2021 Proposed Fee Schedule: Anesthesia Takes a Hit

Summary: 

The proposed Medicare fee schedule for 2021 contains bad news for those whose practices are not heavily dependent upon evaluation and management (E/M) services. In other words, anesthesia will take a hit. Pain providers can take some comfort in the expected increase in E/M reimbursement.

he bad news just seems to keep coming. A pandemic that won't go away, a hit to the individual's and nation's bank accounts, a reduction of fall sports activities, and now this—a potential pay-cut next year for those on the frontlines of the COVID crisis. On August 3, the Centers for Medicare & Medicaid Services (CMS) issued its proposed Medicare physician fee schedule (MPFS) for calendar year 2021. The following reflects some of the key takeaways from the agency's press release regarding the proposed rule that will have direct implications for anesthesia practices.

PAYMENT PROVISIONS

Conversion Factor

With the budget neutrality adjustment accounting for changes in relative value units (RVUs), as required by law, the proposed national CY 2021 MPFS conversion factor (CF) is tentatively set for $32.26, representing a decrease of $3.83 from the CY 2020 CF of $36.09. The CF in your geographical locality may differ slightly from this figure. Keep in mind that this CF category is what will be utilized for payment calculations when anesthesiologists and anesthetists perform surgical services, such as postoperative pain blocks, invasive line placements, emergency intubations, TEEs, etc.

Similarly, the outlook for anesthesia reimbursement next year is also disappointing. The American Society of Anesthesiologists (ASA) is reporting that the proposed 2021 national anesthesia conversion factor is set for $19.96, which is down from the current anesthesia CF of $22.20, reflecting a reduction of $2.24. The ASA is continuing its efforts to urge government officials to reverse course and raise the anesthesia CF before the final rule is released later this year. We remain hopeful in this regard.

Despite the sour news for specialties that rely primarily on surgical or anesthesia services as the primary drivers of their revenue stream, other specialties may actually see an increase in collections. That is because many of the primary E/M visit codes (e.g., 99202–99215) are set to have higher reimbursement rates beginning next year. For example, it has been projected that endocrinology will see a 17 percent increase in allowed charges; rheumatology may realize a 16 percent jump in revenue; and family practice should see increases of around 13 percent. How this plays out with our chronic pain clients is yet to be determined. This will depend on each practice's mix of procedures and visits.

Telehealth and Communications Technology

For CY 2021, CMS proposed to add more services to the Medicare telehealth list on a Category 1 basis, the full list of which can be accessed by going to the following link: https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-4. The agency is soliciting comments on services added to the Medicare telehealth list during the PHE for COVID-19 that CMS is not proposing to add to the Medicare telehealth list permanently or proposing to add temporarily on a category 3 basis.

Direct Supervision by Interactive Telecommunications Technology

For the duration of the PHE related to the COVID-19 pandemic, CMS adopted an interim final policy revising the definition of direct supervision to include virtual presence of the supervising physician or practitioner using interactive audio/video real-time communications technology (85 FR 19245). The agency recognized that in some cases, the physical proximity of the physician or practitioner might present additional infection exposure risk to the patient and/or practitioner.

In the CY 2021 MPFS proposed rule, CMS is proposing to allow direct supervision to be provided using real-time, interactive audio and video technology (excluding telephone that does not also include video) through December 31, 2021.

Payment for Office/Outpatient Evaluation and Management (E/M) and Analogous Visits

As finalized in the CY 2020 MPFS final rule, in 2021 CMS will be largely aligning 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. CMS is proposing a refinement to clarify the times for which prolonged office/outpatient E/M visits can be reported and is proposing to revise the times used for rate-setting for this code set.

PROFESSIONAL SCOPE OF PRACTICE

Supervision of Diagnostic tests by Nonphysician Practitioners (NPPs)

In the CY 2021 MPFS proposed rule, CMS would allow nurse practitioners (NPs), clinical nurse specialists (CNSs), physician assistants (PAs) and certified nurse-midwives (CNMs) to supervise the performance of diagnostic tests in addition to physicians. Accordingly, if finalized, effective January 1, 2021, NPs, CNSs, PAs and CNMs would be allowed under the Medicare Part B program to supervise the performance of diagnostic tests within their state scope of practice and applicable state law, provided they maintain the required statutory relationships with supervising or collaborating physicians.

Medical Record Documentation

In this CY 2021 MPFS proposed rule, CMS clarifies that physicians and NPPs, including therapists, can review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the MPFS. CMS also clarifies that therapy students, and students of other disciplines, working under a physician or practitioner who furnishes and bills directly for their professional services to the Medicare program, may document in the record so long as it is reviewed and verified (signed and dated) by the billing physician, practitioner, or therapist.

Supervision Services of Teaching Physicians

For the duration of the COVID-19 PHE, CMS implemented the following policies on an interim basis through the March 31st COVID-19 IFC and the May 1st COVID-19 IFC. Teaching physicians may use audio/video real time communications technology to interact with the resident through virtual means, which would meet the requirement that they be present for the key portion of the service.

This virtual supervision allowance may not extend to anesthesia cases, however. Here is an instructive excerpt from the proposed rule:

While flexibility to provide direct supervision through audio/video real-time communications technology was adopted to be responsive to critical needs during the PHE to ensure beneficiary access to care, reduce exposure risk and to increase the capacity of practitioners and physicians to respond to COVID-19, we are concerned that direct supervision through virtual presence may not be sufficient to support PFS payment on a permanent basis, beyond the PHE, due to issues of patient safety.  In complex, high-risk, surgical, interventional, or endoscopic procedures, or anesthesia procedures, a patient's clinical status can quickly change. To permit payment under the PFS for these teaching physician services, we believe the services must be furnished with a certain level of personal oversight and involvement of the teaching physician who has the experience and judgment that is necessary for rapid on-site decision-making during these procedures.  [Emphasis added.]

We will continue to review the proposed rule, along with relevant summaries from authoritative entities, and will update our readers as new information comes to light. For those with questions about the proposed rule and how it might impact your practice, please contact us at info@anesthesiallc.com.