Calendar Year 2021 Updates for Physician and Hospital Outpatient Services

 Updated: October 21, 2020

  Tags: AdvocacyCMS

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Recently, the Centers for Medicare and Medicaid Services published proposed rules, with a 60-day public comment period, to update payments under the Physician Fee Schedule (PFS) and the Hospital Outpatient Prospective Payment System (HOPPS) for the calendar year (CY) that begins on January 1, 2021. These federal rules are generally the ones that contain provisions impacting the respiratory care profession. Depending on the issues and proposals from year to year, AARC often submits written comments advocating for respiratory therapists and the value they bring to the health care system. This year, we provided written comments on both proposed rules.

CY 2021 Hospital Outpatient Prospective Payment System Update

The Medicare statute mandates that pulmonary rehab programs be directly supervised by a “physician” and that the physician be “immediately” available during the performance of the service if needed. During the public health emergency (PHE), CMS has indicated this requirement can be met by the virtual presence of the physician via real time, two-way audio/visual telecommunications. In the CY 2021 outpatient hospital update, CMS is proposing to allow the virtual presence of the physician to be permanent, effective January 1, 2021. In comments to CMS, the AARC supported this proposal.

As noted in an earlier News Now article, during the PHE, CMS is allowing outpatient therapy services, including education and training, to be furnished through use of telecommunications technologies by auxiliary personnel who are employed by the hospital and who do not have a specific benefit category.

Certain conditions apply such as the hospital designating the individual’s home as a provider-based department and the individual being registered as an outpatient. We interpret this to mean RTs can provide pulmonary rehab to outpatients in their home via telehealth with the staff located in the hospital outpatient setting or temporary expansion sites and the physician providing direct “virtual” supervision. We have asked CMS to clarify this interpretation in the final rule. We assume the services include G0424 and G0237-9, the latter of which are considered respiratory therapy services for those Medicare beneficiaries who do not meet the COPD criteria for pulmonary rehabilitation.

Read Our Comments

The HOPPS rule is also where we find the proposed rates for pulmonary rehabilitation for CY 2021. Overall, we see a slight increase in all the relevant codes over last year.

  • For services provided to Medicare beneficiaries with moderate, severe, or very severe COPD, the proposed rate for G0424 is $56.50.
  • For Medicare beneficiaries who do not meet the COPD criteria, payment for individual services under G0237 and G0238 described in 15-minute increments is $25.57.
  • For the group code, G0239, billed once per session, the proposed rate is $33.42.

CY 2021 Physician Fee Schedule Update

Under the temporary expansion of covered telehealth services during the public health emergency (PHE), CMS announced in earlier rulemaking that respiratory therapists can furnish telehealth services under Medicare’s Part B “incident to” benefit category with the physician or other qualified non-physician practitioner, such as a physician assistant or nurse practitioner, billing Medicare directly for the service. Recognizing that individual communities could face unique circumstances that may continue after the PHE ends, CMS is proposing in the CY 2021 PFS update to extend the policy to the end of the calendar year in which the PHE ends or December 31, 2021, whichever is later.

With respect to the ability of RTs to continue telehealth services after the PHE ends, we were encouraged by a statement in the proposed physician fee schedule rule that said: “We note that there are no Medicare regulations that explicitly prohibit eligible distant site practitioners from billing for telehealth services provided incident to their services.” We have asked CMS in written comments to clarify that RTs can continue to provide telehealth incident to the practitioners’ services for telehealth services that remain on a permanent list.

Back in the spring, CMS added CPT Code 94664, Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device to the telehealth list of temporary codes that will be removed once the PHE is lifted or a date determined by CMS. The AARC feels strongly that this code should continue to be a covered telehealth service temporarily to allow time to demonstrate there is a clinical benefit to the service via telehealth but for which data are insufficient to consider whether it currently meets the requirements to be added permanently. AARC presents a strong argument in our comments that improper inhaler techniques and lack of medication adherence represent not only additional costs to the health care system but also impact the overall health of patients who need these devices.

AARC also provided comments on remote physiological monitoring and transitional care management/chronic care management services that include the ability of RTs to provide services in the physician office setting.

Read Our Comments

List of Covered Telehealth Services

In a surprise move, CMS announced on Oct. 14, 2020, the addition of 11 new telehealth codes to its list of covered telehealth services of which cardiac and pulmonary rehabilitation services (G0424) are included. There is no indication, however, as to why CMS did not add codes G0237-9 to the list. As a reminder, these are services paid under the physician fee schedule and include only those programs that are furnished in a physician’s office. Since most programs are furnished as hospital outpatient services, we believe pulmonary rehab to be covered via telehealth under that scenario as discussed above.