NAACOS Analysis of the Final 2021 Medicare Physician Fee Schedule

Executive Summary

In early December, the Centers for Medicare & Medicaid Services (CMS) released the final 2021 Medicare Physician Fee Schedule (MPFS) rule and related MPFS factsheet. NAACOS commented on the proposed 2021 MPFS. The final regulation includes a number of policies affecting Medicare physician payment, quality changes for Medicare Shared Savings Program (MSSP) ACOs, and Quality Payment Program (QPP) requirements for 2021. There is a separate QPP factsheet. The key policies affecting ACOs are outlined below and further detailed in this analysis.

Note: A few policies included in the final 2021 MPFS rule were later changed through passage of the Consolidated Appropriations Act, 2021 (H.R. 133), which encompasses nearly $2.4 trillion in federal spending for 2021 and provides additional economic relief and stimulus in response to the COVID-19 pandemic. This comprehensive bill was passed by Congress and signed by President Trump in late December 2020. The policy changes in that law override the policies finalized by CMS in the final 2021 MPFS rule and are noted below. A NAACOS summary of the Consolidated Appropriations Act, 2021 is available.

Actions by CMS in the final 2021 MPFS rule include that the agency did the following:

Medicare Shared Savings Program

• Finalized a significant overhaul to MSSP quality, including:
  • Finalized adjustments to Web Interface quality measures effective for 2021, as well as adjustments to ACO administrative claims measures
  • Removed the Web Interface reporting mechanism with a delayed effective date of Jan. 1, 2022
  • Finalized a new quality assessment structure, the alternative payment model (APM) Performance Pathway (APP) which includes:
    • New scoring methodology for ACO quality
    • New policies for how quality performance contributes to shared savings/loss rates
• Providing ACOs with full credit automatically for CAHPS measures for 2020 due to COVID-19
• Introducing a new MSSP ACO quality measure set, effective Jan. 1, 2022 which relies on reporting electronic clinical quality measures (eCQMs)
• Making the CAHPS for MIPS survey mandatory for ACOs effective Jan. 1, 2021
• Amended the list of primary care services used in ACO assignment by adding 11 more codes
• Revised the policy for determining the amount of repayment mechanism arrangements for certain renewing and re-entering ACOs to allow a decrease of the repayment mechanism amount

Medicare Physician Payment and Quality Payment Program

• Decreased the Medicare conversion factor to $32.41. However, this drop from 2020 was overridden by the COVID-19 stimulus and 2021 Appropriations package which provided an additional $3 billion to raise reimbursement for MPFS services by 3.75 percent in 2021, resulting in a 2021 conversion factor of $34.89
• Continuing implementation of significantly revising payment and coding for office/outpatient Evaluation and Management (E/M) services
• Revalued code sets that include, rely upon, or are analogous to office/outpatient E/M visits commensurate with the increased values finalized for office/outpatient E/M visits for 2021, and finalized a new code G2212 for prolonged office/outpatient E/M visits and another, G2211 for complex E/M (effective 2024)
• Permanently added nine codes to the list of those eligible to be delivered via telehealth and temporarily added 60 codes through the calendar year for which the COVID-19 Public Health Emergency (PHE) ends
• Created HCPCS code G2252, which describes a 11-to-20 minute phone visit (i.e., virtual check-in) to an established patient with payment directly cross walked to CPT code 99442
• Clarified and finalized a number of polices related to remote patient monitoring (RPM), including allowing patient consent to be obtained at the time services are delivered, allowing RPM for patients with acute conditions, as well as chronic conditions, among others
• Changed the methodology for addressing prospectively aligned beneficiaries for Qualifying APM Participant (QP) score calculations and established a targeted review process
• Replaced the MIPS APM Scoring Standard with the new APM Performance Pathway to score all APMs in MIPS, including ACOs