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Congress Passes Legislation Impacting Medicare Payment, Providers & Beneficiaries 1, 2

On December 1, 2020, CMS released the 2021 Medicare Physician Fee Schedule (PFS) Final Rule and three weeks later, on December 21, 2020, the Consolidated Appropriations Act (CAA) of 2021 (H.R. 133), was passed by both houses of Congress and it was signed into law by President Trump on December 27. This is a massive piece of legislature at 5,593 pages.

Included within the bill are several provisions impacting Medicare payments, and issues of importance to both Medicare providers and beneficiaries. Below is a list of some of these provisions.

Medicare Conversion Factor for Calendar Year 2021

Under the Medicare Physician Fee Schedule (PFS) final rule, the 2021 conversion factor (CF) would have decreased 10.2% from $36.09 in 2020, to $32.41 in 2021. The marked reduction in the CF was due to revisions to the relative value units (RVUs) for evaluation and management (E/M) services that triggered the budget neutrality requirement. Under budget neutrality, any changes to the RVUs cannot increase or decrease expenditures for physicians’ services by more than $20 million. If expenditures exceed $20 million, the increases must be offset by decreases in payments for other services. This is accomplished through a budget neutrality adjustment.

CMS responded to commenters who called for the suspension to the budget neutrality adjustment, reminding them that CMS does not have the authority to waive the statutory budget neutrality rule.

In fact, it would take congressional action to mitigate steep cuts in the Physician Fee Schedule payments in 2021. Fortunately, there was wide bipartisan support for such measures and Congress took action through the CAA by including an infusion of $3 billion to pay for a temporary one-year increase in the CF, and the suspension of payments for new HCPCS code G2211, which also impacted the budget neutrality requirement.

As a result of the provisions in the 2021 PFS, and the changes mandated through the CAA of 2021, the new 2021 CF is $34.89.

2020 Conversion Factor 36.0896
Budget Neutrality Factor -6.81%
Congressional Update (mandated in CAA legislation) 3.75%
2021 Conversion Factor
34.8931**

Source: CMS-1734-F Webpage

Office/Outpatient Evaluation and Management Visits

As discussed in our previous newsletters, changes to the Evaluation and Management (E/M) codes are the most consequential changes in 2021. CMS has largely adopted the American Medical Association’s (AMA) revisions to the E/M codes which includes the elimination of CPT 99201, simplified descriptors and documentation standards for CPT codes 99202-99215 and the selection of the E/M visit level based on either medical decision-making (MDM) or total time spent on the date of the encounter including time spent conducting nonface-to-face activities.

Effective January 1, 2021, there are no longer “typical times” associated with an E/M visit, but defined time ranges for each E/M visit code (see Table 1).

Table 1 E/M Time Ranges for 2021

E/M Code Total Time on Day of Encounter: Face-to-Face & Non-Face-to-Face Time
99202 15-29 minutes
99203 30-44 minutes
99204 45-59 minutes
99205 60-74 minutes
99211 N/A
99212 10-19 minutes
99213 20-29 minutes
99214 30-39 minutes
99215 40-54 minutes

Source: Medicare Physician Fee Schedule 2021 Final Rule

In the 2021 PFS final rule, CMS references the new AMA/CPT guidance framework on selecting the level of office/outpatient E/M visits. When selecting the E/M code level based on time, the AMA provides a sample list of activities including both face-to-face and non-face-to-face that may be included in the calculation of total time.

Physician/other qualified health care professional time includes the following activities, when performed:

  • Preparing to see the patient (eg, review of tests)
  • Obtaining and/or reviewing separately obtained history
  • Performing a medically appropriate examination and/or evaluation
  • Counseling and educating the patient/family/caregiver
  • Ordering medications, tests, or procedures
  • Referring and communicating with other health care professionals (when not separately reported)
  • Documenting clinical information in the electronic or other health record
  • Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
  • Care coordination (not separately reported)

This list can be found in the following AMA publications, the AMA E/M Office Visit Compendium 2021, AMA cpt® 2021 Professional Edition, the AMA cpt® Changes 2021 an Insider’s View, and online at https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf. A number of Medicare Administrative Contractors (MACs) have also published this list on their websites.

