MLN Booklet

TELEHEALTH SERVICES

ICN MLN901705 March 2020

Target Audience: Medicare Fee-For-Service Providers

The Hyperlink Table, at the end of this document, provides the complete URL for each hyperlink.

TABLE OF CONTENTS

Originating Sites………………………………………………………………………………………………………………….. 3

Distant Site Practitioners……………………………………………………………………………………………………… 4

Telehealth Services……………………………………………………………………………………………………………… 4

Telehealth Services Billing and Payment………………………………………………………………………………. 7

Telehealth Originating Sites Billing and Payment………………………………………………………………….. 8

Resources…………………………………………………………………………………………………………………………… 8

Helpful Websites………………………………………………………………………………………………………………….. 9

Regional Office Rural Health Coordinators…………………………………………………………………………… 9

CPT codes, descriptions and other data only are copyright 2018 American Medical Association. All Rights Reserved.

Applicable FARS/HHSAR apply. CPT is a registered trademark of the American Medical Association. Applicable FARS/

HHSAR Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors and/or related

components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA

does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data

contained or not contained herein.

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Telehealth Services MLN Booklet

Page 2 of 9 ICN MLN901705 March 2020

CMS Alert!

Medicare Beneficiaries Expanded Telehealth Benefits During COVID-19 Outbreak

Under the Coronavirus Preparedness and Response Supplemental Appropriations Act

and Section 1135 waiver authority, the Centers for Medicare & Medicaid Services (CMS)

broadened access to Medicare telehealth services, so beneficiaries can get a wider range of

services from their doctors and other clinicians without traveling to a health care facility. On

March 6, 2020, Medicare began temporarily paying clinicians to furnish beneficiary telehealth

services residing across the entire country.

Before this announcement, Medicare could only pay clinicians for telehealth services, such

as routine visits in certain circumstances. For example, the beneficiary getting the services

must live in a rural area and travel to a local medical facility to get telehealth services from

a doctor in a remote location. In addition, the beneficiary generally could not get telehealth

services in their home.

Under this Section 1135 waiver expansion, a range of providers, such as doctors, nurse

practitioners, clinical psychologists, and licensed clinical social workers, can offer a

specific set of telehealth services. The specific set of services beneficiaries can get include

evaluation and management visits (common office visits), mental health counseling, and

preventive health screenings. Beneficiaries can get telehealth services in any health care

facility including a physician’s office, hospital, nursing home or rural health clinic, as well

as from their homes. This change broadens telehealth flexibility without regard to the

beneficiary’s diagnosis, because at this critical point it is important to ensure beneficiaries

follow CDC guidance including practicing social distancing to reduce the risk of COVID-19

transmission. This change will help prevent vulnerable beneficiaries from unnecessarily

entering a health care facility when clinicians can meet their needs remotely.

To read the Fact Sheet on this announcement visit: https://www.cms.gov/newsroom/factsheets/

medicare-telemedicine-health-care-provider-fact-sheet

To read the Frequently Asked Questions on this announcement visit: https://www.cms.gov/

files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

Telehealth Services MLN Booklet

Learn about these Medicare telehealth services topics:

●● Originating sites

●● Distant site practitioners

●● Telehealth services

●● Telehealth services billing and payment

●● Telehealth originating sites billing and payment

●● Resources

●● Helpful websites and Regional Office Rural Health Coordinators

Medicare pays for specific (Part B) physician or practitioner services furnished through a

telecommunications system. Telehealth services substitute for an in-person encounter.

ORIGINATING SITES

An originating site is the location where a Medicare beneficiary gets physician or practitioner medical

services through a telecommunications system. The beneficiary must go to the originating site for the

services located in either:

●● A county outside a Metropolitan Statistical Area (MSA)

●● A rural Health Professional Shortage Area (HPSA) in a rural census tract

The Health Resources and Services Administration (HRSA) decides HPSAs, and the Census Bureau

decides MSAs. To see a potential Medicare telehealth originating site’s payment eligibility, go to

HRSA’s Medicare Telehealth Payment Eligibility Analyzer.

Providers qualify as originating sites, regardless of location, if they were participating in a Federal

telemedicine demonstration project approved by (or getting funding from) the U.S. Department of

Health & Human Services as of December 31, 2000.

Beginning July 1, 2019, the

Substance Use-Disorder Prevention

that Promotes Opioid Recovery and

Treatment (SUPPORT) for Patients

and Communities Act removes

the originating site geographic

conditions and adds an individual’s

home as a permissible originating

telehealth services site for treatment

of a substance use disorder or a

co-occurring mental health disorder.

Each December 31 of the prior calendar year (CY),

an originating site’s geographic eligibility is based on

the area’s status. This eligibility continues for a full CY.

Authorized originating sites include:

●● Physician and practitioner offices

●● Hospitals

●● Critical Access Hospitals (CAHs)

●● Rural Health Clinics

●● Federally Qualified Health Centers

●● Hospital-based or CAH-based Renal Dialysis

Centers (including satellites)

●● Skilled Nursing Facilities (SNFs)

●● Community Mental Health Centers (CMHCs)

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Telehealth Services MLN Booklet

●● Renal Dialysis Facilities

●● Homes of beneficiaries with End-Stage Renal Disease

(ESRD) getting home dialysis

●● Mobile Stroke Units

Note: Medicare does not apply originating site geographic

conditions to hospital-based and CAH-based

renal dialysis centers, renal dialysis facilities, and

beneficiary homes when practitioners furnish monthly

home dialysis ESRD-related medical evaluations.

Independent Renal Dialysis Facilities are not eligible

originating sites.

