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Physician E/M Codes and the 8% Cut…

Physician E/M Codes and the 8% Cut…

You may recall that by law, there are no annual statutory increases to the Medicare Physician Fee Schedule for the next five years – from 2020 through 2025. This does not mean that reimbursement via the Fee Schedule won’t or can’t change over the next five years. This was demonstrated in a big way in the CY 2020 Final Rule. CMS finalized an increase in reimbursement for the outpatient/office physician evaluation and management (E/M) CPT codes (99201-99215) beginning January 1, 2021, which will result in an approximately 8% cut in payment for outpatient PT, OT and ST services, to maintain budget neutrality. The physician outpatient/office E/M code set comprises almost a quarter of all physician fee schedule spending. Because of this increase, 36 different specialties will face cuts of some sort in 2021 to balance the increase in payment for the E/M codes.

In Table 120 in the Final Rule, CMS provided estimated impacts of the E/M payment and coding policies – a few of which are noted in the table below.  CMS “believes these estimates provide insight into the magnitude of potential changes for certain physician specialties…” and notes that these estimates should be considered “for illustrative purposes only.” CMS has not determined the actual cuts to each code or the methodology they will use to make the adjustments.

Associations representing impacted providers – including the therapy associations – have joined together to form an informal coalition to advocate with both Capitol Hill and CMS around this issue. The coalition met with CMS in early January and submitted formal comments to the Final Rule by the February 10 deadline.  Letters have been written to CMS from members of both the House and Senate, as well as directly from professional associations and individual providers. Congress and the associations are asking CMS for additional information and transparency on how the cuts were (and will be) calculated and are asking to stop or at least delay implementation. In addition, discussions emphasize concerns about patient access to necessary services, including outpatient therapy, especially in rural areas. CMS and your representatives and senators need to hear from you, from providers, directly. This is not going to be an easy battle, but it is one we need to all engage in.

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Holly Hester

Holly Hester is Casamba’s Senior Vice President of Compliance & Education, as well as the Compliance Officer. She provides regulatory guidance and interpretation, clinical programming and content development, education and training steerage, and compliance support for the company. As a physical therapist for more than 20 years, Holly has multi-venue clinical and management experience, giving her a unique perspective on the integration of compliance and training with therapy service delivery and clinical practice.
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