HCQM News and Updates

December 2020 - CMS Updates


On December 1, 2020, CMS released the Final Rule for the Physicians Fee Schedule (PFS) and for the Quality Payment Program (QPP) for Calendar Year 2021. The Press Release is titled: Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021 and is effective January 1, 2021.

The complete, 2,165-page Final Rule is here.

The Physician Fee Schedule Fact Sheet is here.

The Final Rule is aligned with "CMS’ investment in primary care and chronic disease management by increasing payments to physicians and other practitioners for the additional time they spend with patients, especially those with chronic conditions. The rule allows non-physician practitioners to provide the care they were trained and licensed to give, cutting red tape so health care professionals can practice at the top of their license and spend more time with patients instead of on unnecessary paperwork."
Expansion of telehealth coverage to physicians has been center-stage: "During the COVID-19 pandemic, actions by the Trump Administration have unleashed an explosion in telehealth innovation, and we’re now moving to make many of these changes permanent,” said HHS Secretary Alex Azar. “Medicare beneficiaries will now be able to receive dozens of new services via telehealth, and we’ll keep exploring ways to deliver Americans access to health care in the setting that they and their doctor decide makes sense for them.”

“Telehealth has long been a priority for the Trump Administration, which is why we started paying for short virtual visits in rural areas long before the pandemic struck,” said CMS Administrator Seema Verma. “But the pandemic accentuated just how transformative it could be, and several months in, it’s clear that the health care system has adapted seamlessly to a historic telehealth expansion that inaugurates a new era in health care delivery.”
From March 2020 to October 2020, the adoption of telehealth services has skyrocketed: "Before the COVID-19 Public Health Emergency (PHE), only 15,000 fee-for-service beneficiaries each week received a Medicare telemedicine service. Since the beginning of the PHE, CMS has added 144 telehealth services, such as emergency department visits, initial inpatient and nursing facility visits, and discharge day management services, that are covered by Medicare through the end of the PHE. These services were added to allow for safe access to important health care services during the PHE. As a result, preliminary data show that between mid-March and mid-October 2020, over 24.5 million out of 63 million beneficiaries and enrollees have received a Medicare telemedicine service during the PHE."
A number of important Telehealth billing and documentation requirements are outlined in the Press Release. 

The Medicare Quality Payment Program (QPP) Final Rule Fact Sheet is here.

For complete information from CMS, please CLICK HERE to download a zip file with the following:
  • Fact Sheet and Table – Offers an overview of the QPP final rule policies for 2021; table compares these policies to the requirements for 2020
  • Frequently Asked Questions (FAQs) – Addresses the frequently asked questions for the 2021 QPP final rule policies
  • CMS MVP Submission Template – Provides instructions and a template that stakeholders should use to submit an MVP candidate for consideration

For more information:
CMS will host a webinar on Wednesday, December 9, 2020, to provide an overview of the final rule for the 2021 performance year. During this webinar, CMS will answer questions from attendees at time permits.

2021 Quality Payment Program Final Rule Overview
Wednesday, December 9, 2020 - 2:00 – 3:30 P.M. EST
Registration Link: https://engage.vevent.com/rt/cms/index.jsp?seid=1739

For Questions:
Contact the Quality Payment Program at 1-866-288-8292 or by e-mail at: QPP@cms.hhs.gov
Customers who are hearing impaired can dial 711 to be connected to a TRS Communications Assistant.


On December 1, 2020, CMS also released: Final Policies for the Medicare Diabetes Prevention Program (MDPP) Expanded Model for the Calendar Year 2021 Medicare Physician Fee Schedule. 


On December 2, 2020, CMS released the expected Final Rule concerning the CY 2021 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1736-FC).  

The Press Release from CMS states: "Today, the Centers for Medicare & Medicaid Services (CMS) is finalizing policy changes that will give Medicare patients and their doctors greater choices to get care at a lower cost in an outpatient setting. The Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) final rules will increase value for Medicare beneficiaries and reflect the agency’s efforts to transform the healthcare delivery system through competition and innovation."  This final rule is part of regulation earmarked in the [earlier] President's Executive Order (EO 13890) of October 3, 2020, "Protecting and Improving Medicare for Our Nation's Seniors" which outlines market-based approaches (as outlined in Executive Order 13813, titled, "Promoting Healthcare Choice and Competition Across the United States" of October 12, 2017); such as linking value reimbursement, increasing choice for patients, and reducing the regulatory burden upon providers.  Furthermore, the EO 13890 outlines increasing health outcomes possible via telehealth services and other technologies, allowing providers to spend more time with their patients through updating billing requirements, reduce the interval of time between FDA approval of new medications and treatments and the CMS coverage decisions, empower healthcare providers with data related to practice patterns, and continue to eliminate waste, fraud, and abuse to protect beneficiaries. In summary: the aim is to "increase choice, lower patients’ out-of-pocket costs, empower patients, and protect taxpayer dollars."