Importantly, commercial payers are also required to adopt the E/M office visit code revisions effective January 1, 2021. The AMA explains that the CPT code set, together with the Healthcare Common Procedure Coding System (HCPCS), as maintained by the Department of Health and Human Services, has been adopted as the standard medical data code set for physician services and other health care services in the United States. These updates are now part of CPT code set, and health plans are required by HIPAA to use the most recent version of the medical data code set. 3

New Prolonged Services HCPCS Code G2212 - Medicare

If time is used to determine the E/M code for level 5 visits (99205 or 99215), G2212 may be reported when the maximum time required for the level 5 visit is exceeded by at least 15 minutes on the date of service.

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) “(Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416) (Do not report G2212 for any time unit less than 15 minutes).”

Effective 1/1/2021, CPT codes 99358-99359 are no longer reportable to Medicare in association or “conjunction” with office/outpatient E/M visits.

Medicare Prolonged E/M Visit Reporting G2212 – New Patient

CPT/HCPCS Code(s) Total Time Required for Reporting*
99205 60-74 minutes
99205 x 1 and G2212 x 1 89-103 minutes
99205 x 1 and G2212 x 2 104-118 minutes
99205 x 1 and G2212 x 3 or more
(for each additional 15 minutes)
119 or more

Medicare Prolonged E/M Visit Reporting G2212- Established Patient

CPT/HCPCS Code(s) Total Time Required for Reporting*
99215 40-54 minutes
99215 x 1 and G2212 x 1 69-83 minutes
99215 x 1 and G2212 x 2 84-98 minutes
99215 x 1 and G2212 x 3 or more
(for each additional 15 minutes)
99 or more

*Total time is the sum of all time, with and without direct patient contact and including prolonged time, spent by the reporting practitioner on the date of service of the visit.

Source: Summary of Policies in the Calendar Year (CY) 2021 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List

New Prolonged Services CPT Code 99417 - Other Payers

If time alone is used to determine the E/M code for level 5 visits (99205 or 99215), 99417 may be reported when the minimum time required to report the level 5 visit is exceeded by at least 15 minutes on the date of service.

99417 Prolonged office or other outpatient evaluation and management service(s) (beyond the total time of the primary procedure which has been selected using total time), requiring total time with or without direct patient contact beyond the usual service, on the date of the primary service; each 15 minutes (List separately in addition to codes 99205, 99215 for office or other outpatient Evaluation and Management services)

(Use 99417 in conjunction with 99205, 99215)

(Do not report 99417 in conjunction with 99354, 99355, 99358, 99359, 99415, 99416)

(Do not report 99417 for any time unit less than 15 minutes)

Other Payers Prolonged E/M Visit Reporting 99417 – New Patient

CPT/HCPCS Code(s) Total Time Required for Reporting*
99205 60-74 minutes
99205 x 1 and 99417 x 1 75-89 minutes
99205 x 1 and 99417 x 2 90-104 minutes
99205 x 1 and 99417 x 3 or more
(for each additional 15 minutes)
105 or more

Other Payers Prolonged E/M Visit Reporting 99417 – Established Patient

CPT/HCPCS Code(s) Total Time Required for Reporting*
99215 40-54 minutes
99215 x 1 and 99417 x 1 55-69 minutes
99215 x 1 and 99417 x 2 70-84 minutes
99215 x 1 and 99417 x 3 or more
(for each additional 15 minutes)
85 or more

*Total time is the sum of all time, with and without direct patient contact and including prolonged time,
spent by the reporting practitioner on the date of service of the visit.

Source: “CPT® Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99XXX) Code and Guideline Changes”

E/M Code Revisions - Resources

More information on who is required to implement the E/M office visit code revisions and E/M resources and updates are available from the AMA at:
https://www.ama-assn.org/practice-management/cpt/are-commercial-health-plans-required-adopt-revisions-em-codes.

