Primary Care Doctors Fare OK Under New Fee Schedule

Evaluation-and-management services will be rewarded

Primary care physicians generally are pleased with the 2021 Medicare Physician Fee Schedule, as reimbursement for office-based evaluation and management (E/M) services will increase this year. So will the value of many bundled services, such as maternity services and transitional care management. What’s more, the new fee schedule means primary care doctors should experience less red tape and “note bloat” when seeking reimbursement.

“What will this mean for physicians who see patients in the office?” asked Kathy Blake, M.D., MPH, vice president, Health Care Quality, for the American Medical Association, at a virtual panel in mid-December. “We’re expecting you’ll be able to spend more time with patients and less time on documentation and coding. And really, the hope is that we can correct the current imbalance, which is that for every hour physicians spend with a patient, they spend two hours behind a computer screen.”

Two choices

The final rule simplifies coding for E/M services, so that physician practices can code based either on medical decision-making or total time.

Prior to this, E/M codes were dependent on the physician evaluating the chief complaint, history of present illness, review of physiological systems, and past, family and social history, says Lisa Satterfield, senior director, health economics and practice management, for the American College of Obstetricians and Gynecologists. “These requirements were not clinically applicable to all patients and required significant documentation. Now physicians can choose between the total time caring for the patient on the date of service, which includes the review of records and documentation from other providers, or the complexity of the patient. The changes allow the physician to focus on the patient and their clinical needs, and removes the check-box-like system.”

AMA President Susan R. Bailey, M.D., told Repertoire, “The process for coding and documenting E/M office visit services is now simpler and more flexible. It has been estimated that the new E/M coding and documentation guidelines for office visits will save clinicians 2.3 million hours per year.”

Family physicians

Kent Moore, senior strategist for physician payment, American Academy of Family Physicians, calls the changes to the office/outpatient visit E/M codes “the most significant since the codes were implemented in 1992.

“Prior to the new rule, physicians could only code based on time if counseling and/or coordination of care dominated the encounter, that is, consumed more than half of the physician’s face-to-face time with the patient,” says Moore. Now, physicians can code based on total time spent on the date of service, including time spent before and after the visit, he says. “The significance of coding office visits based either on medical decision-making [MDM] or total time is that physicians have only one element – MDM or total time – to consider when selecting a level service, [instead of] three elements (history, exam, and MDM). How all of this will influence physicians’ behavior remains to be seen.”

CMS had initially proposed implementing a primary care add-on code (G2211) for complexity. But in December, Congress put off implementing the code for three years, in order to make an adjustment to the overall Medicare conversion factor.

The decision disappointed AAFP, says Moore. “CMS estimated that physicians who rely on office visit E/M codes, such as family physicians, would have used G2211 with 90% of visits. The payment associated with G2211 would have helped support family physicians and other primary care physicians in their efforts to meet the needs of their patient populations. For the patients of AAFP members, the delay in implementation of G2211 is neither good nor bad news in most cases, because AAFP members will continue to provide the same high standard of care to those patients, regardless. It will just be harder to do so without the support that G2211 would have otherwise provided.”


“We anticipate that many obstetrician-gynecologists will appreciate the change of the codes being patient-focused, and will likely use the medical decision-making algorithm when seeing their patients,” says Satterfield. That algorithm takes into account three things: patient complexity, the amount and complexity of the data the physician must review in order to determine a proper course of treatment, and the risk of treatment or lack thereof.

Prior to the new rule, decision-making was based in part on how many physiological systems – e.g., neurological, circulatory, etc. – the physician reviewed, in addition to a history and physical. “It was based on what the physician did and not how the patient presented,” says Satterfield. “Now payment is aligning with how physicians
are practicing.”

ACOG takes exception to a few provisions of the 2021 fee schedule. “Because of some technicalities in statute, CMS determined they could not update the post-surgical visits bundled into the surgical codes. That decision, along with the overestimation of G2211, results in a significant decrease for all physicians, and especially surgical services. Gynecologic surgeries are necessary and important to women’s healthcare.

“While Congress temporarily mitigated some of the significant cuts in payment through the recent COVID relief bill, most physicians are going to see approximately 5% decrease in overall payment for Medicare patients in 2021,” Satterfield says. “The effects are even more detrimental to those who provide services for beneficiaries of the Medicaid program, where the average payment is about 68% of Medicare rates. These cuts are occurring when obstetrician-gynecologists are providing care to women across the lifespan and making accommodations in their practices to minimize their patients’ exposure to COVID.”

Like ACOG, the American Medical Association takes exception to a few E/M provisions of the 2021 final rule. Last fall, the AMA had recommended that CMS incorporate increases of reimbursement for office visits into surgical global payments. The final rule does not include that provision.

“Medicare and many other payors do not allow physicians to report hospital and office visits that occur in the post-operative payment,” says Bailey. “For a major surgical procedure, all visits performed for 90 days following the surgery are considered bundled into the payment for the surgery. Historically, when hospitals or office visits have increased, the payment for these visits within the bundle has also increased. The AMA, the RUC [RVS Update Committee], and numerous national medical specialty societies continue to call on CMS to fairly increase the payment for these visits incorporated into the surgical global payments.”