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CMS Proposes Retraction of Original 2021 E/M Plan in Favor of New CPT Proposal and RUC Recommendations

Jul 31, 2019

On Monday July 29 the Centers for Medicare & Medicaid Services (CMS) released the 2020 Physician Fee Schedule Proposed Rule which includes revisions to previously announced proposals for 2021 office/outpatient evaluation and management (E/M) visits. Last July, CMS proposed collapsing payment for office/outpatient E/M visits, creating a single payment rate for level 2-5 visits. Your Academy actively opposed this proposal through several comment periods and participated in an AMA Current Procedural Terminology (CPT) Panel process to create an alternative E/M coding structure to meet the intention of CMS’s proposal without resulting in reduced payment. Your Academy also actively participated in the AMA Relative Value Scale Update Committee (RUC) process to value the revised E/M codes. We are pleased that CMS accepted both the CPT revisions as well as the RUC recommended values.  

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This proposal reflects the hard work of your Academy’s CPT and RUC advisors as well as the Reimbursement and Policy Review Committee who advocated to CMS and worked with the AMA on the alternative proposal throughout 2018 and 2019.

Click here to view a timeline of the efforts or click the image below to enlarge.

em timeline

Key Elements of the 2021 E/M Proposal

CMS identified burden reduction as a primary goal of its original proposal for 2021.  The updated proposal includes many elements that also seek to achieve this goal while reflecting current medical practice.  Key elements include:

  • Elimination of history and physical as elements for code selection – pertinent history and physical are still taken/performed, but physicians won’t use this information to determine the E/M level.
  • Code selection will be based on level of Medical Decision Making (MDM) or based on Total Time – revised definitions for MDM and Total Time are included in the 2021 CPT E/M guidelines.
  • Elimination of code 99201
  • Creation of a new shorter prolonged services code – the new code captures physician time in 15-minute increments and can be reported with 99205 and 99215.

Additional information about the revised code structure can be found on the AMA website.

Add-On Code for Single, Serious, or Complex Chronic Conditions

In addition to the above described changes for 2021, CMS is proposing to create an add-on code to be used only with office/outpatient E/M services.  This code is intended to capture the per-visit work inherent to caring for patients added complexity.  CMS notes in the proposed rule that “we believe the typical visit described by the revised code set still does not adequately describe or reflect the resources associated with primary care and certain types of specialty visits.” 1

The new add-on code is described as:

GPC1X – 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, or complex chronic condition.  (add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established). 

Proposed 2021 Office and Outpatient E/M Payment

CMS has proposed accepting the RUC recommended values and times for the updated E/M code set.  This includes an increase in work RVU value for most codes (as described in the table below).  The increased RVUs may result in increased payment in 2021 for certain codes.  However, the proposed rule does not indicate a conversion factor for 2021.  To maintain budget neutrality, CMS will likely decrease the conversion factor in 2021 to account for the increase in RVUs.  AAPM&R will monitor proposals related to this change and inform members when information becomes available.  

HCPCS Code

Current Phys Time

Current Work RVU

RUC/Proposed Phys Time

RUC/Proposed Work RVU

99201

17

0.48

N/A

N/A

99202

22

0.93

22

0.93

99203

29

1.42

40

1.6

99204

45

2.43

60

2.6

99205

67

3.17

85

3.5

99211

7

0.18

7

0.18

99212

16

0.48

18

0.7

99213

23

0.97

30

1.3

99214

40

1.5

49

1.92

99215

55

2.11

70

2.8

GPC1X (add-on code)

N/A

N/A

11

0.33

 

Conclusion and Anticipated Impact of the 2021 E/M Proposal

CMS has estimated that the overall impact of the 2021 E/M proposal (including the proposed add-on code) will be -2% for Physical Medicine.  Academy staff is still analyzing this impact estimate, but it is suspected that this negative impact is based on an understanding that Physical Medicine will not bill the add-on code.  Contrary to the CMS estimate, we believe that for our members who bill higher-level office and outpatient E/M visits, this proposal will result in a positive impact.  We also believe certain Academy members will bill the add-on code.  Academy staff is continuing to review the proposed rule.  We will update members as new details about the proposal are identified.