office visit codes, a boon for urgent care facilities (which report using office codes). Importantly, the large increase in the office codes triggered a statutory requirement to decrease the conversion factor to maintain budget neutrality. ACEP has worked with Congress, highlighting the unprecedented strain emergency physician practices already face due to the ongoing COVID-19 pandemic.
Learn more about the 2021 Physician Fee Schedule at the Regs & Eggs blog by Jeffrey Davis, ACEP’s regulatory affairs director, at www.acep.org/2021-PFS-blog.
Congressional Action
On Dec. 21, 2020, Congress passed the Consolidated Appropriations Act of 2021, and President Donald Trump signed it into law on Dec. 27. The 5,593-page document that included several favorable adjustments to offset the 10.2 percent budget neutrality cuts, including:
- Delaying for three years the implementation of an add-on code (G2211) to office and other outpatient E/M services, which adds back about 3 percent to the conversion factor
- Authorizing new additional funds to support the conversion factor by 3.75 percent
- Delaying the 2 percent sequestration cuts for three months to allow time for the next Congress to address that issue on a more permanent basis
The above changes significantly improve emergency medicine’s outlook for 2021.
As noted above, the work RVUs for 99283–99285 were increased by more than 5 percent for 2021. Those three codes account for about 90 percent of the ED E/M services reported to Medicare.
Net Impact of RVU Increase and Congressional Actions
10.2% (the conversion factor cut) – 5.0% (a conservative estimate of all the ED code RVU increases combined) = 5.2% prior to the recent Congressional action.
With the relief provided by the Consolidated Appropriations Act of 2021 reducing cuts by 3.75 percent through an influx of congressionally approved funds and eliminating a roughly 3 percent contribution to budget neutrality by delaying the implementation of the office add-on code G2211, overall emergency medicine could potentially swing to a positive for 2021.
All in, emergency medicine went from a potential 10.2 percent cut to a gain, which could be as much as 2 percent, depending on the group.
The temporary removal of the sequestration cuts is a bonus. However, if sequestration is not delayed again and goes back into effect in April 2021, all Medicare physician payments will be reduced by 2 percent for the remainder of the year.
This is a tremendous win based on the advocacy work through the ACEP Relative Value Scale Update Committee Team and the legislative and regulatory efforts of ACEP’s staff.
ED Continued Traction with Telehealth Services
CMS considered which codes temporarily on the list of approved Medicare telehealth services during the COVID-19 public health emergency will remain on the list permanently. Ultimately, CMS agreed to keep ED E/M code levels 1–5 (Current Procedural Terminology [CPT] codes 99281–99285), critical care, and observation codes 99217 and 99224–99226 on the list of approved Medicare services through the duration of the year the public health emergency expires. Unfortunately, CMS did not add any of these codes to the permanent approval list for telehealth, citing these services as too intense to be routinely performed via telehealth.
Teaching Physicians and Residents
For rural settings only, CMS has made oversight via telemedicine permanent for teaching physicians supervising residents in residency training sites outside of an Office of Management and Budget–defined metropolitan statistical area (generally defined as an urban cluster of more than 50,000 people). Moonlighting resident flexibilities, allowing an emergency medicine resident to work elsewhere outside the scope of their residency duties, have been extended to Dec. 31, 2021, or may be made permanent to help cover physician shortages due to the public health emergency.
Medical Documentation Requirements
In last year’s rule, CMS finalized numerous changes to the medical record documentation requirements for physicians and other health care practitioners. In this 2021 Final Rule, CMS is clarifying that physicians and other health care practitioners, including therapists, can review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the Physician Fee Schedule.
Merit-based Incentive Payment System (MIPS)
For 2020 and 2021, the four typical reporting categories—quality, cost, improvement activities, and promoting interoperability—continue (see Table 3).
Table 3: 2020 and 2021 MIPS Performance Category Weighting
| Category | 2020 | 2021 |
|---|---|---|
| Quality | 45% | 40% |
| Cost | 15% | 20% |
| Improvement Activities | 15% | 15% |
| Promoting Interoperability | 25% | 25% |
CMS is granting hardship exemptions on a case-by-case basis due to COVID-19. It is therefore possible for clinicians or groups to request to be exempted from all four performance categories in 2020. If clinicians submit a hardship exemption application and their application is approved, they will be held harmless from a payment adjustment due to that category in 2022—meaning that they will not be eligible for a bonus and not face a penalty based on their MIPS performance in 2020. Importantly, the Final Rule published a continuation of the hardship exemption process for 2021.
Performance Threshold: CMS has set the threshold that clinicians need to achieve to avoid a penalty in 2021 at 60 points. In the proposed rule, CMS had stated that the performance threshold would be 50 points in 2021, but CMS is now instituting a higher threshold.
MIPS Value Pathways (MVPs): CMS is committed to developing MVPs that would combine all four categories of MIPS reporting into a single more harmonized process. However, due to COVID-19, the implementation of MVPs is being delayed until 2022. ACEP is working with CMS on developing an MVP for emergency medicine and is examining how ACEP’s Qualified Clinical Data Registry, the Clinical Emergency Data Registry (CEDR), can help emergency physicians participate in an MVP.
2021 ED Facility Payments
CMS is increasing the Hospital Outpatient Prospective Payment System (OPPS) rate by 2.4 percent for 2021. Payments for the ambulatory payment classifications (APCs) related to the five ED E/M codes and critical care appear in Table 4.
Table 4: OPPS Rates for ED E/M Codes
| Facility Level | APC | 2020 |
|---|---|---|
| 99281 | 5021 | $74.19 |
| 99282 | 5022 | $134.57 |
| 99283 | 5023 | $236.87 |
| 99284 | 5024 | $372.01 |
| 99285 | 5025 | $535.13 |
| 99291 | 5041 | $708.57 |
Dr. Granovsky is president of LogixHealth, an ED coding and billing company, and currently serves as the course director of ACEP’s Coding and Reimbursement courses. He may be reached at mgranovsky@logixhealth.com.
Mr. McKenzie is ACEP’s reimbursement director and can be reached at dmckenzie@acep.org.