The Effective Date for the CMS OPPS [Outpatient Prospective Payment System] and Ambulatory Surgical Center (ASC) Final Rule is January 1, 2021.

The Final Rule is noteworthy in that: "CMS will begin eliminating the Inpatient Only (IPO) list of 1,700 procedures for which Medicare will only pay when performed in the hospital inpatient setting over a three-year transitional period, beginning with some 300 primarily musculoskeletal-related services.  The IPO list will be completely phased out by CY 2024. This will make these procedures eligible to be paid by Medicare when furnished in the hospital outpatient setting when outpatient care is appropriate, as well as continuing to be payable when furnished in the hospital inpatient setting when inpatient care is appropriate, as determined by the physician.  In the short term, as hospitals face surges in patients with complications from coronavirus disease 2019 (COVID-19), being able to provide treatment in outpatient settings will allow non-COVID-19 patients to get the care they need."  Procedures performed in the outpatient setting, when appropriate for the patient, could provide lower-cost options.  Table 48, page 709/1312 in the Final Rule lists the SERVICES REMOVED FROM THE INPATIENT ONLY (IPO) LIST FOR CY 2021 (N=298).  "In the March 2020 MedPAC “Report to the Congress: Medicare Payment Policy,” MedPAC found that, based on its analysis of indicators of payment adequacy, the number of ASCs had increased, beneficiaries’ use of ASCs had increased, and ASC access to capital has been adequate." [See Chapter 5, page 143 -Ambulatory surgical center services]. 

The Fact Sheet states: "In this rule, we are finalizing a policy in which procedures removed from the IPO list beginning January 1, 2021, will be indefinitely exempted from site-of-service claim denials under Medicare Part A, eligibility for Beneficiary and Family-Centered Care-Quality Improvement Organization (BFCC-QIO) referrals to Recovery Audit Contractors (RACs) for noncompliance with the 2-midnight rule, and RAC reviews for “patient status” (that is, site-of-service). This exemption will last until we have Medicare claims data indicating that the procedure is more commonly performed in the outpatient setting than the inpatient setting. This exemption will allow providers more time to become accustomed to the new ability to bill for Medicare payment of claims for services that were previously only paid on an inpatient basis. Providers are still expected to bill in compliance with the 2-Midnight rule. The BFCC-QIOs will still have the opportunity to review such claims in order to provide education for practitioners and providers regarding compliance with the 2-midnight rule, but claims identified as non-compliant will not be denied with respect to the site-of-service under Medicare Part A."

"CMS is announcing that it will continue its policy of paying for 340B-acquired drugs at Average Sales Price (ASP) minus 22.5% after the July 31, 2020 decision of the Court of Appeals for the D.C. Circuit upholding the current policy. This policy lowers out-of-pocket drug costs for Medicare beneficiaries by letting them share in the discount that hospitals receive under the 340B program. Since this policy went into effect in 2018, Medicare beneficiaries have saved nearly $1 billion on drug costs, with expected Medicare beneficiary drug cost savings of over $300 million in CY 2021."

CMS Star Rating changes to be finalized include (Critical Acces Hospitals [CAHs] and Veterans Health Administration [VHA] Hospital to be included): 
  • Simplify the methodology by reducing the total number of measure groups and create an explicit approach to calculating measure group scores;
  • Improve the predictability of the Overall Star Rating over time through a simple average of measure scores  with equal measure weightings that hospitals can better anticipate; and
  • Improve the comparability of the Overall Star Rating through updating the reporting threshold, and peer grouping.
Regarding the ongoing public health emergency," CMS is finalizing a new requirement for the nation’s 6,200 hospitals and critical access hospitals to report information about their inventory of therapeutics to treat COVID-19. This reporting will provide the information needed to track and accurately allocate therapeutics to the hospitals that need additional inventory to care for patients and meet surge needs".

In conclusion, CMS is continuing to empower Seniors by giving them more choice, allow them to spend more time with their providers, reduce their costs, and to reduce waste. 

Thompson H. Boyd, III, M.D.

CY 2021 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System Final Rule (CMS-1736-FC)

Final Rule 

Fact Sheet