The American Society of Clinical Oncology (ASCO) also maintains an updated page dedicated to 2021 Medicare changes and updates as well as the 2021 E/M changes. This page includes ASCO’s Guide to 2021 Evaluation & Management Changes resource book that can be downloaded and printed for easy distribution within your practice:
https://practice.asco.org/billing-coding-reporting/medicare-program?cid=DM6863&bid=68521413.

The AMA develops and maintains the CPT® code set. When purchasing CPT® coding resources, it is recommended that you purchase resources published by the AMA as they are the official coding source for the CPT® code set and contain information that other coding books don’t.

Recommended Resources from the AMA

  • AMA cpt® 2021 Professional Edition
  • AMA E/M Office Visit Compendium 2021
  • AMA cpt® Changes 2021 an Insider’s View

Medicare Sequestration

The Budget Control Act of 2011 required mandatory across-the-board reductions in federal spending (also known as sequestration). As required by law, sequestration resulted in a 2% reduction in Medicare fee-for-service claims (does not include payments for drugs) with dates of service on or after April 1, 2013.4

Section 3709 of the Coronavirus Aid, Relief, and Economic Security (CARES) Act temporarily suspended the 2% sequestration adjustment for claims with dates of service from May 1 through December 31, 2020.5 Subsequently, and in response to the ongoing public health emergency (PHE) the CAA extends the suspension of the 2% Medicare sequestration cuts from December 31, 2020 to March 31, 2021.

Work Geographic Practice Cost Index (GPCI)

The CAA extends through December 31, 2023 the provision that raises the Work GPCI to 1% for all localities that currently have a Work GPCI of less than 1%. Services paid under the PFS are assigned RVUs that reflect the amount of provider work, practice expense, and malpractice cost involved in providing that service. These three RVUs for each service are then adjusted by three GPCIs that adjust payment based on the cost to provide the service in that locality. The 1% floor to the Work GPCI was extended several times in 2020 in response to the COVID-19 PHE.

PFS Payment Formula
Payment = [(RVU work x GPCI work) + (RVU PE x GPCI PE) + (RVU MP x GPCI MP)] x CF

Estimated Impact Modeling and Analysis

Analysis by the AMA estimates the overall payment impact of the final rule and the CAA is an increase of 12% for hematology/oncology and 1% for radiation oncology. The impact will vary between practices based on the services provided, payer and patient mix.

Specialty CY2021 MPFS Final Rule Combined Impact – prior to CAA 2021) Legislative Impact -
CY2021 Combined Impact with New MFS CF of $34.8931, and without G2211
Hematology/Oncology 14% 12%
Radiation Oncology/Radiation Therapy Centers -5% 1%
Radiology -10% -3%
Rheumatology 15% 13%

Source: https://www.ama-assn.org/health-care-advocacy/advocacy-update/jan-8-2021-national-advocacy-update

If you want to see how the 2021 Medicare Final Rule and the CAA may impact your practice you can input your practice data in the Community Oncology Alliance’s (COA’s) 2021 Medicare Impact Model. This revised version of COA’s modeling tool reflects the GPCI, RVU and Conversion Factor changes that were published 12/29/20 to 1/4/21.

COA offers this as a free tool to members of the COA Administrator’s Network (CAN) and membership in COA’s CAN is complimentary.

Access COA’s 2021 Medicare Impact Model Here:
https://communityoncology.org/mycoa/can-support-network/can-resources/

ASCO also provides information on the impact of the PFS and the CAA legislation. ASCO’s analysis uses billing and reimbursement data from its PracticeNET network of oncology practices and cancer centers to project the estimated impact to oncology.

Access ASCO’s PracticeNET Analysis of the Medicare Physician Fee Schedule Final Rule Here:
https://practice.asco.org/sites/default/files/drupalfiles/2021-01/PracticeNET-MPFS-Report.pdf

MACRA Alternative Payment Model (APM)

In an effort to reduce provider burden during the current PHE, the CAA enacts a two year freeze on the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Alternative Payment Model (APM) incentive thresholds. The legislation freezes the thresholds needed to secure a 5% bonus at the 2020 level of 50% of payments or 35% of patients in an advanced APM.

