PRS Alert: Final Rule 2021 Update

The Final Rule for 2021 has been released.

On December 1, 2020, the Centers for Medicare & Medicaid Services (CMS) issued the final rule for physician payments for the Calendar year 2021.  We have provided a summary of a few relevant topics for Urology here. 

CY 2021 Conversion Factor

The final CY 2021 PFS conversion factor is $32.41, a decrease of 10.2% from the CY 2020 conversion factor of $36.09.

The decrease is based on budget neutrality adjustments projected to impact the fee schedule primarily reflecting the increase in RVUs assigned to E/M and related codes, which account for approximately 40% of all charges allowed under the Medicare fee schedule.  Other factors that are projected to impact the final Medicare budget include changes to Practice Expense values based on market factor changes, mal-practice updates, and changes to the Geographic Cost of Practice Indices (GCPI) started two (2) years ago. 

The impact on Urology overall is projected to be an 8% increase.  The projections are based on payments to all Urologists billing Medicare.  Due to the decrease in the conversion factor practices providing a majority of services in the ASC or HOPD will likely have lower increases in revenue from Medicare.

Office/Outpatient Evaluation and Management Visits

CMS as adopted the CPT changes and associated rules as proposed by the AMA CPT 2021.  Values for the E/M codes have also been revised and finalized in the rule resulting in increased payment.   Code 99201 has been deleted.  Code 99211 has been retained without change. 

This represents the first major change in E/M codes in over 25 years.  New guidelines allow greater flexibility for documentation of History and Physical Examination excluding these from level determination, however, medically appropriate documentation for both Hx and PE are required.  Billing for the new codes will now be determined by either Medical Decision Making (MDM) or total time.  MDM guidelines have been revised to reflect risk and avoid payment for data separately reported.  Time has been revised to include pre, intra, and post-service requirements for the visit.  PRS has several courses available to assist in understanding these new guidelines that should reform medical documentation to a more clinically focused and much less onerous process.

Other categories of E/M codes such as Consultations (not paid for by Medicare), Hospital visits, Emergency Department visits, etc. will continue to follow current guidelines requiring HX, PE, and MDM. 

Proposed Code GPC1X has been finalized with a slight change to the description and a more HCPC compliant identifier  G2211.

Officially the new code is

G2211 Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)

The G2211 can be used by any specialty, however, Urology is one of several specialties identified specifically (thank you LUGPA) to use the code in addition to each E/M visit in which the patient encounter meets the description.  Including visits reported with modifier -25. 

CPT code 99417 was determined by CMS to be confusing and as such has added a new HCPCS Code for use in reporting prolonged Office or other Outpatient visit codes in addition to 99205 or 99215.  The HCPCS code, G2212, Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services) “(Do not report G2212 on the same date of service as 99354, 99355, 99358, 99359, 99415, 99416). (Do not report G2212 for any time unit less than 15 minutes) is descriptive in both use and restriction.  As stated it can only be reported for time-based visits which exceed the maximum time for 99205 (74 minutes) or 99215 (54 minutes) by a minimum of 15 minutes.  G2212 can be reported more than once in addition to the appropriate base code but only for each full 15 minutes above the previous combined time. 

As an example of appropriate use, any visit between 84- 98 minutes would be reported  99215 x 1 and G2212 x 2.


As proposed CMS has expanded the number of services payable under Telehealth.  Several services were added to the permanent covered list including the two new HCPCS codes G2211 and G2212. 

CMS has also finalized for the duration of 2021 the inclusion of a list of services that will be covered under Telehealth rules.  These codes include Established patient codes for Rest Home visits (99336-99337), Home Visits (99349-99350), and Therapy Services, (97161-97168, 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507).  This list also includes Adult and pediatric Critical care codes (99469, 99472, 99476, 99478-99480,99291-99292) and Discharge codes for Nursing facilities (99315-99316), Hospital ( 99238-99239), and Observation Management (99217).  Emergency department codes (99281-99285) and Subsequent Observation codes (99224-99226) are also included on the temporary list. 

Coverage for Telehealth will revert to pre-PHE rules for the remainder of 2021 once the Public Health Emergency is discontinued.  This means that all services on the covered list including E/M codes will be covered only if the patient is located in a Health Professional Shortage Area (mostly Rural areas) and in an approved Medicare Facility (a location with billing privileges for Medicare).  Additionally, services will need to be provided to patients that have an established relationship with the patient, with some noted exceptions, including hospital, emergency department visits, and Outpatient visits that are conducted with a patient under the care of another physician during the visit.   Telehealth visits after the PHE ends should be reported using POS 02 and will be reimbursed at the facility rate. 

Services provided via Telehealth technology when the patient and the physician/APP are located within the same facility are not considered Telehealth visits and will instead be considered as covered.  These services should be reported as if the encounter was provided face to face. 

RPM services

The final rules has provided clarification with two changes for codes  99453, 99454, 99091, 99457, and 99458. RPM services can only be furnished to Established Patients once the PHE ends.  RPM services for codes 99453 and 99454 may be reported as incident to the billing practitioner’s services and under their supervision and included contracted employees.  Devices used for these services must be FDA approved medical devices.  16 days of data each 30 days must be collected and transmitted to meet the requirements to bill CPT codes 99453 and 99454.  For CPT codes 99457 and 99458, an “interactive communication” is a conversation that occurs in real-time and includes synchronous, two-way interactions that can be enhanced with video or other kinds of data and that the 20-minute requirement for the service can include time for furnishing care management services in addition to the required interactive communication.

Direct Supervision

CMS finalized that direct supervision may be provided using real-time, interactive audio and video technology through the later of the end of the calendar year in which the PHE ends or December 31, 2021. 

For more information on the final rule, we encourage you to review the information from the following links.

2021 Medicare Physician Payment Schedule Final Rule.

For a CMS summary

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Mark N. Painter is a managing Partner of PRS Consulting, LLC, the CEO of PRS, LLC and the Vice President of Coding and Reimbursement Information for Physician Reimbursement Systems, Inc. (PRS). Since co-founding PRS in 1989, Mr. Painter has served as the primary coding resource for the PRS products including Hotlines, Coding Manuals and quick reference tools, the Internet based application and seminars. He has lectured to a variety of groups concerned with health care reimbursement. Mr. Painter's extensive knowledge of physician reimbursement issues has allowed him to assist insurance companies, physicians and their staff members, legal counsel, actuaries, Specialty Societies and consultants on a daily basis. He has serves has an expert to legal counsel, bio device companies and pharmaceuticals. He was a co-chair of the Colorado Clean Claims Task Force, a committee of nationally known industry experts charged with the development of single payment edit database for the state. Mr. Painter is a CPMA. Mr. Painter received his B.A. from Grinnell College at Grinnell, Iowa.