PRS Alert: Conversion Factor Update, Impacts of G2211 Deletion, PHE Extension

CMS has released the final conversion factor for 2021.  The updated conversion factor based on the Consolidated Appropriations Act, 2021 (CAA) is $34.8931.  This represents a decrease of 3.3% from the 2020 conversion factor.   

The new complexity code G2211 was barred from payment until 2024.   The latest version of the Relative Value data set from Medicare released on December 29, 2020, did not include code G2211.  These two facts in combination lead to a PRS recommendation that you do not use this code.  Reporting the code is not required for payment and further having the code removed from the data set loaded for payment by Medicare carriers and Medicare advantage plans may lead to rejections at either the clearinghouse or payer level and could delay or result in denied claims submitted with code G2211. 

The reduction in the decrease of the conversion factor represents a combination of new funds from the US treasury and a reallocation of the funds that were expected to be paid using code G2211.  Based on the changes we are going to project an increase in payments to Urology of 8.5% (the AMA is projecting 8%).  Specifically, the reduction in the decrease of the conversion factor includes funds from the US Treasury Fund mandated by the CAA to offset 3.75% of the initial conversion factor drop and an estimated reallocation of the 3% projected from the G2211 at 50% impact to Urology.    (The complete AMA analysis estimating the impact of the Medicare payment changes [excluding the sequester moratorium extension] can be found here.)

In addition, CAA blocked the reinstatement of Sequestration reductions for the first quarter of 2021, a 2% impact on payments. 

Finally, the CAA reestablished the GCPI floor.  The GCPI floor impacts those physicians practicing in lower-cost areas of the country a positive impact for many rural areas. 

The implementation of these changes will likely delay payments of 2021 Medicare and Medicare advantage plans by up to one month.  Taking this in combination with deductible collection requirements practices need to plan accordingly.  The Medicare Deductible for 2021 is $203.  You may wish to establish policies to collect deductibles from Medicare patients prior to service in 2021 assuming processing delays will further delay patient invoicing. 

On January 7, 2021, the PHE was extended by the HHS secretary.  Thus, current Telehealth rules allowing patients to receive telehealth care from their home has been extended until April 21, 2021.   We expect that this will affect telehealth rules for many private payers that will follow Medicare rules and extend telehealth benefit coverage until the end of the first quarter.  Check with your payer for confirmation.  

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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.