Medicare Proposed Fee Schedule for 2021

[king22]

New Proposed OPPS rule is out. Looks like CMS is pushing ahead with it's changes in how to document and determine E&M levels (No more H+P component, MDM and time only) as well as significantly increasing reimbursement for office based E&Ms. Due to budget neutrality though, this increase is offset by an across the board decrease in the conversion factor of about 11%. This is going to result in a significant decrease in fees for many procedures.

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[CutsWithFury]

New Proposed OPPS rule is out. Looks like CMS is pushing ahead with it's changes in how to document and determine E&M levels (No more H+P component, MDM and time only) as well as significantly increasing reimbursement for office based E&Ms. Due to budget neutrality though, this increase is offset by an across the board decrease in the conversion factor of about 11%. This is going to result in a significant decrease in fees for many procedures.

Are you saying that in office procedures like nail avulsions/matrixectomies for example will be reimbursed less? Or are you talking about surgical procedures in general?

 

[king22]

Are you saying that in office procedures like nail avulsions/matrixectomies for example will be reimbursed less? Or are you talking about surgical procedures in general?

Both. Medicare Lowered the conversion factor from $36.0896 to $32.2605 to adjust for increased RVUs assigned to office based E&M codes. Essentially the increase in reimbursement for E&Ms is going to be offset by a general reduction in all other codes.

Interesting enough, Medicare does not increase RVUs for any other type of E&M (Inpatient, assisted living, home etc) nor does it increase the E&M component of surgical procedures.

 

[air bud]

Don't worry pods will just start billing more level 3s instead of 11042 and 97597.

 

[king22]

Keep in mind this is the proposed schedule, it hasn't been finalized yet. From what I've been reading, there's significant push back against this proposed cuts from pretty much every stakeholder. From what I've seen, if this is finalized, it would be the largest decrease in the conversion factor ever enacted. The end result could be reductions of 10%+ in medicare reimbursements for some specialties. With many providers struggling due to Covid-19, these reductions are akin to being kicked in the groin when you're on the ground.

Hopefully congress steps in to waive the "budget neutrality" rule. They've done this in several cases when large cuts are proposed (i.e. the SGR).

 

[king22]

Don't worry pods will just start billing more level 3s instead of 11042 and 97597.

You mean level 4's . New E&M guidelines make it much easier for pods to justify higher level E&Ms

 

[G0dFather]

New Proposed OPPS rule is out. Looks like CMS is pushing ahead with it's changes in how to document and determine E&M levels (No more H+P component, MDM and time only) as well as significantly increasing reimbursement for office based E&Ms. Due to budget neutrality though, this increase is offset by an across the board decrease in the conversion factor of about 11%. This is going to result in a significant decrease in fees for many procedures.

At this point medicare can do whatever they want .... if all innetwork insurances paid like medicare does and with its speed it would make life much better .... this is an insurance company that actually gives you some kind of raise ( albeit sometimes lower than inflation) compared to others which dont at all, they actually lower them from year to year. When i was a student and resident all i heard was the utmost extreme negativity and D&G about medicare .. turns out it was all BS... medicare is one of the best innetwork payers

 

[king22]

At this point medicare can do whatever they want .... if all innetwork insurances paid like medicare does and with its speed it would make life much better .... this is an insurance company that actually gives you some kind of raise ( albeit sometimes lower than inflation) compared to others which dont at all, they actually lower them from year to year. When i was a student and resident all i heard was the utmost extreme negativity and D&G about medicare .. turns out it was all BS... medicare is one of the best innetwork payers

I tend to agree. Where I practice, Medicare pretty much pays significantly more than most private insurers for E&Ms and most procedures.

The problem is that this change will hit us. We're a procedure heavy field. I did a quick look at some of the codes and it appears a 10% reduction in fees for many of the codes we commonly use (11721/11720, X-rays, wound debridement) are being proposed.

Again, we're not alone, pretty much all procedure heavy specialties are getting hit hard. I might be naively optimistic, but I think congress might decide to waive the budget neutral rule for this change. It appears congress has taken notice and some reps are planning on introducing legislation to correct this.

 

[heybrother]

Written from my phone so I'll be brief. Maybe just the way I practice. But a level 3 follow up on a plantar fasciitis that isn't improving often takes the same amount of time as a plantar fascia injection. The patient still wants to talk. They still want to understand what's being done. It isn't like I ever just walk in and inject a draped foot and walk out of the room. it's all kind of funny to me because the injection essentially would be a prescription medication. It's steroid. Am I crazy for thinking no one is ever going to bill for a injection again when they would be better paid for the E&M. (Sort of already the case but more so in the future...)

 

[G0dFather]

. Am I crazy for thinking no one is ever going to bill for a injection again when they would be better paid for the E&M.

I agree with you ... but if there is nothing else new and your continuing the treatment with an injection then thats what you should bill if your not injecting and just E & M with an rx continue stretching etc then E&M ( and your now MDM is pretty clear and more heavily weighted )

The problem is that this change will hit us. We're a procedure heavy field. I did a quick look at some of the codes and it appears a 10% reduction in fees for many of the codes we commonly use (11721/11720, X-rays, wound debridement) are being proposed.

So instead of 120 bucks allowable for a 97597 for example we get 109 allowable .... no problem still waaaay over what many others pay us ... just try to add another extra patient a day and problem solved ... im all for a slight reduction as long as they can keep the program sustained ... but with this recent crisis we just saw that all this is fake and they can just print LOL !

 

[air bud]

Written from my phone so I'll be brief. Maybe just the way I practice. But a level 3 follow up on a plantar fasciitis that isn't improving often takes the same amount of time as a plantar fascia injection. The patient still wants to talk. They still want to understand what's being done. It isn't like I ever just walk in and inject a draped foot and walk out of the room. it's all kind of funny to me because the injection essentially would be a prescription medication. It's steroid. Am I crazy for thinking no one is ever going to bill for a injection again when they would be better paid for the E&M. (Sort of already the case but more so in the future...)

draped foot for an injection?

also, I have always wondered this - do you consider an injection a prescription medication, thus getting level 4 risk? or is that pushing it? how do you deal with "medication management"? patient comes in for follow up, you saw 1 month ago for paresthesias, you put on gabapentin 300-600mg at night, they say much better, but room from improvement. assuming other data points since that is not a worsening problem, is that medication management and thus on the way to potential level 4?

 

[dtrack22]

Written from my phone so I'll be brief. Maybe just the way I practice. But a level 3 follow up on a plantar fasciitis that isn't improving often takes the same amount of time as a plantar fascia injection. The patient still wants to talk. They still want to understand what's being done. It isn't like I ever just walk in and inject a draped foot and walk out of the room. it's all kind of funny to me because the injection essentially would be a prescription medication. It's steroid. Am I crazy for thinking no one is ever going to bill for a injection again when they would be better paid for the E&M. (Sort of already the case but more so in the future...)

They’ll bill for both