Act Now to Prevent Drastic Medicare Physician Fee Cuts to Ophthalmology; Contact Your Members of Congress Today!
The Centers for Medicare and Medicaid Services (CMS) recently released its proposed 2021 Medicare Physician Fee Schedule rule. As a result of the restructuring and revaluing of Evaluation and Management (E/M) codes and other payment changes, in addition to CMS refusing to increase the post-op E/M visits in 10- and 90-day global surgical codes, ophthalmology is expected to get a 6% reduction in overall reimbursement effective January 1, 2021. This is despite the objections and warnings from ASCRS and the medical specialty community on the impact this would have on physician practices already struggling from the negative impacts of the COVID-19 pandemic.
For CMS to offset this increased spending and due to budget neutrality rules, the conversion factor will be reduced by 10.6% – a $3.83 decrease from the 2020 conversion factor. Therefore, the estimated conversation factor for 2021 will be $32.26, the lowest it has been since 1993.
The impact of this and other changes results in a significant reduction to cataract surgery reimbursement (66984) by 9% from the 2020 rate of $557.58 to $505.84. Other ophthalmic codes are also negatively impacted. These cuts will have a devasting impact on ophthalmology and have the potential to reduce patients’ access to surgical care.
To prevent these drastic payment cuts and preserve access to care for patients, Congress must act!
ASCRS is working with the Surgical Coalition to pressure Congress to:
- Waive Medicare’s budget neutrality requirements, which allow the implementation of the payment increases for the stand-alone E/M services and the establishment of add-on codes but avoid the reimbursement cuts to other physician services required to offset these costs.
- Require CMS to apply the increased E/M payment to the post-op visits included in the 10- and 90-day global surgical services.
To help us to get Congress to act, it is imperative that members of Congress hear from you! They need to hear how the proposed 2021 Medicare Physician Fee Schedule Rule jeopardizes patient care and threatens the continued viability of your practice.
Act Now to Support Our Efforts.
- Call Your Members of Congress Today!
- Urge your representatives and senators to preserve patient access to surgical care and stop drastic payments cuts for surgical services.
- Call 202-224-3121 and ask to be connected to your elected officials’ offices.
- Use our talking points to incorporate in your discussions
- Use the ASCRS eye Contact Grassroots Advocacy Tool to tell your elected officials to act to prevent Medicare physician reimbursement cuts for surgical services.
2021 Medicare Physician Fee Schedule (MPFS) Proposed Rule Released; Includes Significant Reductions for Ophthalmology
On August 3, CMS released the CY 2021 MPFS Proposed Rule. CMS also released a fact sheet and press release. This proposed rule includes updates to payment policies and reimbursement, as well as quality provisions and is effective on or after January 1, 2021. The administration also issued an Executive Order on Improving Rural and Telehealth Access.
2021 MPFS Conversion Factor
The CY 2021 proposed MPFS conversion factor is $32.26, which reflects a 10.61% budget neutrality adjustment and the 0.00% update adjustment factor as established in MACRA. This represents a decrease of $3.83 from the CY2020 MPFS conversion factor of $36.09. The drastic, nearly 11% reduction in the conversion factor is a result of an additional proposed spending of $10.2 billion.
E/M Payment and Documentation
The CMS final Medicare Physician Fee Schedule (MPFS) for 2020 included a restructuring and revaluing of the office-based Evaluation and Management (E/M) codes effective January 1, 2021, which results in increased primary care payments. CMS proposes to implement those finalized changes. Adhering to budget neutrality requirements for implementing this new policy, as well as additional CMS proposals to increase valuation for specific services, results in sizable cuts for the surgical specialty community, including ophthalmology. The impact of the CY 2021 MPFS Proposed Rule represents an estimated 6% reduction in total allowed charges for ophthalmology and a 9% reduction in cataract surgery, 66984.
