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What Do the Changes to the Medicare 2021 Physician Fee Schedule Mean for Your Practice?

On December 2, 2020, CMS released the final rule for the 2021 Physician Fee Schedule (PFS). It was revised on January 7th as part of the COVID Recovery Act. Every year, practices can expect to see small changes to the RBRVS scale and the expected budgetary modifications to the RVU Conversion Factor, but the 2021 changes to the PFS are significant.

RVU values for some of the highest volume codes were increased substantially. However, to maintain budget neutrality, the RVU conversion factor utilized to determine the approved payments to providers for services rendered was decreased at a proportional level. These changes could have significant impacts not only on practices with high Medicare and Medicaid patient panels, but also practices that rely heavily on the CMS RVU calculations for anything ranging from provider productivity reporting and benchmarking, to utilizing RVUs to determine physician compensation. The modifications are significant enough that practices should start modeling these changes immediately to be able to plan for the impact they will have on their bottom line.

2021 Physician Fee Schedule Change Finalized

On the positive side for physician practices, there was a revaluation of the RVU values for common Evaluation and Management (E/M) procedures – particularly the New and Established Patient Office Visit codes. In most practices, these are the most commonly billed codes by a fairly significant margin. The highest-level New Patient E/M Codes (99203-99205) increased by an average of approximately 10%. The Established Patient Outpatient E/M Codes increased by an average of 30% to 35%. Because these codes are so commonly billed in most practices and RVU values are universal across all patients, many providers will see significant RVU increases in their productivity reports. Additionally, most CPT codes will see a small increase in Practice Expense components of the Total RVU which is utilized to calculate Medicare reimbursement.

These RVU increases are offset from a budgetary standpoint by CMS originally proposing to drop the RVU conversion factor for all codes from the 2020 value of $36.08 to $32.41 in 2021. This equates to approximately a 10.5% decrease. The COVID stimulus act appropriated some additional funds for the physician fee schedule so that the decrease would only be around 4% to approximately $34.89.

To understand what this means, we will use an example of billing code 99213 - Established Patient Office Visit:

  • In 2020, the Work RVU value for this code was .97 and the NF Total RVU was 2.11.
  • When the 2.11 is multiplied by the 2020 $36.08 Conversion Factor, it led to an approved payment of $76.13.
  • In 2021, the Work RVU component for the same code increases to 1.3, and, with the practice expense increase the NF Total RVU increases to 2.68.
  • When multiplied by the 2021 RVU Conversion factor of $34.89, the approved payment amount is $93.51 – an increase of $17.38 or nearly a 23% increase.

Most codes, however, do not see similar increases.

For example, a New Patient Office Visit Level 5 – CPT Code 99205 – which does have an increase in the Work RVU component, does not see as significant an increase. This particular code projects a 2% increase from the 2020 approved reimbursement of $211.07 to $215.62 Other codes including surgery, radiology, etc., do not see an RVU increase at all, so the reimbursement could decrease by up to 4%.

Modeling the Medicare Reimbursement impact can help practices better understand how this rule affects their bottom line. By taking the utilization of the seven impacted E/M codes, modifying the RVU, and then repricing their Medicare Total RVU values – including the E/M increases – at the 2021 RVU Conversion Factor, a practice can predict the change in Medicare reimbursement that will be realized. This should be done at a division, specialty, or and provider level depending upon the organization and the level of Medicare in the organization’s payer mix.

Keep in mind, however, that the Reimbursement changes are not the only impact. The RVU changes are universal, regardless of payer. This will have an impact on Provider Productivity reporting and benchmarking. Depending upon the benchmarking service a practice uses, new benchmarks incorporating the E/M changes may not be available for 6-months to a year. As such, the provider’s RVU productivity compared to the benchmark may be artificially inflated by the E/M RVU modifications for all payers. Practices may want to adjust the benchmarks or productivity reports to take these changes into account.

RVU based physician compensation is also a key area to monitor with regards to the RVU changes. Organizations will see RVU increases across the board for most physicians, even when reimbursement remains flat or decreasing. This may have a significant financial impact on many organizations. Often, there is not a lot that the organization can do about the compensation plan; however, modeling the expected compensation increase based upon each provider’s E/M utilization can be a huge benefit to finance and payroll departments as they plan for the impending financial impact and adjust the budgets and projections accordingly.

The 2021 proposed rule for the Physician Fee Schedule is the most significant change in Medicare reimbursement in a single year that I have seen in my 20+ years in Healthcare. Organizations should model the changes and plan now, to fully understand the impact on their organization.


Written by Scott Everitt, VP of Healthcare Solutions at Practical Data Solutions

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