The Quality Payment Program (QPP) 2021 Qualifying APM Participant (QP) Quick Start Guide was updated on January 14, 2021 to reflect the freeze to QP thresholds for payment years 2023 and 2024 as a result of the CAA of 2021.

Qualifying APM Participant (QP) Threshold Update

Performance Year 2020 2021 2022
Payment Year 2022 2023 2024
QP Payment Amount Threshold 50% 50% 50%
QP Patient Count Threshold 35% 35% 35%

Source: https://qpp.cms.gov/resources/resource-library

For more information

Radiation Oncology Model

The CAA includes a six-month delay in the implementation of the CMS Innovation Center’s Radiation Oncology (RO) Model. The new RO Model is a mandatory episode-based payment model that requires participation from radiotherapy (RT) providers and suppliers in randomly selected geographic areas that contain approximately 30% of all eligible Medicare fee-for-service RT episodes nationally. The Model performance period was originally scheduled to begin on January 1, 2021 and run through December 31, 2025.6, 7

The legislation prohibiting the RO Model from starting until January 1, 2022 was supported by the American Society for Radiation Oncology (ASTRO) and a bipartisan group of U.S. representatives who called for changes to the RO Model in order to protect cancer patients’ access to life-saving radiation treatments. 8

Visit the CMS Innovation website for complete details and updates on the mandatory RO Model:
https://innovation.cms.gov/innovation-models/radiation-oncology-model.

Cost-Sharing for Colorectal Cancer Screening Tests

Although Medicare previously covered colorectal cancer screening tests without cost-sharing, Medicare beneficiaries could be responsible for 20% coinsurance if the colonoscopy included a procedure.

Beginning Jan. 1, 2022, the CAA gradually eliminates cost-sharing for Medicare beneficiaries for colorectal screening tests where a polyp is detected and removed, if the test results in a biopsy, or if the beneficiary receives a colonoscopy after a fecal occult blood test indicates the presence of cancerous cells. Cost-sharing will be reduced from 20%, beginning in 2022, to 10% by 2029, after which the cost-sharing will be eliminated altogether.

Clinical Trials

Medicare has long covered routine costs of care associated with clinical trials. However, until passage of the CAA, state Medicaid programs were not required to cover these services. The CAA requires state Medicaid programs, beginning January 1, 2022, to cover routine care costs, such as lab tests, doctor visits, and treating complications from such studies, associated with participation in a qualifying clinical trial for serious or life-threatening conditions. Qualifying clinical trials will include those with government sponsors or an eligible clinical drug trial.

The legislation also requires coverage determinations to be completed within 72 hours based on attestation regarding the appropriateness of the qualifying clinical trial by the health care provider and principal investigator.

The stated goal of this provision is to ensure that Medicaid patients with life-threatening conditions have access to the best treatment option for their condition.

Surprise Medical Billing

Included in the immense CAA legislation is the “No Surprises Act”. This act amends Title XXVII of the Public Health Service Act to require that both fully-funded and self-funded group health plans hold health plan participants harmless from surprise medical bills. Patients are only required to pay the in-network cost-sharing (i.e., copayment, coinsurance, and deductibles) amount for out-of-network emergency care, for certain ancillary services provided by out-of-network providers at in-network facilities, and for out-of-network care provided at in-network facilities without the patient’s informed consent.

The provision also allows patients with complex care needs to have up to a 90-day period of continued coverage at in-network cost-sharing to allow for a transition of care to an in-network provider.

Any cost-sharing payments for these services must count towards the in‑network deductible and out-of-pocket maximum as if they were performed by in-network providers. The Act prohibits out-of-network providers from balance billing the participant for such services unless the notice and consent requirements are met.

Notice and consent requirements are met if:

  • The patient is provided written notice and consent 72 hours in advance of appointment.
  • Documents provided to patients must include a good faith estimate of the costs of the services (the language specifies this advanced notice does not constitute a contract).
  • Must also provide a list of in-network providers at the facility and information regarding medical care management, such as prior authorization.

