2021 proposed rule: Get ready for E/M changes


Also watch for practice expense increases for many high-volume procedures.

Jonathan Rubenstein, MD

Jonathan Rubenstein, MD

On August 3, the Centers for Medicare & Medicaid Services (CMS) finally released its proposed rule for the 2021 Medicare Physician Fee Schedule (PFS). The release date was later than previous years, as it is typically released the last week of June or the first week of July.

What do the proposed changes mean to your practice? In this article, we will address a few of the proposed changes that we feel are most important to urologists and the field of urology. We also encourage you to review other articles for updates to the Merit-based Incentive Payment System (MIPS)/Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and related value-based payment programs that affect your practice.

Mark Painter

Mark Painter

Due to the late release of this proposed rule, CMS has stated that it will invoke a protocol that allows late posting of the final rule only 30 days before it goes into effect on January 1, 2021. Thus, we project that the final rule will be released in late November or early December—which gives little time to react or prepare for any major additional changes posted in that final rule.

The process for comment on this proposed rule is unaffected by the late release and leaves time to read and react fully. The changes we discuss below may or may not warrant your individual action. However, a few of the proposed changes have a major negative impact on some specialties, and the reaction to some of the proposed rule changes has already begun. We will have to carefully watch the actions of Congress and President Donald Trump to attempt to anticipate changes that may impact the final rule.

As reported in the past, all changes to the PFS fall under a constraint of budget neutrality, and 2021 is no different. However, a number of specialties are arguing to change the impact of the changes by suspending or amending budget neutrality for this year. Any change of this magnitude will take an act of Congress. Although the circumstances are slightly different, we have played a similar waiting game before.

First and maybe most important, the change in evaluation and management (E/M) codes as related to their structure and value will likely have the most effect and may also be the most controversial change. Although everyone can agree that an update to E/M structure was needed regarding how it related to the modern practice of medicine, it is the revaluation that has garnered the most interest. Overall, E/M services will increase in value due to updates in the value of the work and practice expense. Because of the volume of services reported using these codes within the Medicare program, CMS is projecting an increase in the total number of relative value units (RVUs) for the next calendar year. In response, to keep budget neutrality, the conversion factor (used to calculate the payment for services based primarily upon the total RVU) is projected to drop by 10.6%.

Interestingly, even with the reduced value for professional fees of surgical services due to this conversion factor decrease, urology as a specialty is projected to see a bump of 8% in Medicare reimbursements. This projection is based on urologists as a group. Because not all urologists bill for the same services, individual urologists may be impacted differently.

The 8% projected increase for urology, along with increases for several other specialties (mainly those that perform a high number of E/M services), will come at the expense of specialties across the spectrum that bill more surgical or procedural services and fewer E/M services. This group includes many surgical specialties along with radiology, anesthesia, audiology, emergency medicine, infectious disease, chiropractic care, pathology, and most therapies. Those that are projected to gain include general practice, endocrinology, oncology, and rheumatology—with some increases in the double digits and some more than two times the increase for urology.

Predictably, those facing decreases are leading the charge to address the dramatic shift. For example, the Surgical Care Coalition is requesting an adjustment to the Medicare budget to allow the E/M code changes without the decrease in payments to other specialties. We have seen this before: For 9 years, CMS and Congress worked to avoid significant conversion factor decreases by “kicking the can down the road” with paybacks to the budget from future years. We will keep an eye on this to see what happens.

E/M code changes

As mentioned, changes to the outpatient E/M code structure and valuation will have the most impact in 2021. The majority of the 2020 final rule as released by CMS remains unchanged and is scheduled to be implemented in 2021. You will likely recall that the American Medical Association has created new outpatient CPT E/M codes and guidelines for 2021. CMS has reaffirmed that they will adopt these changes as well as the value changes proposed by the Relative Value Scale Update Committee (RUC) with a few minor changes, such as the use of the 15-minute add-on code if using time for code selection.

The changes will only affect outpatient visit codes and will include the following:

• Code 99201 will be deleted.

• Documentation requirements: The history and physical examination section bullet point requirements will be eliminated and will require only a medically appropriate history and physical examination.

• Medical decision-making: Definitions and corresponding level requirements will be further defined and amended to more closely reflect clinical efforts for each level.

• Time values and time definitions: Time will no longer be counted by face-to-face time when more than 50% is counseling and coordinating care. Rather, it will be the additive time of the entire time on the date of service that the provider spends on the patient’s care, including previsit, intravisit, and postvisit time.

• Value increase for each level for codes 99202-99205 and 99211-99215: This increase will be reflected in both the work and practice expense components.

