Professional Providers — CMS final rule 2021

The Centers for Medicare & Medicaid Services (CMS) has released the final rule for the 2021 Physician Fee Schedule and Quality Payment Program. Released on Dec. 1, 2020, the final rule includes:

·         the final changes to the 2021 Medicare Physician Fee Schedule (PFS)

·         final policies for the Quality Payment Program (QPP)

The Medicare Physician Fee Schedule (PFS)


The background:

Medicare has paid for the services of physicians and other billing professionals under the PFS since 1992. There are different settings in which physicians’ services paid under the PFS are furnished. These settings include physician offices, hospitals, ambulatory surgical centers, skilled nursing facilities and other post-acute care settings, clinical laboratories, hospices, outpatient dialysis facilities, and beneficiaries’ homes. Several types of suppliers for technical services also receive payment under the PFS, often in settings for which no institutional payment is made. For most of those services rendered in a physician’s office, Medicare makes the payment to physicians and other professionals at a single rate that is based on the full range of resources involved in rendering the service. 

Highlights of the final rule

Supervision of Diagnostic Tests by Certain Non-physician Practitioners

CMS is finalizing a proposal to make permanent rule and allow  nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs), certified registered nurse anesthetists (CRNAs), and certified nurse-midwives (CNMs) to supervise the performance of diagnostic tests within their scope of practice and state law.  These practitioners must maintain the required statutory relationships under Medicare with supervising or collaborating physicians. 

Changes to Evaluation and Management Documentation Guidelines and Codes

There are significant changes in E/M visit coding and documentation policies beginning January 1, 2021. CMS also reevaluated fees for some code sets that are analogous to office/outpatient E/M visits, to name a few:

ü  Transitional Care Management (TCM) Services

ü  Cognitive Impairment Assessment and Care Planning

ü  Initial Preventive Physical Examination (IPPE) and Initial and Subsequent Annual Wellness Visits (AWV)

ü  Emergency Department Visits

ü  Therapy Evaluations

ü  Psychiatric Diagnostic Evaluations and Psychotherapy Services

New add-on code Visit Complexity Inherent to Certain Office/Outpatient E/Ms (HCPCS G2211) is added effective 01/01/2021.

CMS also finalized new prolonged HCPCS code G2212  “Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services).

Coding and Payment for Personal Protective Equipment (PPE)

On an interim basis, many supply pricing will be increased, considering the market costs for some types of PPE.


Immunization Services

In the CY 2021 PFS final rule, CMS is keeping the payment rates for immunization administration services defined by CPT codes 90460, 90461, 90471, 90472, 90473, and 90474, and HCPCS codes G0008, G0009, and G0010 at their CY 2019 payment levels in consideration of payment stability, public health concerns, and the need for these services by Medicare beneficiaries.


Owing to the quick adoption of telehealth services during the COVID-19 PHE, CMS is finalizing many of their proposals which will help retain the expanded access to these services beyond the emergency waiver authority.

Modifications to the Telehealth List:

CMS has decided to permanently add several CPTs to their list of services that are reimbursable if conducted via telehealth; those are mainly CPTs related to behavioral and home visits, as well as the two new E/M add-on codes for prolonged services (G2212) and Visit complexity (G2211).


  • Home Visits, Established Patient (CPT codes 99347-99348)  
  • Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes
  • 99334-99335)
  • Psychological and Neuropsychological Testing (CPT code 96121)
  • Cognitive Assessment and Care Planning Services (CPT code 99483)
  • Group Psychotherapy (CPT code 90853)

CMS also finalized the “Category 3” criteria to temporarily add codes to the CMS list of telehealth codes. Category 3 would remain on the Medicare telehealth services list through the calendar year in which the PHE for COVID-19 ends.


  • Emergency Department Visits, Levels 1-5 (CPT codes 99281-99285)
  • Nursing facilities discharge day management (CPT codes 99315-99316)
  • Psychological and Neuropsychological Testing (CPT codes 96130-96133; CPT codes 96136-96139)
  • Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes
  • 99336-99337)
  • Home Visits, Established Patient (CPT codes 99349-99350)
  • Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161-97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507)
  • Hospital discharge day management (CPT codes 99238-99239)
  • Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT codes 99469, 99472, 99476)
  • Continuing Neonatal Intensive Care Services (CPT codes 99478-99480)
  • Critical Care Services (CPT codes 99291-99292)
  • End-Stage Renal Disease Monthly Capitation Payment codes (CPT codes 90952, 90953, 90956, 90959, 90962)
  • Subsequent Observation and Observation Discharge Day Management (CPT codes 99217; CPT codes 99224-99226)


CMS also clarified that telehealth rules do not apply when the beneficiary and the practitioner are in the same location even if audio/video technology assists in furnishing a service.


