In August 2020, the Centers for Medicare and Medicaid published two proposed rules for the calendar year (CY) 2021 with provisions that may be of interest to wound care programs and clinicians. CMS is collecting comments on the following proposed rules until early October, 2020:

• Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021: published on August 3 2020, open to public comments until October 5, 2020
• Proposed Updates to the Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs Year 2021: published on August 12 2020, open to public comments until October 10, 2020

A summary of relevant proposals is provided in this blog post. Clinicians may submit comments directly to CMS or to the Alliance of Wound Care Stakeholders (by October 5, 2020). 

Physician Fee Schedule - Proposed Rules

Based on the CMS Fact Sheet and Federal Register [CMS–1734–P].

1. CY 2021 Physician Fee Schedule

• Rate-setting and Conversion Factor: with the budget neutrality adjustment to account for changes in RVUs, as required by law, the proposed CY 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09.
• Payment adjustments for several medical specialties: CMS has proposed payments adjustments for several specialties. Adjustments vary from an increase by 17% for endocrinology to a decrease by 11% for radiology.  

2. Medicare Telehealth and Other Services Involving Communications Technology

The proposed rule includes several important telehealth policy proposals. Below is a summary of salient proposals: 

• Adding Services to the Medicare Permanent Telehealth Services List: during the public health emergency (PHE), CMS added 135 services (e.g. emergency department visits, initial inpatient and nursing facility visits, and discharge day management services) that could be paid when delivered by telehealth. CMS is proposing to permanently allow some of those services to be delivered via telehealth, including home visits for the evaluation and management of a patient (in the case where the law allows telehealth services in the patient’s home) and certain types of visits for patients with cognitive impairments. The CY 2021 proposal includes the permanent addition of 9 CPT codes to the list of services offered via telehealth (i.e. services meeting Category 1 criteria). Furthermore, 13 CPT codes will be covered through the calendar year in which the PHE ends, to give physicians a chance to deliver services virtually before CMS decides whether to permanently allow them or not (i.e. services meeting Category 3 criteria). See list of CPT codes in Figure 1. 

• Furnishing Telehealth Visits in Inpatient and Nursing Facility Settings, and Critical Care Consultations: During the PHE, CMS waived the requirement in 42 CFR  483.30 for physicians and nonphysician practitioners to personally perform required visits for nursing home residents, and allowed visits to be conducted via telehealth. CMS is seeking public comment on whether it would be appropriate to maintain this flexibility on a permanent basis outside of the PHE for the COVID-19 pandemic. 
• As for frequency limitations: for CY 2021 CMS is proposing to revise the frequency limitation from one visit every 30 days to one visit every 3 days, or to remove frequency limitations altogether.
• Communication Technology-Based Services (CTBS):
• During the PHE, CMS allowed codes G2061 through G2063 (qualified nonphysician healthcare professional online assessment and management, for an established patient) to be billed by licensed clinical social workers and clinical psychologists, as well as PTs, OTs, and SLPs who bill Medicare directly for their services when the service furnished falls within the scope of these practitioner’s benefit categories. CMS is proposing to adopt this policy on a permanent basis. While CMS noted that similar check-ins provided by nurses and other clinical staff can be important aspects of coordinated patient care (83 FR 59486), CMS did not explicitly mentioned these professionals.
• CMS is also proposing to allow billing of other CTBS by certain nonphysician practitioners, consistent with the scope of these practitioners’ benefit categories through the creation of two additional HCPCS G codes that can be billed by practitioners who cannot independently bill for E/M services:
• G20X0 (Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the  previous 7 days nor leading to a service or procedure within the next 24 hours or soonest  available appointment.)
• G20X2 (Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion)  
• CMS is proposing to value these services identically to HCPCS codes G2010 and G2012, respectively. For more information on G2010 and G2012 and CTBS, see blog post "Reimbursement for Telemedicine Services in Wound Care".
  
• Comment Solicitation on Continuation of Payment for Audio-only Visits: CMS is proposing to discontinue payment for audio-only visits as telehealth services after conclusion of the PHE for the COVID-19 pandemic. However, CMS is seeking comment on whether it should develop coding and payment for a service similar to the virtual check-in but for a longer unit of time and with an accordingly higher value. 
• Proposed Clarification of Existing Physician Fee Schedule Policies for Telehealth Services: CMS received questions regarding its incident-to billing policy for telehealth services. Incident-to billing is a way of billing outpatient services (rendered in a physician’s office located in a separate office or in an institution, or in a patient’s home) provided by a non-physician practitioner or by other non-physician provider. CMS is proposing to clarify that services that may be billed incident-to may be provided via telehealth incident to a physicians’ service, and under the direct supervision of the billing professional. Direct supervision means the physician is on site or virtually present.

3. Payment for Office/Outpatient Evaluation and Management (E/M) 

• As finalized in the CY 2020 PFS final rule, in 2021 CMS will be largely aligning its E/M visit coding and documentation policies with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits, beginning January 1, 2021.

4. Quality Payment Program

• In light of the PHE, CMS is limiting the number of significant changes to the Quality Payment Program in 2021, continuing a gradual implementation timeline for the Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs), and introducing the Alternative Payment Model (APM) Performance Pathway (APP). For more information, please see the Quality Payment Program fact sheet.

Hospital Outpatient Prospective Payment System

Based on the CMS Fact Sheet and Federal Register [CMS–1736–P].

CY 2021 Overall Hospital Quality Star Rating for CY 2021 and Subsequent Years

• In continuing the agency’s efforts to reduce burden and improve efficiencies through the Patients Over Paperwork Initiative, for the first time through the rulemaking process, CMS is proposing to establish, update, and simplify the methodology that would be used to calculate the Overall Hospital Quality Star Rating (Overall Star Rating) beginning with 2021. 

Updates to OPPS Payment Rates

• In accordance with Medicare law, CMS proposes to update OPPS payment rates for hospitals that meet applicable quality reporting requirements by 2.6 percent. 
  

Cellular and/or Tissue-based Products for Wounds (CTPs) 

• Payment methodology for CTPs: in the CY 2021 proposed rule, CMS did not propose any new payment methodology changes. As such, the current system will remain for CY 2021
• Determination of high cost/low cost status for each skin substitute product: for CY 2021, consistent with CMS policy established in CY 2016, CMS proposes to continue to determine the high cost/low cost status for each skin substitute product based on either a product's geometric mean unit cost (MUC) exceeding the geometric MUC threshold or the product's per day cost (PDC, the total units of a skin substitute multiplied by the mean unit cost and divided by the total number of days) exceeding the PDC threshold.
• The proposed CY 2021 MUC threshold is $47 per cm2 (rounded to the nearest $1) and the proposed CY 2021 PDC threshold is $936 (rounded to the nearest $1).
• See proposed high cost/low cost determinations per product

New HCPCS Codes 

• CMS sought comments on over 100 new codes it published in July 2020, some of which are related to products utilized in wound care (e.g. skin substitutes).
  

Resources

• Fact sheet on the CY 2021 Physician Fee Schedule proposed rule
• Fact sheet on the CY 2021 Hospital Outpatient Prospective Payment System proposed rule
• Fact sheet on the CY 2021 Quality Payment Program proposed rule
• Fact sheet on the CY 2021 Updates Medicare Payment Policy for SNFs
• Alliance of Wound Care Stakeholders | Wound Care Advocacy News Update
• Reimbursement for Telemedicine Services in Wound Care
• Cellular and/or Tissue Based Products (Premium) See Plans
• TeleVisit Tool - Wound Care-specific Telehealth and Telemedicine