Key Areas to Focus on Regarding the Medicare Proposed Rule 2021

On August 17, 2020, the Centers for Medicare & Medicaid Services (CMS) published its proposed plans for payment and reporting changes for 2021. In contrast to previous years on record, the final rule is likely to be released in early December instead of early November. This means that there may be less than 30 days to prepare and implement changes prior to January 1, 2021. Given the ongoing COVID-19−related public health emergency (PHE), the election, and other challenges, there is a lot to unpack in this proposed rule. Here is a look at 5 key areas you need to focus on when preparing for 2021.

1. Reimbursement Changes

  • Say goodbye to Current Procedural Terminology (CPT) code 99201This code had an extremely low utilization rate, and last year’s Physician Fee Schedule (PFS) final rule called for its deletion in 2021. The rule proposal this year would finalize that deletion.
  • Get more for evaluation and management (E/M) codesThe work relative value units (wRVUs) for CPT codes 99202-99205 and 99211-99215 were reevaluated. None were decreased and only 2 stayed the same (99202 and 99212), meaning that the rest will experience reimbursement increases as the wRVU is a factor of the reimbursement formula.
  • Time or medical decision-makingCMS has modified the framework so that E/M levels would be documented by either time spent or medical decision-making. There are also proposed add-on codes to account for additional time/complexity. Notably, this will not automatically change documentation requirements with other payers.
  • Conversion factor decreaseCMS estimates the 2021 conversion factor will be $32.26, which is a decrease of more than 10% from the 2020 PFS. This significantly affects reimbursement rates across the fee schedule, so please review this carefully in the final rule.
  • Delay of laboratory payment reductionsCMS will not implement the previously planned reductions to the Clinical Laboratory Fee Schedule in 2021. In addition, CMS commented on delaying the reporting collection period, but the period being reported on will not change. Therefore, although a reporting deadline may be pushed back, the data will be for the same reporting dates of service.

2. Scope of Practice

There are several changes proposed by CMS regarding scope of practice for nurse practitioners, physician assistants, and other nonphysician practitioners. The intent is to create some permanence in changes made during the PHE this year and to expand upon the abilities of advanced practice providers without supervision.

If you have advanced practice providers in your organization, it is important to review these sections of the proposed rule. For example, if finalized, these individuals would have more leniency to supervise diagnostic testing within the confines of their state regulations.

3. Quality Program Proposals

  • Medicare Shared Services Program changesThese seem to be ever-changing but include replacing the web interface reporting mechanism, reducing the required quality measures, and increasing thresholds.
  • Quality Payment Program changesThese include 2020 hardship exemption policies, as well as other COVID-19–related changes, such as doubling the complex patient bonus for reporting year 2020.
  • Merit-based Incentive Payment System (MIPS)Points and weighting changes as seen in previous years will include the following:
    • 50 points minimum in 2021 to avoid a penalty of up to 9% in 2023
    • Increased weight of cost category to 20% in 2021
    • Decreased weight of quality category to 40% in 2021.
  • MIPS Value PathwaysThe proposal includes a delay of this reporting until 2022.

4. Estimated Impact on Allowed Charges

As always, CMS’s reimbursement changes have a net neutral goal. This means that some specialties will see an increase, whereas others will see a decrease. Hematology and oncology are projected to see an overall increase of 14% to the Medicare PFS. The confirmation is, of course, dependent upon the finalization of this proposed rule and is primarily due to the large increases in wRVU evaluations (up 9%) and physician expense RVUs (up 5%).

5. Telehealth and Remote Services

  • TelehealthIf the proposed rule is finalized, telehealth will see significant expansions, including adding permanency to 9 services, adding 13 services temporarily (until the end of the calendar year in which the PHE ends), and changes to frequency limitations on nursing facility visits. A highly debated policy being proposed is the discontinuation of audio-only visits (CPT codes 99441-99443).
  • Remote monitoringThe proposed rule includes clarification on remote physiological monitoring or wearables monitoring.


There are 2 things to keep in mind once you have identified the key areas to review. First, although the deadline to submit comments has passed (October 5, 2020), the plan is not yet finalized. Expect to see the final rule released sometime in early December. Second, since it is not possible to include all the details of the proposed rule in this article, it is important to dig into areas that will affect your practice to help prepare for the changes on the horizon. The CMS proposed rule can be accessed online.

Article provided through a partnership with
Practice Management Institute
Michigan Society of Hematology & Oncology

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