MPFS 2020 Proposed Rule: E/M Blended Payment for 2021 Is Dead

Medicare physician fee schedule proposed rule 2020

Another day, another change to E/M plans for 2021! Medicare has released the 2020 proposed rule for the Medicare Physician Fee Schedule (MPFS), bringing in the recent AMA plan to revise E/M coding in 2021. But what does the MPFS say about Medicare payment for office/outpatient visits in 2021? Here’s the scoop.

Know What to Expect for E/M Payment in 2021

First, let’s repeat that although we’re talking about the 2020 proposed MPFS, the changes below won’t take effect until Jan. 1, 2021. Plus, these are proposed rules at this point, and as you’re about to see, even items that make it into the final MPFS rule may change again before 2021.

Now on to what you really want to know. In the 2019 MPFS final rule, Medicare announced a plan to blend payment rates for office/outpatient E/M code levels two to four. In other words, providers would get the same reimbursement for 92202-99204 and for 99212-99214.

But the 2020 MPFS proposed rule has news about that plan around page 506 of the PDF (page numbers refer to the PDF currently available for public inspection before publication in the Aug. 16, 2019, Federal Register).

Medicare’s new plan is to continue paying distinct rates for each office/outpatient E/M code in 2021. The proposed work RVUs, based on RUC recommendations, are below (from page 510 of the PDF). In parentheses, you’ll see how the 2021 work RVUs compare to current work RVUs for each code:

  • 99202: 0.93 (2019: same)
  • 99203: 1.6 (2019: 1.42)
  • 99204: 2.6 (2019: 2.43)
  • 99205: 3.5 (2019: 3.17)
  • 99211: 0.18 (2019: same)
  • 99212: 0.7 (2019: 0.48)
  • 99213: 1.3 (2019: 0.97)
  • 99214: 1.92 (2019: 1.5)
  • 99215: 2.8 (2019: 2.11).

Expect 1 New Add-On Code for Complexity

The 2019 final rule finalized these two codes (the code characters were yet to be determined):

  • Specialist visits: GCG0X (Visit complexity inherent to evaluation and management associated with non-procedural specialty care including endocrinology, rheumatology, hematology/oncology, urology, neurology, obstetrics/gynecology, allergy/immunology,  otolaryngology, interventional pain management, cardiology, nephrology, infectious disease, psychiatry, and pulmonology (Add-on code, list separately in addition to level 2 through 4 office/outpatient evaluation and management visit, new or established))
  • Primary care: GPC1X (Visit complexity inherent to evaluation and management associated with primary medical care services thatserve as the continuing focal point for all needed health care services (Add-on code, list separately in addition to level 2 through 4 office/ outpatient evaluation and management visit, new or established)).

Medicare planned to value both codes the same, at 75 percent of +90785 (Interactive complexity …), which is an add-on code for psychiatric and psychotherapy services.

The 2020 proposed rule shows instead that there will be only one new code, valued the same as +90785, and reportable in addition to any level of office and outpatient E/M visit:

  • GPC1X (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious, or complex chronic condition.    (Add-on code, list separately in addition to office/ outpatient evaluation and management visit, new or established)).

Don’t Forget About 2020 Changes

You’ve still got a lot of encounters to code before we get to 2021, so here are a few payment provision highlights based on Medicare’s fact sheet for the 2020 MPFS proposed rule with help on how to find more info in the proposed rule PDF.

CF: The conversion factor may go up $.05 from the current $36.0391 to $36.0896 (look around PDF page 1181 or search 36.0896).

Opioid tx: Medicare is planning three new telehealth G codes to represent a bundled episode of care for opioid use disorder treatment (search the PDF for GYYY1). There are also proposals for opioid treatment programs (OTPs), including enrollment policies and bundled payment information (search the PDF for OTP).

PAs: If a state doesn’t specify the physician supervision level for physician assistants (PAs), “the physician  supervision  required  by  Medicare  for  PA services  would  be evidenced  by documentation  in  the medical  record of the PA’s approach to working  with  physicians  in furnishing  their  professional  services” (that’s from page 1286 of the PDF).

Re-documentation: Medicare plans to allow physicians, PAs, and advanced practice registered nurses (APRNs) who furnish and bill professional services to “review and verify” information from the medical team rather than re-document (see page 214 of the PDF).

Care management: You may see increased pay for transitional care management and new G codes for some chronic care management services. There may be a new principal care management service, too, for providers caring for patients with a single serious, high-risk condition (start reading around PDF page 216).

PT/OT assistants: Modifiers for outpatient therapy services provided completely or partially by a therapy assistant will be effective Jan. 1, 2020 (start on PDF page 252 for details).

What About You?

Do you like that the plan for blended payment appears to be gone for E/M coding in 2021?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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