The Departments of Health and Human Services (HHS), Treasury, and Labor must issue a regulation by January 1, 2022. The provisions in the No Surprises Act generally apply to plan years beginning on or after January 1, 2022.

For more information, the AMA has published a five-page high-level summary of the No Surprises Act that can be accessed at: https://www.ama-assn.org/system/files/2020-12/no-surprises-act-summary.pdf

Provider Relief Fund (PRF)

The CAA provides an additional $3 billion in additional grants for hospital and health care providers for health care-related expenses or lost revenue due to the coronavirus PHE. Additionally, not less than 85% of unobligated funds in the Provider Relief Fund (PRF) is to be used to reimburse health care providers for financial losses incurred in 2020.

The legislation allows providers to calculate lost revenues using the Frequently Asked Questions guidance released by the Department of Health and Human Services (HHS) in June 2020, which specified that providers could use “any reasonable method” for the calculation. It also clarifies that such methods include the difference between budgeted and actual revenue if such budget had been established and approved prior to March 27, 2020.

The legislation also states that a parent organization may allocate any or all of its subsidiary organizations’ PRF payments, including targeted distributions, among subsidiary eligible health care providers of the parent organization.

In response to the legislation, HHS updated its reporting requirements for PRF distributions, updated the PRF FAQs, and on January 15, 2021 opened the PRF Reporting Portal for registration and issued a new User Guide.

Notice of Post-Payment Reporting Requirements for PRF Recipients – Updated January 15, 2021:
https://www.hhs.gov/sites/default/files/provider-post-payment-notice-of-reporting-requirements-january-2021.pdf

CARES Act Provider Relief Fund Frequently Asked Questions – Updated January 28, 2021:
https://www.hhs.gov/sites/default/files/provider-relief-fund-general-distribution-faqs.pdf

PRF Reporting Portal:
https://prfreporting.hrsa.gov/s/

Consolidated Appropriations Act of 2021:
https://www.congress.gov/116/bills/hr133/BILLS-116hr133enr.pdf

Other Last Minute Regulations and Actions

CMS Pends Prior Authorization Final Rule

On December 10, 2020, CMS issued a proposed rule, the Reducing Provider and Patient Burden by Improving Prior Authorization Processes, and Promoting Patient’s Electronic Access to Health Information. According to CMS, therule would improve the electronic exchange of health care data among payers, providers, and patients and streamline prior authorization processes.

However, the rule only applies to Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service (FFS) programs, and Qualified Health Plans (QHP) issuers on the Federally-facilitated Exchanges (FFEs), it does not apply to Medicare Advantage plans.

Further, prior authorizations for prescription or outpatient drugs are not included in the rule, and QHPs are exempt from several major provisions in the rule.

The comment period for the proposed rule closed January 4, and the rule was initially finalized on January 15, 2021. Since that date, the previously released Final Rule CMS-9123-F was pended and links to the final rule and fact sheets are no longer operational.

On January 28, a Memorandum for the Heads of Executive Departments and Agencies: Regulatory Freeze Pending Review was published in the Federal Register. The memorandum informs the departments and agencies of temporary halts to the implementation of certain new or pending rules, in order to ensure that President Biden’s administration has the opportunity to review any new or pending rules. 9

https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/20/regulatory-freeze-pending-review/.

On January 28, a subject matter expert and policy analyst at the Office of the Burden Reduction & Health Informatics (OBRHI) relayed to us that “the prior authorization final rule is pending review by the new administration.” The proposed rule is still available at: https://www.cms.gov/files/document/121020-reducing-provider-and-patient-burden-cms-9123-p.pdf.

Most Favored Nation Model for Medicare Part B Drugs and Biologicals 10

The Most Favored Nation (MFN) Model Interim Final Rule was published on November 20, 2020 and was scheduled to begin on January 1, 2021. The fact that this is a mandatory MFN Model, and CMS’ failure to follow the required notice and comment procedures was widely criticized and legal challenges were immediately filed.

