The Centers for Medicare & Medicaid Services (CMS) has released the 2021 Physician Fee Schedule (PFS) proposed rule, which will affect emergency medicine reimbursement significantly. Following a commentary period lasting until Oct. 5, 2020, CMS is expected to issue its final PFS rule, which will impact services beginning Jan. 1, 2021.

Here are some highlights from this year’s PFS rule. A longer summary is available here.

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. Even though the ED codes received increases of about 5 percent for code 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 Proposed Increases to ED Work RVUs

2021 Conversion Factor Decrease

For 2021, CMS proposes a Medicare PFS conversion factor of $32.26, a 10.6 percent decrease from the 2020 conversion factor of $36.09. This historic decrease was due to the CMS decision to increase reimbursement for the office visit codes, a boon for urgent care (which reports using office codes). However, this increased spending triggered a significant “budget neutrality adjustment,” as required by law. However, in light of the COVID-19 pandemic and the stresses placed on the whole house of medicine, Congress may waive the budget neutrality requirements, which could shield us from this significant potential decrease.

Due to the budget neutrality adjustment in the conversion factor for the whole house of medicine, emergency medicine could see as much as a 6 percent net decrease. ACEP has mounted a vigorous campaign to protect the safety net and is urging Congress to support the conversion factor at current levels (see “Advocate to Waive Budget Neutrality” for more on this effort).

Table 2: MIPS Performance Category Weighting in Final Score

ED Continued Traction with Telehealth Services

CMS is examining which of the codes that are temporarily on the list of approved Medicare telehealth services during the COVID-19 public health emergency will remain on the list permanently. CMS is proposing to keep ED E/M code levels 1–3 (CPT codes 99281–99283) on the approved telehealth list for the remainder of the year after the public health emergency expires. However, CMS is not proposing to include ED E/M code levels 4 and 5 (CPT codes 99284 and 99285) on the list of approved Medicare services past the duration of the public health emergency, citing these services as too intense to be routinely performed via telehealth.

Merit-Based Incentive Payment System

• 2020 Reporting Exemptions Due to COVID-19: CMS is granting hardship exemptions to Merit-Based Incentive Payment System (MIPS) reporting requirements on a case-by-case basis due to COVID-19. It is therefore possible for a clinician or group to request exemption from all four performance categories in 2020 (see Table 2). If clinicians submit a hardship exception application for all four MIPS performance categories and their application is approved, they will be held harmless from a payment adjustment in 2022—meaning they will not be eligible for a bonus and not face potential penalties based on their MIPS performance in 2020.
• Performance Threshold: CMS proposes to set the performance threshold that clinicians need to achieve to avoid a penalty in 2021 at 50 points, down from 60 points, which had been floated previously.
• MIPS Value Pathways (MVPs): CMS is committed to developing MVPs, which 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.

Additional information on MIPS is available here.

Other Resources

Resources for these and other topics can be found on the reimbursement section of the ACEP website. ACEP Director of Reimbursement David McKenzie, CAE, is also available to field your questions at 800-708-1822, ext. 3233. Finally, ACEP offers well-attended and highly recommended coding and reimbursement educational conferences annually. Visit www.acep.org/rc for more information.

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 director of reimbursement.