Telehealth Reimbursement Update: Top Takeaways from CMS’ Proposed Rule

 

We are excited to share some very good news for the telehealth and healthcare community that has transpired in the past few months. Here on the TeleQuality blog, we’ve covered telehealth reimbursement (see our beginner’s guide to telehealth reimbursement) and an update is in order. CMS published their 2019 Physician Fee Schedule and Quality Payment Program which included several proposed amendments for increased telehealth reimbursement in its 1,400+ pages of regulation. Also, the deadline to submit comments to the docket was Sept. 10th and several key industry stakeholders and organizations made their voices and opinions heard about the proposed rules.  

Let’s break down what new codes were proposed, what they could mean for telehealth reimbursement, and summarize the industry’s reaction.  

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New Virtual Care Codes 

CMS proposed three new virtual care codes for services to be reimbursed under specific conditions:

1.     Virtual Check-Ins, officially titled “Brief Communication Technology-Based Service”

  • HCPCS code GVCI1

  • If adopted, providers could bill for a “brief non-face-to-face check-in with a patient via communication technology, to assess whether the patient’s condition necessitates an office visit.”

2.     Asynchronous Images and Video, officially titled “Remote Evaluation of Pre-Recorded Patient Information”

  • HCPCS GRAS1

  • If adopted, providers could bill for a review of “recorded video and/or images captured by a patient in order to evaluate the patient’s condition” in order to determine whether an office visit is necessary. This review is commonly referred to as store-and-forward communication, one of the four main telemedicine types in the healthcare industry. CMS currently only pays for asynchronous telehealth in limited demonstration programs; therefore, this proposed code would apply to all participating providers.  

3.     Peer-to-Peer Internet Consults, officially titled “Interprofessional Internet Consultation”

  • CPT Codes- 994X6, 994X0, 99446, 99447, 99448, 94449

  • If adopted, providers could bill for “assessment and management services conducted through telephone, internet, or electronic health record consultations furnished when a patient’s treating physician or other qualified healthcare professional requests the opinion and/or treatment advice of a consulting physician…with specific specialty expertise to assist with the diagnosis and/or management of the patient’s problem without the need for the patient’s face-to-face contact with the consulting physician.” These new codes would be incredibly useful for physicians and various healthcare providers treating chronic conditions like heart disease, diabetes, breast cancer, allergies, obesity, etc.

Why are these codes so significant?

The newly proposed CMS virtual care codes are a ground-breaking update from the traditional Medicare telehealth codes. The traditional telehealth reimbursement codes are severely limited in terms of qualifying providers, site and location. CMS’ proposal to cover asynchronous telemedicine and non-face-to-face services is a major step forward for the validity of store-and-forward medical care on the national level. The biggest impact is these codes will not require the use of interactive AV technology and they don’t require a patient be located in a rural area or a specific qualifying originating site.  

New RPM Codes 

CMS also introduced proposed remote patient monitoring (RPM) as its own entirely new and separately-reimbursable service under Medicare. The three new RPM codes, retitled “Chronic Care Remote Patient Physiologic Monitoring”, aimed to better reflect how RPM services can be delivered to patients. The specific codes are: CPT 990X0, CTP 990X1, and CPT 994X9.

Before, billing Medicare for RPM had been allowed using CPT 99091 codes but the new codes have a few key changes for reimbursement:

1.     Less treatment time needed to qualify for reimbursement. With the previous CPT 99091 codes required at least 30 minutes per 30-day period in order to be eligible for reimbursement. The new code only requires 20 minutes per calendar month which means it’s easier to track and requires 33% less time for eligibility.

2.      Additional reimbursement for RPM set-up and patient education. CPT 99091 does not allow for additional reimbursement to providers for time spent setting up any RPM equipment or educating their patients on its use. The new proposed codes would offer additional reimbursement for on-boarding a new patient, setting up the RPM equipment, and educating patients on equipment.

3.     New medical staff eligible for reimbursement. CPT 99091 expressly states RPM-delivering providers must be “physicians and qualified health care professionals” leaving out key medical and clinical staff such as RNs, medical assistants, etc. This requirement meant the physician or qualified health care professional had to perform the full 30 minutes per 30-day period to be eligible for reimbursement. Many providers could not justify spending that amount of time and resources for the $58.68 per month reimbursement rate from CMS. The new code allows RPM services to be performed by clinical staff, clearing a key hurdle for providers across the country.  

Highlights from Stakeholder Comments

Several industry stakeholders and organizations have praised and provided additional comments and recommendations to CMS’ proposal.

  • The American Medical Association’s (AMA) President Barbara McAneny, MD stated that:  “The AMA has urged CMS to adopt the new codes for remote patient monitoring and internet consulting and designate the related services for payment under federal health programs in 2019.  Medicare's acceptance of the new codes would signal a landmark shift to better support physicians participating in patient population health and care coordination services that can be a significant part of a digital solution for improving the overall quality of medical care.”

  • Medical Group Management Association (MGMA): “MGMA supports CMS’ efforts to increase access to care by providing reimbursement for communications-based technology and telehealth services. This is a step in the right direction toward recognizing that medical practices connect with patients using new technologies.”

  • American Medical Informatics Association (AMIA): “We view these policies as addressing long-standing Medicare reimbursement barriers to widespread adoption of virtual care tools meant to reach more patients in more places, especially those in underserved and rural areas.”

  • American Hospital Association- https://www.aha.org/letter/2018-09-07-letter-physician-fee-schedule-proposed-rule-cy-2019

  • National Committee for Quality Assurance- https://www.ncqa.org/comment-letter/ncqa-comments-on-proposed-2018-medicare-physician-fee-schedule-rule/

AMA Releases 2019 CPT Code Set

In a similar groundbreaking fashion, the American Medical Association (AMA) released their 2019 Current Procedural Terminology (CPT) code set and included new codes to allow doctors to bill for remote patient monitoring and internet consulting. The AMA said the new CPT codes, which are used by insurers to help determine reimbursement for doctors and other providers for medical, surgical and diagnostic services, were updated to reflect new technological and scientific advancements. The AMA is urging the CMS to adopt the new codes and designate the related services for payment under federal health programs in 2019. The new codes are effective as of Jan. 1, 2019. 

Conclusion

The CMS’ proposed virtual care and RPM codes and AMA’s CPT codes are clear advancements for telehealth reimbursements and has received excellent praise from the industry. Final regulations will be released by CMS in early November. Check back on the blog and our social media channels later this year for updates!  

Further Reading & Resources: