On August 3, 2020, the proposed Medicare Physician Fee Schedule for 2021 was released. This 1,355 page document includes some sweeping changes to the Medicare program. There are a few items in particular which should be noted by chiropractic offices. Instructions for submitting comments can be found HERE.

Telehealth Expansion Continues in 2021

Even though telehealth will keep much of it’s expanded services, Medicare will only reimburse a doctor of chiropractic for spinal manipulation; therefore the impact of this particular change might be considered negligible, except that where Medicare goes, other payers tend to follow so this could have a positive impact. Since Medicare is expanding their list, it is likely that the AMA will also add more services to their list of telehealth services which are found in Appendix P of the CPT codebook. For these reasons, the 2021 ChiroCode DeskBook will include a chapter on telehealth services. Watch your mail for special Express Renewal bundle pricing.

It should be noted that Physical Therapy services 97110, 97112, 97116, 97535, 97750, 97755, 97760, and 97761 are not being considered for continued inclusion once the public health emergency (PHE) is over. However, they are currently taking public comments prior to publishing the final rule. If CMS were to include some of these services on their telehealth listing, it might pave the way for other payers to also include them as a covered telehealth service. CMS has stated that they have not been previously included because the law specifically states that only certain types of providers (e.g., physicians) may provide telehealth services and the majority of these services are provided by physical therapists who are excluded from providing telehealth services (except during this PHE). 

Note: There are also some proposed changes in relation to physical therapy assistants. Click HERE and do a search on “physical therapy assistant” for more information.

Reimbursement Reductions

Medicare and many other payers rely on calculations based on the Relative Value Unit (RVU) and a conversion factor. Some services provided by doctors of chiropractic are expected to have changes to these calculations.

Medicare Conversion Factor: The estimated conversion factor is “32.2605 which reflects the budget neutrality adjustment under section 1848(c)(2)(B)(ii)(II) of the Act and the 0.00 percent update adjustment factor specified under section 1848(d)(19) of the Act.” This effectively amounts to a 10.61 percent reduction in the conversion factor. This alone would reduce Medicare payments, but they didn’t stop there. Many specialties, including chiropractic, will also be hit with RVU reductions. 

RVU Changes: For the chiropractic specialty, the work RVU will be decreased 7% and the practice expense RVU will be decreased by 3%. The following table estimates the impact of these changes (RVUs are the national unadjusted amounts):

While an $8.11 reduction might not seem like a lot, when applied over the course of a month or year, those numbers can add up.

The RVUs for acupuncture services also have proposed changes. Even though Medicare does not cover acupuncture services, many payers use the CMS RVUs for fee calculations. CMS has proposed revising the work RVUs for codes 97810 through 97814 by changing them to the work RVUs for the dry needling codes (20560, 20561) which were added last year. While the ruling doesn’t say what the final RVUs will be for 2021 we can look at the 2020 RVUs for a comparison; the 2020 work RVU for 97810 was 0.60 and the work RVU for 20560 was 0.32. Because CMS RVUs will be reduced, it is likely that reimbursement for these services by third-party payers will also be reduced.

MIPS / QPP Revisions

While many chiropractic offices are exempt from participation in MIPS due to the low volume threshold, it should be noted that there is a “Chiropractic Medicine” specialty set established by CMS. The following quality measures are included on that list:

• 182: Functional Outcome Assessment: Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies.
• 217: Functional Status Change for Patients with Knee Impairments: A patient-reported outcome measure of risk-adjusted change in functional status for patients aged 14 years+ with knee impairments. The change in functional status (FS) is assessed using the Knee FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
• 218: Functional Status Change for Patients with Hip Impairments: A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with hip impairments. The change in functional status (FS) is assessed using the Hip FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
• 219: Functional Status Change for Patients with Lower Leg, Foot or Ankle Impairments: A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with foot, ankle and lower leg impairments. The change in functional status (FS) is assessed using the Foot/Ankle FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure). 
• 220: Functional Status Change for Patients with Low Back Impairments: A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with low back impairments. The change in functional status (FS) is assessed using the Low Back FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure)
• 221: Functional Status Change for Patients with Shoulder Impairments: A patient-reported outcome measure of risk-adjusted change in functional status for patients 14 years+ with shoulder impairments. The change in functional status (FS) is assessed using the Shoulder FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.). The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
• 222: Functional Status Change for Patients with Elbow, Wrist or Hand Impairments: A patient-reported outcome measure of risk-adjusted change in functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS is assessed using the Elbow/Wrist/Hand FS patient-reported outcome measure (PROM) (©2009-2019 Focus on Therapeutic Outcomes, Inc.) The measure is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality. The measure is available as a computer adaptive test, for reduced patient burden, or a short form (static measure).
• 478: Functional Status Change for Patients with Neck Impairments: This is a patient-reported outcome performance measure (PRO-PM) consisting of a patient-reported outcome measure (PROM) of risk-adjusted change in functional status (FS) for patients aged 14+ with neck impairments. The change in FS is assessed using the Neck FS PROM.* The measure is risk-adjusted to patient characteristics known to be associated with FS outcomes. It is used as a performance measure at the patient, individual clinician, and clinic levels to assess quality. *The Neck FS PROM is an item-response theory-based computer adaptive test (CAT). In addition to the CAT version, which provides for reduced patient response burden, it is available as a 10-item short form (static/paper-pencil)

Originally, CMS had plans to implement a new program called Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs) beginning in 2021. Instead, they proposed a more gradual implementation timeline for MVPs and also introduced a new Alternative Payment Model (APM) Performance Pathway (APP). For more information on these, CLICK HERE.