• New shorter prolonged services add-on code that measures time in 15-minute increments: This will be used with codes 99205 or 99215 when the total time the provider spends on the patient on the date of service exceeds the maximum time allowed by 15 minutes or more.

• New proposed HCPCS G-code: The GCP1x add-on code will be used to better describe the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition. If finalized, the details of GCP1x will be better defined.

These are the first major changes to E/M codes in 23 years. Urology practices rely heavily on this set of codes for income. To prepare for these changes, each practice will need to reevaluate their previsit requirements for both patients and staff, implement a transition plan to address changing electronic health record templates and calculators, explore schedule and patient flow changes, project financial changes, amend compliance programs, and train personnel appropriately. A number of training programs will be available later this year.


E/M code values are not the only changes contributing to urology’s projected reimbursement increase. The practice expense of many high-volume in-office urology procedures is going up, which may help offset the proposed 10.6% conversion factor drop. Notable practice expense increases include urodynamics, UroLift, Rezum, cystoscopy, and cystoscopy-based procedures, including biopsy of the bladder and treating small bladder tumors.

The changes to work RVUs are minimal, granting a reprieve to urologists paid on work RVU production, which is good news short term. However, the decrease in the conversion factor will negatively impact the professional fees of procedures/services by as much as 10.6%, which is especially challenging when provided in house because the practice expense value for that facility bumps up a bit. This decrease may negatively impact the income of employers whose physicians provide services in the facility setting. RVU-based contracts will need monitored for reindexing to mimic payments from Medicare and/or private payers.


CMS has proposed shifting more of the balance of MIPS onto the cost portion, which is slated to increase from the current 15% to the new level of 20%, along with increasing the threshold minimum score from the 45 points to 50 points.


The proposed rule is written to accommodate the current public health emergency (PHE). The rule includes a number of provisions to indicate that the PHE will likely be renewed for at least 1 additional 90-day period. Currently, the PHE is scheduled to end on October 23, 2020. The PHE can be extended in successive 90-day terms. Many provisions for the 2021 proposed rule are written to extend through the end of the calendar year in which the PHE expires to allow for tracking and study of the services provided via telehealth, indicating that CMS expects the PHE to extend into 2021.

We will not take the time in this article to cover the many changes that Medicare made to telehealth in the face of the PHE. It is important to note that CMS has acknowledged the success of telehealth and will attempt to keep many of the changes in place after the PHE ends. CMS has added a number of codes to the permanent covered service list for telehealth and has indicated that some remote supervision rules implemented during the PHE will be adopted.

The proposed rule also indicates that CMS will add a third temporary category of services that will be considered covered through the end of the calendar year in which the PHE ends. Extending the use of these codes will allow Medicare to test their utility.

Medicare has further attempted to clarify both communication technology–based services (CTBS) and remote monitoring services to increase the use of both and to continue to address the lack of health care access for many Americans. New proposed CTBS codes for therapists and other professionals not qualified to bill E/M service will allow for remote check-in and image review services similar to codes G2010 and G2012.

CMS has also clarified requirements for remote physiologic monitoring and care coordination for codes 99453, 99454, 99091, and 99457. These clarifications indicate that after the PHE ends, (1) services can only be provided to established patients, (2) codes 99353 and 99354 will require data monitoring for at least 16 days within a 30-day period, and (3) code 99457 will require synchronous communication with the patient for at least 20 minutes in a 30-day period. Code 99091 is to be used to report the analysis of data obtained from remote monitoring, which is reported separately from treatment planning (code 99457).

The rule indicates that telephone-only codes 99441-99443 will not be covered after the PHE has ended; however, CMS has indicated a willingness to hear from patients and physicians with regard to the importance of telephone-only services. We would encourage you to contact CMS, your state medical society, and/or your senators and representatives to encourage the continued coverage of these service types.

All these rules clearly reflect efforts by CMS to increase the reach of telehealth and remote care. However, Medicare by rule cannot extend coverage for telehealth beyond what is allowed by law. For example, after the PHE ends, Medicare cannot cover telehealth services when the patient is at home. As such, without action by Congress, Medicare beneficiaries will be required to go to a Medicare-approved facility to receive telehealth services after the PHE ends. CTBS and remote monitoring services can be provided in a home-based setting but must follow the rules established by the program.

Again, we encourage you to contact your members of Congress and to encourage your patients to do the same to request that Medicare rules be changed to allow patients to receive telehealth from home. Currently, regulations are written in a way that indicate that the PHE is expected to extend into 2021.

We are all interested to see what changes may take place between this proposed rule and the final rule. In the meantime, we should all start preparing for 2021 with these proposed changes in mind.

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

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