On August 3, 2020, CMS issued a proposed rule which updates payment policies, payment rates, and other provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2021 (the Proposed Rule). The Proposed Rule introduces a number of updates to the PFS, including, but not limited to payment provisions; telehealth service expansion; care management services and remote physiologic monitoring services; professional scopes of practice; and direct supervision by interactive telecommunications technology. CMS will be accepting comments on the Proposed Rule until 5:00 pm EST on October 5, 2020.

Payment Provisions

In the Proposed Rule, CMS proposes a series of technical proposals “involving practice expense, including the implementation of the third year of the market-based supply and equipment pricing update, and standard rate-setting refinements to update premium data involving malpractice expense and geographic practice cost indices.”

The Proposed Rule also includes a budget neutrality adjustment that accounts for changes in relative value units (RVUs) that are converted into PFS payments rates. With the budget neutrality adjustment to account for changes in RVUs, the proposed CY 2021 PFS conversion factor is $32.26, a decrease of $3.83 from the CY 2020 PFS conversion factor of $36.09.

Telehealth Service Expansion

The Proposed Rule introduces a number of telehealth policy proposals, including the expanded use of telehealth services covered by Medicare. In the Proposed Rule, CMS looks to add 22 services to the list of telehealth services that Medicare covers. Examples of such services to be added to the Healthcare Common Procedure Coding System (HCPCS) include:

• Group psychotherapy (other than of a multiple-family group)
• End-Stage Renal Disease (ESRD) Services
• Psychological and Neuropsychological Testing
• Domiciliary, Rest Home, or Custodial Care services

In the Proposed Rule, CMS clarifies that Medicare telehealth rules are not meant to apply when providers provide services via telehealth technology when the provider is in the same location as the patient. For example, if a provider uses telehealth services to provide care to a patient in the same room due to concerns regarding exposure to COVID-19, the telehealth rules will not apply.

Additionally, CMS proposes revising frequency limitations for nursing facility visits provided via Medicare telehealth. Currently, CMS limits the provision of subsequent inpatient visits via Medicare telehealth to once every three days and subsequent nursing facility visits to once every 30 days. CMS is also considering removing frequency limitations for the visits altogether.

Care Management Services and Remote Physiologic Monitoring Services

The Proposed Rule clarifies Medicare payment policies for certain remote physiologic monitoring (RPM) services. Such clarifications include:

• Clarifying payment policies related to the RPM services described by CPT codes 99453, 99454, 99091, 99457, and 99458;
• Requiring that an established patient-physician relationship exist for RPM services to be furnished;
• Explaining that RPM services are considered to be evaluation and management (E/M) services; and
• Explaining that practitioners may furnish RPM services to patients with acute conditions as well as patients with chronic conditions.

Professional Scope of Practice

Under the Proposed Rule, CMS looks to make final certain allowances available under the federal public health emergency declaration, including allowing certain nonphysician practitioners to supervise diagnostic testing within state limits, so long as such nonphysician practitioners maintain required relationships with collaborating or supervising physicians.

CMS also clarifies that pharmacists fall within the regulatory definition of “auxiliary personnel” under the “incident to” regulations, meaning that pharmacists may provide services incident to the services, and under the appropriate level of supervision, of the billing physician or nonphysician practitioner, if payment for the services is not made under the Medicare Part D benefit.

Additionally, CMS no longer believes that all maintenance therapy services require that a physical therapist or occupational therapist personally perform such services. In turn, CMS proposes allowing physical and occupation therapists the same discretion to delegate the performance of maintenance therapy services, as clinically appropriate, to a therapy assistant.

Direct Supervision by Interactive Telecommunications Technology

In the Proposed Rule, CMS proposes allowing providers to provide “direct supervision” by using “real-time, interactive audio and video technology” through December 31, 2021. In connection with this proposal, CMS has asked stakeholders whether there should be any guardrails included for this policy and to highlight what risks this policy may introduce to beneficiaries as they receive care from practitioners that would supervise care virtually in this way.

Comments may be submitted online at http://www.regulations.gov.