The Centers for Medicare and Medicaid Services Release CY 2019 Proposed Physician Fee Schedule

Original Source: Center for Connected Health Policy

Last week CMS released its proposed Calendar Year (CY) 2019 Physician Fee Schedule (PFS) containing its proposal for 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 are 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 proposed rule expresses CMS’ belief that their obligation to impose the restrictions in the Social Security Act 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 is proposing 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 GVCI1): Check-in services used to evaluate whether or not an office visit or other service is necessary. CMS proposes to pay $14 for this service (unless it is the result of a previous appointment or leads to a face-to-face appointment).  CMS argues that, through the check-ins, practitioners would be able to mitigate the need for potentially unnecessary office visits.
  • Remote Evaluation of Pre-Recorded Patient Information (HCPCS code GRAS1):  CMS proposes creating 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. CMS is seeking comments on the code descriptor and valuation for HCPCS code GRAS1, although the rule states that they do plan to value the service by a direct crosswalk to CPT code 93793.
  • Interprofessional Internet Consultation (CPT codes 994X6, 994X0, 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.  They propose to pay separately for each code and request that the Relative Value Scale (RVS) Update Committee (RUC) at the American Medical Association assist in establishing values for the six CPT codes.

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 with previous years, 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 (990X0, 990X1, and 994X0) for remote physiologic monitoring as well as added a new code (994X7) 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.  Finally, CMS is also considering developing 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.

CMS makes multiple requests within each of the above subject areas for comments on specific details of their proposals.  Comments on the proposed rule are due September 10, 2018.  CCHP encourages reading the full text of the rule to learn more about CMS’ proposals and the requested comments.
See CCHP’s factsheet on the rule for a detailed breakdown and analysis of the various elements, as well as CCHP’s infographic for a quick look at the changes