In addition, the MFN model came under heavy criticism by healthcare providers, ASCO, the Association of Community Cancer Centers (ACCC), the AMA, the American Hospital Association (AHA), COA, the National Coalition for Cancer Survivorship and many more. Stakeholders criticized the disregard shown for the inevitability that the rule is projected to result in Medicare patients not being able to access their needed drugs, the final rule states, “Beneficiaries lacking continued availability of their drugs through their current provider or supplier are assumed to seek access outside the model, to obtain their drugs through 340B providers, or to forgo access.” Moreover, they point out that the interim final rule admits that a considerable portion of the estimated savings under the MFN model “is attributable to beneficiaries not accessing their drugs through the Medicare benefit, along with the associated lost utilization.”

On January 13, 2021, a federal court agreed to a stay in the lawsuit that ACCC filed in partnership with the Pharmaceutical Research and Manufacturers of America (PhRMA), the Global Colon Cancer Association (GCCA) and National Infusion Center Association (NICA) against CMS. Under the agreement, CMS cannot implement the MFN Model until it considers public comments and issues a final rule, and if CMS issues a final rule, it must provide at least 60 days notice between publication of the rule and any change in payment rates.

If CMS does issue a final rule, then ACCC and the other parties can resume their suits challenging the rule. Read the ACCC news release at: https://www.accc-cancer.org/home/news-media/press-releases/news-template/2021/01/15/accc-lawsuit-challenging-legality-of-hhs-most-favored-nation-placed-on-hold.

Resources for More Information:

CMMI Most Favored Nation Model: https://innovation.cms.gov/innovation-models/most-favored-nation-model.

Most Favored Nation Model Fact Sheet: https://www.cms.gov/newsroom/fact-sheets/fact-sheet-most-favored-nation-model-medicare-part-b-drugs-and-biologicals-interim-final-rule-0

ASCO Policy Statement on the MFN Model:
https://www.asco.org/practice-policy/policy-issues-statements/asco-in-action/most-favored-nation-model-misguided-and-will

Order Extending Temporary Restraining Order:
https://innovation.cms.gov/media/document/mfn-d-md-tro-extend-memo

COVID-19 - Updates

Pfizer Covid-19 Vaccine

On December 11, 2020, the U.S. Food and Drug Administration issued an Emergency Use Authorization (EUA) for the Pfizer-BioNTech COVID‑19 Vaccine for the prevention of COVID-19 for individuals 16 years of age and older. Review Pfizer’s Fact Sheet for Healthcare Providers Administering Vaccine (Vaccination Providers) regarding the limitations of authorized use.

During the COVID-19 PHE, Medicare will cover and pay for the administration of the vaccine (when furnished consistent with the EUA). Review the updated payment and HCPCS Level I CPT code structure for specific COVID-19 vaccine information. Only bill for the vaccine administration codes when you submit claims to Medicare; don’t include the vaccine product codes when vaccines are free.

Related links:

FDA COVID-19 Vaccines webpage

AMA Vaccine Calculator Tool

On January 12, 2021 the AMA announced their new free tool to find the right COVID-19 vaccine Current Procedural Terminology (CPT®) code. This free tool helps clinical staff determine the appropriate CPT® code combination for the type and dose of vaccine that they are using. It uses a series of questions to help you arrive at the appropriate code. These codes incorporate the specialized tracking needs of the Centers for Disease Control and Prevention (CDC) and CMS by identifying two code groups. One group identifies a specific vaccine product and the other provides a vaccine administration code that is both vaccine and dose specific.

Visit the AMA website to access the vaccine calculator.

New Special Enrollment Period for Federal HealthCare.gov

On January 28, 2021, President Biden signed an Executive Order Strengthening Medicaid and the Affordable Care Act. The executive order allows the Department of Health and Human Services (HHS) to open a special enrollment period for the Affordable Care Act. In response, CMS issued a Fact Sheet announcing a Special Enrollment Period (SEP) for individuals and families to apply and enroll in coverage in the 36 states served by Marketplaces that use the HealthCare.gov platform. The SEP will run from February 15, 2021 to May 15, 2021.

Fact Sheet: 2021 Special Enrollment Period in Response to the COVID-19 Emergency:
https://www.cms.gov/newsroom/fact-sheets/2021-special-enrollment-period-response-covid-19-emergency.