Impact on CY 2021 Payment for Selected Procedures
CMS Makes No Changes to Increase the Value of E/M Visits Included in 10- and 90-Day Global Codes Effective 2021
Despite intense advocacy from ASCRS, the AMA, and the surgical community that included a direct meeting with CMS and bipartisan letters from Congress, CMS indicated in the 2020 MPFS Final Rule they would not incorporate the office visit increases into the 10- and 90-day global surgery codes, as they continue to evaluate the data. That decision remains unchanged.
ASCRS and the surgical community opposed CMS’ policy because it disrupts the relativity of the physician fee schedule by changing the value of some E/M services, but not all, and violates current law that requires Medicare to reimburse physicians equally for the same services regardless of specialty. In addition, CMS’ rationale for not increasing the values because of its ongoing data collection on post-operative care in the global codes runs afoul of the MACRA statute that gave it the authority to study the codes but noted that CMS should continue to update individual code values. We maintain that if CMS identifies specific codes it believes are overvalued, it should refer them to the RUC for review as part of the misvalued code initiative. In addition, we reminded CMS that these values have been increased each time E/M services were revalued since the advent of the physician fee schedule and the Resource-Based Relative Value Scale (RBRVS) in 1992.
ASCRS will continue to work with the Surgical Coalition, the broader Provider Coalition, and the Alliance of Specialty Medicine in asking Congress to waive budget neutrality requirements associated with the finalized E/M proposal and to address the 10- and 90-day global surgical codes to prevent these cuts from taking place.
Medicare Telehealth Services
As part of the waiver authority given to the agency as a result of the COVID-19 Public Health Emergency (PHE) declaration, CMS has waived the geographic and site of service originating site restrictions from their homes. These flexibilities remain in effect through October 23, 2020. However, CMS does not propose to permanently waive these restrictions because it lacks the authority to make this change. Permanent changes to these restrictions will require congressional intervention.
CMS has proposed to permanently keep several codes that were temporarily added to the Medicare telehealth list, including the prolonged office or outpatient E/M visit code and certain home visit codes. In addition, CMS is also proposing to keep additional services, including emergency department visits, on the list until the end of the calendar year in which the PHE ends to allow more time to study the benefit. There is also language about allowing physicians to supervise non-physicians in rural areas using telehealth.
Quality Payment Program - Merit-based Incentive Payment System (MIPS)
CMS continues to propose modifications to the Quality Payment Program (QPP), which includes the Merit-based Incentive Payment System (MIPS) program.
Key proposals for CY 2021 MIPS performance, which impacts 2023 payment:
- Increasing the MIPS performance threshold from 45 points in 2020 to 50 points
- The exceptional performance threshold will be 85 points
- Revising category weights for Quality (40%) and Cost (20%)
- Adding telehealth services to the existing cost measures and to use performance period benchmarks rather than historical benchmarks for quality measures
CMS had finalized a new participation pathway: MIPS Value Pathways (MVPs), that would begin in the 2021 performance year. However, due to concerns expressed by ASCRS and the physician community on this timeline and with the added burden of the pandemic, CMS will not be introducing the MVP into the program in 2021. However, they are proposing to add to the framework’s guiding principles and the development criteria to support stakeholder involvement in codeveloping MVPs in future rulemaking.
CMS is also proposing a new Alternative Payment Model (APM) Performance Pathway (APP) reporting option in 2021 to align with the MVP framework. As part of this effort, CMS is sunsetting the CMS Web Interface as a collection type beginning in 2021 performance period.
In response to the PHE, CMS did establish a 2020 hardship exception policy, which allows physicians and groups to (1) opt out of MIPS entirely and be held harmless from a penalty, or (2) opt out of any of the individual MIPS categories.
We will continue to provide additional information and details.
All CMS documents related to the proposed rule can be found here.
2021 Ambulatory Surgery Center (ASC) Payment System and Quality Reporting (ASCQR) Program Proposed Rule Released; Includes 2.6% Update to the Conversion Factor
On August 4, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2021 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Policy Changes and Payment Rates proposed rule. The rule has a 60-day comment period, and ASCRS will be providing comments.