Audio Only Telehealth Reimbursement

CMS did not propose that they would continue to pay for ‘audio-only’ telephone (E/M) services after the end of the PHE. However, CMS is creating, in the final rule, payment on a provisional final basis for a new HCPCS G-code (G2252), which covers 11-20 minutes of medical discussion to ascertain the necessity of an in-person visit.

G2252 (Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can 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 an E/M service or procedure within the next 24 hours or soonest available appointment; 11-20 minutes of medical discussion.).

Remote Physiologic Monitoring Services

·         CMS clarified that after the COVID-19 PHE ends, there must be an established patient-physician relationship for RPM services to be furnished.

·         CMS finalized that consent to receive RPM services may be obtained at the time that RPM services are furnished.

·         CMS finalized that auxiliary personnel may provide services described by CPT codes 99453 and 99454 incident to the billing practitioner’s services and under their supervision. Auxiliary personnel may include contracted employees.

·         CMS clarified that the medical device supplied to a patient as part of RPM services must be a medical device as defined by Section 201(h) of the Federal Food, Drug, and Cosmetic Act, that the device must be reliable and valid, and that the data must be electronically (i.e., automatically) collected and transmitted rather than self-reported.

·         CMS clarified that after the COVID-19 PHE ends, 16 days of data each 30 days must be collected and transmitted to meet the requirements to bill CPT codes 99453 and 99454.

·         CMS clarified that only physicians and NPPs who are eligible to furnish E/M services may bill RPM services.

·         CMS clarified that RPM services may be medically necessary for patients with acute conditions as well as patients with chronic conditions.

·         CMS clarified that for CPT codes 99457 and 99458, an “interactive communication” is a conversation that occurs in real-time and includes synchronous, two-way interactions that can be enhanced with video or other kinds of data as described by HCPCS code G2012.  We further clarified that the 20-minutes of time required to bill for the services of CPT codes 99457 and 99458 can include time for furnishing care management services as well as for the required interactive communication.

Direct Supervision by Interactive Telecommunications Technology

CMS finalized rule that direct supervision may be provided using real-time, interactive audio and video technology through the later of the end of the calendar year in which the PHE ends or December 31, 2021.

Changes to IPPE and AWV

Section 2002 of the SUPPORT Act required the Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) to include screening for potential substance use disorders (SUDs) and a review of any current opioid prescriptions. 

Payment Impact

Table below shows the payment impact on PFS services of the policies contained final rule. To the extent that there are year-to-year changes in the volume and mix of services provided by practitioners, the actual impact on total Medicare revenues will be different from those shown in Table.


MIPS changes 2021

Eligible professionals must participate in merit-based incentive program (MIPS), otherwise an adjustment of -9% will be applied to Medicare payments in 2023 calendar year.

Check eligibility here

2021 thresholds and category weights for the MIPS

•          The performance  threshold will remain at 60 points

•          The  threshold for exceptional performance continues to be 85 points: While CMS has not proposed a change to this threshold, you should note that the 2022 performance year (2024 payment year) will be the last year of the additional positive adjustment for exceptional performance.

Category Weights

o          Quality – 40% 

o          Cost – 20%

o          Improvement Activities – 15% - No change

o          Promoting Interoperability – 25% - No change

Please note that CMS is required to have cost and quality equally weighted (30%) by the 2022 performance year.


MIPS Value Pathways (MVPs) 

In the finalized CMS proposals, both MIPS Value Pathways and Alternative Payment Pathways, which are the future framework of Quality Payment Program (QPP) participation, provide MIPS participants with a smaller, standardized set of measures across all performance categories which lowers the reporting burdens of the program.

CMS will include MVPs in the 2022 proposed rule, while the Alternative Payment Pathway, the Alternative Payment Model (APM) version of an MVP, are available to report in 2021. 


2020 Performance Year Flexibilities 

  • CMS is doubling the maximum points available for the complex patient bonus from 5 to 10 points (for the 2020 performance period only) to be added to MIPS 2020 final score
  • Extreme and Uncontrollable Circumstances Application - Deadline Extended to February 1, 2021