Executive Order on Strengthening Medicaid and the Affordable Care Act
https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/executive-order-on-strengthening-medicaid-and-the-affordable-care-act/.

1 CMS.gov. Centers for Medicare & Medicaid Services. CMS-1734-F. Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2021.
https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1734-f. Accessed January 2, 2021.

2 Congress.Gov. H.R.133 - Consolidated Appropriations Act, 2021. https://www.congress.gov/bill/116th-congress/house-bill/133. Accessed January 22, 2021.

3 AMA Practice Management. Are Commercial Health Plans Required to Adopt Revisions to the E/M Codes? https://www.ama-assn.org/practice-management/cpt/are-commercial-health-plans-required-adopt-revisions-em-codes. Accessed January 4, 2021.

4 CMS.gov. CMS Medicare FFS Provider e-News. https://www.cms.gov/outreach-and-education/outreach/ffsprovpartprog/downloads/2013-03-08-standalone.pdf. Accessed December 22, 2020.

5 Congress.gov. Coronavirus Aid, Relief, and Economic Security Act https://www.congress.gov/116/bills/hr748/BILLS-116hr748enr.pdf. Accessed December 22, 2020.

6 CMS.gov. Newsroom. Radiation Oncology (RO) Model Fact Sheet. https://www.cms.gov/newsroom/fact-sheets/radiation-oncology-ro-model-fact-sheet. Accessed January 15, 2021.

7 CMS.gov. Newsroom. Press Release: CMS Announces Innovative Payment Model to Improve Care, Lower Costs for Cancer Patients. https://www.cms.gov/newsroom/press-releases/cms-announces-innovative-payment-model-improve-care-lower-costs-cancer-patients. Accessed January 15, 2021.

8 Astro.org. News and Publications. Congressional Leaders Urge HHS to Reevaluate the RO Model Design. https://www.astro.org/News-and-Publications/What-is-Happening-in-Washington/2020/Congressional-Leaders-Urge-HHS-to-Reevaluate-the-R. Accessed January 15, 2021.

9 Federal Register Vol. 86, No. 17, Thursday, January 28, 2021. Memorandum for the Heads of Executive Departments and Agencies. https://www.govinfo.gov/content/pkg/FR-2021-01-28/pdf/2021-01868.pdf. Accessed January 30, 2021.

10 CMS.gov. Most Favored Nation Model. https://innovation.cms.gov/innovation-models/most-favored-nation-model. Accessed January 13, 2021.

 

CONTACT US
Risė Marie Cleland Rise@Oplinc.com

Oplinc, Inc.
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www.Oplinc.com
Rise@Oplinc.com

UPCOMING ISSUE
Comments and suggestions for future issues are welcome, please forward correspondence to Risė Marie Cleland by email at: Rise@Oplinc.com

Genentech BioOncology® Access Solutions
https://www.genentech-access.com/hcp/biooncology.html?cid=gas_WE_00008163_1
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https://www.gene.com/patients/patient-foundation

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ABOUT THE EDITOR
Risė Marie Cleland is the Founder and CEO of Oplinc, Inc., a national organization of oncology professionals. Through Oplinc, Inc., Ms. Cleland publishes the monthly Oplinc Fast Facts focusing on the timely dissemination of information pertaining to billing, reimbursement and practice management in the oncology office and Oplinc’s Best Practices Review, which provides a more in-depth look at the issues and challenges facing oncology practices. Ms. Cleland also works as a consultant and advisor for physician practices, pharmaceutical companies and distributors.

IMPORTANT NOTICES
Please note that this newsletter is presented for informational purposes only. It is not intended to provide coding, billing or legal advice. Regulations and policies concerning Medicare reimbursement are a rapidly changing area of the law. While we have made every effort to be current as of the issue date, the information may not be as current or comprehensive when you review it. Please consult with your legal counsel for any specific reimbursement information. For Medicare regulations visit: www.cms.gov.

CPT® is a Trademark of the American Medical Association Current Procedural Terminology (CPT) is copyright 2021 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein.

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