ASC Conversion Factor
For CY 2021, CMS proposes to adjust the CY 2020 ASC conversion factor ($47.747) by the wage adjustment budget neutrality factor of 0.9999 in addition to the MFP-adjusted hospital market basket update factor of 2.6%, which results in a proposed CY 2021 ASC conversion factor of $48.984 for ASCs meeting the quality reporting requirements.
For ASCs not meeting the quality reporting requirements, CMS is proposing to adjust the CY 2020 ASC conversion factor ($47.747) by the wage adjustment for budget neutrality factor of 0.9999 in addition to the quality reporting/MFP-adjusted hospital market basket update factor of 0.6%, which results in a proposed CY 2021 ASC conversion factor of $48.029 for ASCs not meeting the quality reporting requirements.
ASC Center Quality Reporting (ASCQR) Program
The ASCQR Program is a pay-for-reporting quality program for the ASC setting. The ASCQR Program requires ASCs to meet quality reporting requirements or receive a reduction of 2.0 percentage points in their annual fee schedule update if these requirements are not met. CMS is not proposing to add or remove any measures in this rulemaking.
No Agreement Reached on Next COVID-19 Package; Negotiations Continue Between the Administration and House Democratic Leadership
Senators left for the weekend without a deal on the next COVID-19 bill. Negotiations continue between the administration and the House Democratic leadership, however the two sides are far apart on major issues.
HHS Clarifies Audit Requirements for the CARES Act Provider Relief Fund
In implementing the CARES Act Provider Relief Fund, the U.S. Department of Health and Human Services (HHS) has clarified key polices in a series of frequently asked questions (FAQs). Recently, HHS updated its FAQs to provide clarity regarding the audit requirements for certain entities who received funds under the program.
In June 2020, the American Institute of Certified Public Accountant’s Governmental Audit Quality Center (GAQC) issued a document to summarize how Uniform Guidance applies (“Single Audit” or other audit requirements) to new federal programs established due to the COVID-19 pandemic (the Summary).
In recent updates to the FAQs, HHS has clarified the application of the Single Audit for the Provider Relief Fund payments. Specifically, HHS notes that for all entities other than commercial, for-profit entities, the Single Audit applies if the entity otherwise expends $750,000 or more in federal awards. For the commercial, for-profit entities, the entity has two options – (1) Single Audit; or (2) “a financial audit conducted in accordance with Generally Accepted Government Auditing Standards (45 CFR 75.216).”
In general, the objectives of a financial audit conducted in accordance with Generally Accepted Government Auditing Standards are to provide an opinion on whether an entity’s financial statements are presented fairly and to report on the adequacy of internal controls. Single Audits have additional objectives, including a determination that the auditee has complied with federal statutes, regulations, and terms and conditions of federal awards.
In reviewing the audit processes, if a provider is subject to the requirements, it would be best to consult with an accountant about whether the audit should be limited to entity that received the funds or encompass the entire organization (i.e., parent and subsidiaries), given that the Provider Relief Fund FAQs are not clear on that matter.
Provider Relief Fund Deadlines Extended
On July 31, the U.S. Department of Health and Human Services (HHS) announced the extension of key deadlines for the Provider Relief Fund. Specifically, Medicaid, CHIP, and dental providers, who previously had until August 3 to apply, now have an application deadline of August 28. In addition, starting the week of August 10, providers who previously missed the June 3 deadline for applying for the additional $20 billion distribution from the General Distribution can once again apply, with an application deadline of August 28. Finally, providers who had a change of ownership such that they did not have tax documents for 2019, but have provided care to a potential COVID-19 case since the start of the public health emergency, will also be eligible to apply for funding starting the week of August 10, with a deadline for the application of August 28. HHS also noted in its announcement that additional providers slated to receive funds include those that “may only bill commercially, or do not directly bill for the services they provide under the Medicare and Medicaid programs and thus did not receive any funding yet.”