A Timeline of Regulatory Activity Leading up to This Cut

June 2018 MedPAC report to Congress stated: For illustration, we modeled the impact of a 10 percent increase in the payment rate for ambulatory E&M services (higher or lower increases could be considered). A 10 percent increase would raise annual spending for ambulatory E&M services by $2.4 billion. To maintain budget neutrality, payment rates for all other fee schedule services would be reduced by 3.8 percent.

Certain specialties would receive a large increase in their total fee schedule payments (on net) as a result of this change. The three specialties that would receive the highest proportional increases in payments are endocrinology, rheumatology, and family practice.

Other specialties-including diagnostic radiology, pathology, physical therapy, and occupational therapy—would experience reductions in their fee schedule payments of about 3.8 percent because they provide very few ambulatory E&M services.

This change would be a one-time adjustment to the fee schedule to address several years of passive devaluation of ambulatory E&M services. Even if this approach is adopted, we urge CMS to accelerate its efforts to improve the accuracy of the fee schedule by developing a better mechanism to identify overpriced services and adjust their payment rates.

If successful, these efforts would improve the accuracy of prices for ambulatory E&M and other services going forward and could reduce the need for future significant adjustments to the prices of E&M services. Together, these actions will help reduce the risk of beneficiaries experiencing problems accessing these services and will send a more positive signal to medical students and residents contemplating careers in specialties that provide large shares of these services.

July 2019: CMS 2020 MPFS proposed rule proposed increases to E&M codes in 2021 which would result in those providers who do not bill E&M codes experiencing an overall reduction in payment.  PT/OT was projected to be cut by 8%.

November 2019: CMS 2020 MPFS Final Rule finalized the proposal to increase E&M codes and maintained the same projected cut of 8% for PT/OT; CMS offered no explanation or rationale for the cuts or amounts of cuts-despite repeated inquiries from stakeholders and Members of Congress.

August 2020: CMS, despite strong and unequivocal pushback since August 2019, released the 2021 MPFS proposed rule which included plans to move forward with the E&M code payment boost ranging between 1% and 17%, while also increasing the depth of the cut to 9% for PT/OT.  35 specialists are projected to receive cuts raging from -1% to -11%.

What exactly are E&M codes and why did CMS elevate primary care?

E&M stands for "evaluation and management". E&M coding is used when a patient encounter includes notation of relevant history, physical examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; and medical decision making. Effective January 1, 2021, CMS is planning to increase payment for office/outpatient E&M visits for primary care and non-procedural specialty care for work associated with visits that are part of ongoing, comprehensive primary care and/or ongoing visits related to a patient's serious or complex chronic condition. This is happening in part because in 2017 it was determined that in about 60% of visits Current Procedural Terminology (CPT) codes used for medical billing did not account for all the care provided by primary care physicians; therefore, this adjustment is intended to make payment to primary care better reflect the time spent on evaluation and management since they are less likely to be performing specific procedures.


PPS Lobbying Efforts to date

PPS has been lobbying on this issue since it arose in 2018. Following is a timeline of actions and letters.


What Can You Do?

Advocate

  • Ask your Member of Congress to Include in upcoming legislation a waiver of the budget neutrality requirement that is forcing CMS to pay for an increase in Evaluation and Management (E/M) codes.  If CMS proceeds to cut physical therapy reimbursement by 9% as planned, many community-based outpatient physical therapy clinics who are barely hanging on through the joint impact of the public health emergency and economic crisis will go out of business.

     Take Action Here

Send Comments to CMS

Send your comment letter to CMS today, and encourage your staff to do the same, through the APTA Regulatory Action Center

Watch this video from PPS Government Affairs Committee Member Theresa Marko to see just how easy it is.

Engage your staff

Ask your staff to send their own letters con Congress!  Send them through the APTA Action Center,  or use the templates below to email or call their members of congress. 

 


Engage your patients, friends, and family in advocacy

Every voice counts!  Ask your Medicare patients to call or email their Senators and Representatives.  Consider engaging your office staff to help them take action while in your office. 

Use the Patient Advocacy Center on the APTA website, or give them this template to send their own email or phone call.

 

Patient Advocacy Works!  Watch this video from PPS member Anthony DiFilippo and see how easy and effective it can be!

Social Media Resources – download these images provided by APTA and post them to your social media account.  Be sure to include a link to the Action Center.

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Post these images on social media and tag your legislator 

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Use these images to encourage your patients, friends, and family to advocate. Post these with a link to the Patient Action Center 

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