The Department of Health and Human Services Center for Medicare and Medicaid Services (CMS) is in the process of modernizing the use of telehealth for both Medicare Fee-For Service (FFS) and Medicare Advantage (MA) plans. The agency realizes the advantages of telehealth for improving access and addressing cost and disparities even as the commercial market zooms ahead in utilization.
To counter acknowledged limitations, CMS has published several proposed and final rules that will have a major impact on providers and beneficiaries. This blog will discuss some of the major changes to Medicare FFS, effective January 1, 2019. Proposed changes to Medicare Advantage will be discussed in a later blog.
CMS releases an annual calendar year Physician Fee Schedule (PFS) that contains proposed and final rule changes that affect a variety of programs. In the CY2019 PFS published in the November 23, 2018 Federal Register, the agency offered a new interpretation of how existing statute applies to the reimbursement of telehealth under 1834(m) of the Social Security Act. This change alters what is considered a “Medicare telehealth service.”
Previously, telehealth services have been sharply curtailed by limits on the types of providers, services, patient locations, geography and technology that qualified for reimbursement. CMS recognized these requirements were likely affecting the coding of services and impacting new types of services that use communication technology. These restrictions will now apply only to services specifically referenced in the statute: professional services that would otherwise be provided in-person between a healthcare professional and a patient such as an office visit or professional consultation.
The new interpretation is a major advance: other services offered remotely and using communications technology are no longer considered “Medicare telehealth services.” As a result, virtual check-in, interprofessional internet consultations and remote evaluation of pre-recorded patient information have new billing codes and are no longer subject to previous restrictions, effective January 1, 2019, as summarized below. For additional details, click here.
Brief Communication Technology-Based Service or “Virtual check-in”
Used to evaluate whether a patient requires an in-person office visit or not, this new billable service will only apply to established patients. CMS believes virtual check-ins will likely reduce unnecessary in-person visits but was concerned about a potential increase in utilization of the telehealth alternative. CMS will monitor utilization to guide any future adjustments.
Allowable technologies include audio-only, real-time telephone interaction and synchronous, two-way audio interaction enhanced with video or other types of data transmission.
The service will not be billable if it’s a follow-up to an office visit or results in an in-person appointment. Only physicians or health professionals who provide evaluation/management services may use the code, so RNs, physical therapists and other clinical staff are excluded. Co-payments continue to apply. HCPCS code G2012.
Remote Evaluation of Pre-Recorded Patient Information or “Store and Forward”
A stand-alone billable service that applies only to established patients who send pre-recorded images or videos for professional evaluation. There may be circumstances where this is a follow-up and would be considered part of a bundled service, therefore not eligible for separate reimbursement. Verbal or written patient consent is required so patients are aware of cost-sharing requirements. HCPCS code G2010.
Interprofessional Internet Consultation
New codes support a team-based care approach that allows payment for consultation among physicians and other qualified health professionals. A treating/requesting physician and consulting physician may provide assessment and management by discussion or review of a written report; health record referral; or assessment and management of a health record with a written report via internet or telephone.
Only providers who offer evaluation/management services may use these codes. Different codes apply based on type of service and duration. CPT codes 99446-99449; 99451-52.
The changes described in this blog pertain only to Medicare FFS. Comments on a proposed rule for telehealth and Medicare Advantage plans were due by December 31, 2018. Commercial carriers constantly assess and update what they’ll cover and pay for and often follow Medicare coverage and payment policy. Telehealth, however, may be an area where the commercial market is moving at a faster pace.
Next time, more on major proposed or final changes from the CY19 PFS including an expansion of where patient and provider may be located (originating sites and geographic area) for acute telestroke and ESRD treatment plus changes to how telehealth may be applied to substance use disorders (SUD) and co-occurring mental health disorders as required by the SUPPORT for Patient and Communities Act.