2021 Proposed Rules and RO Model: Q&A with James Hugh, MHA
By Tammy McCausland
In this Q&A, James Hugh, MHA senior vice president of American Medical Accounting and Consulting, Inc., (AMAC) shared his thoughts on the 2020 CMS Final Rules.
Q: What’s new regarding the proposed rules for hospitals?
A: The main point of the hospital proposed rules was an increase in the APC payment rates as opposed to last year, when there was no increase. This year is the normal increase of about 3.5 percent on hospital services, so that’s good news for hospitals. In the final rules, from 2018 and 2019, there was very little increase, and then from 2019 to 2020, it was roughly a 3.5 percent increase.
Q: What about the physician side?
A: On the physician side, we all know that we have new rules and regulations for the evaluation and management (E&M) codes. That has not changed from the proposed rule of 2020 to the final rule for 2020 to the proposed rules in 2021. It’s pretty much what everyone has known for the past year about the changes with evaluation and management codes.
The biggest change is the change of the conversion factor, which is currently $36.0896; the current conversion factor will be going down to $32.2605. It’s a big deal because it results in an approximate 10 percent decrease in physician income, a 3 percent decrease in the physician technical, and an overall global decrease of 5.5 percent.
Q: Is there anything else about the proposed rules that administrators should know about?
A: No, not for radiation. There are some other things, but they’re not really applicable to radiation. The big items are increases for hospitals. On the physician side, it’s the changing E&M documentation starting next year. The change in the conversion factor, which is resulting in a decrease in payments to physicians and freestanding centers. The COVID exceptions for supervision in the office (freestanding centers) and telehealth was extended to January 21, 2021.
ASTRO, CMS and other commenters are hoping that many of the radiation oncology codes that contain relative value units for E&M will be increased.
Q: What about the RO Model—will anything catch people by surprise?
The radiation oncology model final rule was published on September 18th. Little changed in the proposed rules that came out in July of 2019 and now CMS has delayed the implementation until July 2021. This is still too short of a period and hopes it will be pushed back until 2022.
Q: What happens now that CMS has delayed the RO Model until July 2021?
A: We’re going to have a lot of problems. AMAC commented on the proposed rules for the RO model, as did many others, to exclude brachytherapy sources, which CMS is not going to do. CMS said it excluded surgical brachytherapy procedures, but it missed some such as 55920, 57155 and 77778, and it included proton centers, which we were vehemently opposed to.
A standard single LINAC radiation center with an equipment cost of about $5 million will have a difficult time, as it is with the current proposed payment rates, but a proton center with equipment ranging from $30 million to $100 million will go out of business if the RO model is implemented, not excluding proton centers. These and other issues will be worked on this year and through the summer of next year.
Q: Are you basically saying all proton centers will go out of business?
A: The proton centers included in the 30 percent of zip codes are used to getting paid by Medicare around $40–60,000, and they’re going to be going down to $15–20,000, which is unsustainable. I don’t know what CMS is thinking.
Q: Do you have any other thoughts?
CMS is holding an open-door forum on billing for the RO model on October 29. I encourage administrators to participate.
Q: Why is there a disconnect between what the practitioners tell CMS what makes sense and what CMS proposes?
A: I think it has to do with the CMMI, the Centers for Medicare and Medicaid Innovation. Their head guy left in January of this year. Then COVID-19 hit, and all those people working on the RO model were moved to work on the COVID-19 issues.
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