Implications for Home-Based Care Providers in the CY 2021 Medicare Physician Fee Schedule (MPFS) Final Rule

Healthcare provider at home visit

On December 1,  The Centers for Medicare & Medicaid Services (CMS) released the long-awaited CY 2021 Medicare Physician Fee Schedule (MPFS) Final Rule. The MPFS Final Rule includes payment and policy changes that will significantly impact home-based care providers.

Decreased Reimbursement for Home and Domiciliary Visits

CMS is moving forward with revising documentation and coding guidelines and re-valuing the office Evaluation and Management (E/M) CPT code range 99201-99215. It is important to realize the new documentation and coding guidelines allowing services to be billed on time alone or on Medical Decision Making (MDM) apply only to the office setting. Providers who bill home and domiciliary CPT codes will continue using the same E/M documentation and coding guidelines (either 1995 or 1997 guidelines).

As a result of the budget neutrality provision, in which CMS increased the value of the office visit E/M CPT codes, reimbursement will be decreased in 2021 for all other E/M services (including those billed using home and domiciliary CPT codes). There are a few exceptions; below is the list of services most relevant to Home-Based Primary Care (HBPC) that will receive positive payment adjustments in CY 2021, along with the office visit code set:

  • Transitional Care Management (CPT 99495, 99496)
  • Cognitive Assessment and Care Planning (CPT 99483)
  • Annual Wellness Visits (HCPCS G0438, G0439)

At the time of this update, there is still pending legislation that could potentially postpone or prevent the pay cuts to the home and domiciliary codes (Bera Bucshon bill and Burgess bill); however, no action has been finalized as of yet.

Telehealth

Unless further legislative action is taken, once the Public Health Emergency (PHE) officially comes to an end, telehealth access will revert to previous limitations in the home setting. What that means is, according to CMS, the home is only an approved originating site for the treatment of mental health and substance abuse disorders under the SUPPORT (Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities) Act. In the Final Rule, CMS explains their new designations of Category 1 vs. Category 3 telehealth services (see below). Services considered Medicare telehealth Category 1 will be permanently added to Medicare’s approved list of telehealth services. In contrast, Category 3 telehealth services will be temporarily reimbursed only through the calendar year in which the PHE ends. See below for the breakdown of which levels of service are in each category.

Category 1 (Permanent Medicare Telehealth Services)

  • Domiciliary, established patient, CPT levels 1-2 (99334, 99335)
  • Home visit, established patient, CPT levels 1-2 (99347, 99348)
  • Cognitive Assessment and Care Planning Service (CPT 99483)

Category 3 (Temporary Medicare Telehealth Services, to remain covered only through the calendar year in which the PHE ends)

  • Domiciliary, established patient, CPT levels 3-4 (99336, 99337)
  • Home visit, established patient, CPT levels 3-4 (99349, 99350)

Further advocacy is needed to encourage CMS to include all levels of service for the home and domiciliary codes under Category 1 as permanent Medicare telehealth services. This would allow access in the home when and if we receive legislative change to remove or revise the geographic and originating site restrictions.

What You Can Do Now

For additional information, please visit the CMS CY 2021 MPFS Fact Sheet. Telehealth policy is something all stakeholders in home-based care will need to closely follow. The duration of the PHE and the extent to which it impacts telehealth policy are uncertain, and if, for example, another regulatory COVID-19 relief package is approved, certain waivers and flexibilities might be changed or extended. HCCI and its partners, including the American Academy of Home Care Medicine, will continue to monitor policy changes that impact the field of home-based care.

Providers, practices, and individual stakeholders are encouraged to provide feedback on these changes and their projected impact. The Department of Health & Human Services (HHS) is requesting feedback in the following Requests for Information (RFIs):

HCCIntelligence™ Webinar

HCCIntelligence webinarSee a replay of our HCCIntelligence Webinar, 2021 Coding: Impact for Home-Based Providers and Practices, to learn more about the MPFS Final Rule, as well as 2021 changes in documentation and coding requirements.
Register Here