Last week CMS released its finalized Calendar Year (CY) 2019 Physician Fee Schedule containing momentous changes for Medicare, aiming to modernize the healthcare system and help “restore the doctor-patient relationship” by reducing administrative burden. Among the changes, the proposed rule not only expands telehealth reimbursement, but communicates a new interpretation by CMS of the applicability of their statutory requirements for reimbursement of telehealth. Telehealth-delivered services under Medicare is limited in statute by 1834(m) of the Social Security Act which limits the use of telehealth to certain services, providers, technology (mainly live video) and patient locations (needing to be in certain types of healthcare facilities in rural areas). CMS, in their rule, expresses concern that these requirements may be limiting the coding for new kinds of services that utilize communication technology.
The new rule expresses CMS’ belief that their obligation to impose those restrictions only apply to “the kinds of professional services explicitly enumerated in the statutory provisions, like professional consultations, office visits, and office psychiatry services.” These are services that are paid for as if they were furnished during an in-person encounter between a patient and health care professional. Certain other kinds of services that are furnished remotely using communications technology are not considered “Medicare telehealth services” and are not subject to the restrictions. This includes interactions between a medical professional with a patient via remote communication technology. Thus, CMS has finalized reimbursement for virtual check-ins, remote evaluation of pre-recorded patient information and interprofessional internet consultation, which CMS believes fall outside the scope of Medicare telehealth services. Each is described below.
- Brief Communication Technology-based Service, e.g. Virtual Check-in (HCPCS code G2012): Check-in services used to evaluate whether or not an office visit or other service is necessary. The modalities will include audio-only real-time telephone interaction in addition to synchronous, two-way audio interaction that are enhanced with video or other kinds of data transmission. CMS will pay approximately $14 for this service (unless it is the result of a previous appointment or leads to a face-to-face appointment). CMS believes the check-ins will mitigate the need for potentially unnecessary office visits.
- Remote Evaluation of Pre-Recorded Patient Information (HCPCS code G2010): CMS finalized the creation of a specific new code to describe remote professional evaluation of patient-transmitted information conducted via pre-recorded “store-and-forward” video or image technology. These services would not be subject to the Medicare telehealth restrictions because they could not substitute for an in-person service currently separately payable under the PFS.
- Interprofessional Internet Consultation (CPT codes 99452, 99451, 99446, 99447, 99448, and 99449): These codes would cover interprofessional consultations performed via communications technology such as telephone or Internet. This would support a team-based approach to care that are often facilitated by electronic medical record technology.
For both the Virtual Check-In and the Remote Evaluation for Pre-Recorded Patient Information, CMS made very clear that the codes will only be available to practitioners who furnish E/M services which would exclude clinical staff such as RNs and physical therapists and that copayments will continue to apply.
In addition to adding the above services, CMS also addressed making the necessary changes to add additional originating sites and geographic exemptions for the treatment of end stage renal disease and acute stroke (as required by the Bipartisan Budget Act of 2018). As they do every year, CMS also considered new codes for inclusion in their list of services eligible to be delivered through telehealth, and have added G0513 and G0514, both codes related to prolonged preventive services. CMS also added new codes (99453, 99454, and 99457) for remote physiologic monitoring as well as added a new code (99491) for chronic care management. Additionally, the rule details how many of the new policies described above will apply to FQHCs and RHCs and their PPS rates, including clarification that a FQHC or RHC is not eligible to bill for the interprofessional internet consultation codes.
Finally, within the final rule, is an interim final rule, which implements changes made by the SUPPORT for Patients and Communities Act, providing exemptions from some of CMS’ telehealth requirements for the treatment of substance use disorder (SUD), and providing a comment period. CMS also is continuing to accept comments regarding the development of a separate bundled payment for an episode of care for treatment of Substance Use Disorders (SUD), which can include elements of Medication Assisted Therapy (MAT), including potentially web-based routine counseling. Comments on the interim final rule and bundled payments are being accepted for 60 days following this rule’s publication (Nov. 23).
CCHP encourages reading the full text of the rule to learn more about CMS’ finalized policies and the requested comments in the interim final rule. Also, see CCHP’s factsheet and infographic on the rule for a breakdown and analysis of the various elements. Additionally, check out CCHP’s infographic on how the rule will apply to FQHCs and RHCs specifically.
Changes to Medicare Advantage
The Centers for Medicare & Medicaid Services (CMS) released a proposal to address required changes for telehealth reimbursement for Medicare Advantage plans (MA) made by the Bipartisan Budget Act of 2018. The CMS proposal would allow MA plans to provide “additional telehealth benefits” to enrollees and treat those as basic benefits under the Medicare fee-for-service option, however plans will not be required to adopt these benefits and will retain the ability to continue providing telehealth services as separate supplemental benefits for those services that do not meet the definition of an “additional telehealth benefit”. The proposed definition for “additional telehealth benefits” is services that meet the following:
“(1) are furnished by an MA plan for which benefits are available under Medicare Part B but which are not payable under section 1834(m) of the Act; and (2) have been identified by the MA plan for the applicable year as clinically appropriate to furnish through electronic exchange.”
MA plans would determine which services are considered clinically appropriate, though CMS is soliciting comments regarding whether there should be further limitations on what types of Part B services and items should be eligible as additional telehealth benefits.
Under the proposed regulation, MA plans offering additional telehealth benefits would also need to meet specific requirements:
- Services offered as additional telehealth benefits must also be available as in-person services.
- Plans must use their provider directory to identify providers offering telehealth benefits.
- Plans need to comply with provider selection and credentialing requirements found in 42 CFR § 422.204, have written policies and procedures for the selection and evaluation of providers, and follow a documented process with providers and suppliers.
- Plans must provide information on additional telehealth benefits upon the request of CMS.
- Plans may only provide additional telehealth benefits using contracted providers.
- Services provided as additional telehealth benefits must meet the same access and coverage requirements that apply to all basic benefits.
- State laws regarding the practice of medicine would apply.
MA plans complying with the requirements could include additional telehealth benefits in bids for basic benefits. If a plan fails to meet the requirements, it must treat the benefits as supplemental. Additionally, plans could maintain different cost sharing for in-person and telehealth services.
Comments on the proposal must be submitted electronically or by mail before 5PM EST on December 31st 2018.
For further information, access the full text of the proposal on the Federal Register.
Remote Patient Monitoring Under the Home Health Benefit
In a separate notice scheduled to be released November 13, 2018, CMS states that it is finalizing its proposal for defining remote patient monitoring (RPM) under the Medicare home health benefit. The new definition for RPM is “the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency.” Under this definition, RPM will only be reimbursable when reported as a service in the provision of another skilled service. Home visits for the purpose of supplying or maintaining RPM equipment without the provision of another skilled service will not be separately billable, but will constitute an allowable administrative cost under amendments to 42 CFR 409.46.
For more information on the new regulations and to read the CMS responses to comments on the original proposal, access the final rule at the Federal Register.