Beginning January 1, 2019, the

Bipartisan Budget Act of 2018

removed the originating site

geographic conditions and added

eligible originating sites to diagnose,

evaluate, or treat symptoms of an

acute stroke. Go to MLN Matters®

article, New Modifier for Expanding

the Use of Telehealth for Individuals

with Stroke to learn how to use the

new modifier for billing.

DISTANT SITE PRACTITIONERS

Distant site practitioners who can furnish and get payment for covered telehealth services (subject to

State law) are:

●● Physicians

●● Nurse practitioners (NPs)

●● Physician assistants (PAs)

●● Nurse-midwives

●● Clinical nurse specialists (CNSs)

●● Certified registered nurse anesthetists

●● Clinical psychologists (CPs) and clinical social workers (CSWs)

o CPs and CSWs cannot bill Medicare for psychiatric diagnostic interview examinations with

medical services or medical evaluation and management services. They cannot bill or get paid

for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838.

●● Registered dietitians or nutrition professional

TELEHEALTH SERVICES

You must use an interactive audio and video telecommunications system that permits real-time

communication between you at the distant site, and the beneficiary at the originating site.

Transmitting medical information to a physician or practitioner who reviews it later is permitted only in

Alaska or Hawaii Federal telemedicine demonstration programs.

CPT only copyright 2018 American Medical Association. All rights reserved.

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Telehealth Services MLN Booklet

CY 2019 Medicare Telehealth Services

Service HCPCS/CPT Code

Telehealth consultations, emergency department or initial inpatient G0425–G0427

Follow-up inpatient telehealth consultations furnished to

beneficiaries in hospitals or SNFs

G0406–G0408

Office or other outpatient visits 99201–99215

Subsequent hospital care services, with the limitation of 1 telehealth

visit every 3 days

99231–99233

Subsequent nursing facility care services, with the limitation of

1 telehealth visit every 30 days

99307–99310

Individual and group kidney disease education services G0420–G0421

Individual and group diabetes self-management training services,

with a minimum of 1 hour of in-person instruction furnished in the

initial year training period to ensure effective injection training

G0108–G0109

Individual and group health and behavior assessment

and intervention

96150–96154

Individual psychotherapy 90832–90838

Telehealth Pharmacologic Management G0459

Psychiatric diagnostic interview examination 90791–90792

End-Stage Renal Disease (ESRD)-related services included in the

monthly capitation payment

90951, 90952, 90954, 90955,

90957, 90958, 90960, 90961

End-Stage Renal Disease (ESRD)-related services for home dialysis

per full month, for patients younger than 2 years of age to include

monitoring for the adequacy of nutrition, assessment of growth and

development, and counseling of parents

90963

End-Stage Renal Disease (ESRD)-related services for home

dialysis per full month, for patients 2–11 years of age to include

monitoring for the adequacy of nutrition, assessment of growth

and development, and counseling of parents

90964

End-Stage Renal Disease (ESRD)-related services for home

dialysis per full month, for patients 12–19 years of age to include

monitoring for the adequacy of nutrition, assessment of growth

and development, and counseling of parents

90965

End-Stage Renal Disease (ESRD)-related services for home dialysis

per full month, for patients 20 years of age and older

90966

End-Stage Renal Disease (ESRD)-related services for dialysis

less than a full month of service, per day; for patients younger than

2 years of age

90967

End-Stage Renal Disease (ESRD)-related services for dialysis less

than a full month of service, per day; for patients 2–11 years of age

90968

CPT only copyright 2018 American Medical Association. All rights reserved.

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Telehealth Services MLN Booklet

CY 2019 Medicare Telehealth Services (cont.)

Service HCPCS/CPT Code

End-Stage Renal Disease (ESRD)-related services for dialysis less

than a full month of service, per day; for patients 12–19 years of age

90969

End-Stage Renal Disease (ESRD)-related services for dialysis less than

a full month of service, per day; for patients 20 years of age and older

90970

Individual and group medical nutrition therapy G0270, 97802–97804

Neurobehavioral status examination 96116

Smoking cessation services G0436, G0437, 99406, 99407

Alcohol and/or substance (other than tobacco) abuse structured

assessment and intervention services

G0396, G0397

Annual alcohol misuse screening, 15 minutes G0442

Brief face-to-face behavioral counseling for alcohol misuse,

15 minutes

G0443

Annual depression screening, 15 minutes G0444

High-intensity behavioral counseling to prevent sexually transmitted

infection; face-to-face, individual, includes: education, skills training

and guidance on how to change sexual behavior; performed

semi-annually, 30 minutes

G0445

Annual, face-to-face intensive behavioral therapy for cardiovascular

disease, individual, 15 minutes

G0446

Face-to-face behavioral counseling for obesity, 15 minutes G0447

Transitional care management services with moderate medical

decision complexity (face-to-face visit within 14 days of discharge)

99495

Transitional care management services with high medical decision

complexity (face-to-face visit within 7 days of discharge)

99496

Advance Care Planning, 30 minutes 99497

Advance Care Planning, additional 30 minutes 99498

Psychoanalysis 90845

Family psychotherapy (without the patient present) 90846

Family psychotherapy (conjoint psychotherapy) (with patient present) 90847

Prolonged service in the office or other outpatient setting requiring

direct patient contact beyond the usual service; first hour

99354

Prolonged service in the office or other outpatient setting requiring direct

patient contact beyond the usual service; each additional 30 minutes

99355

Prolonged service in the inpatient or observation setting requiring

unit/floor time beyond the usual service; first hour (list separately in

addition to code for inpatient evaluation and management service)

99356

CPT only copyright 2018 American Medical Association. All rights reserved.

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Telehealth Services MLN Booklet

CY 2019 Medicare Telehealth Services (cont.)

Service HCPCS/CPT Code

Prolonged service in the inpatient or observation setting requiring

unit/floor time beyond the usual service; each additional 30 minutes

(list separately in addition to code for prolonged service)

99357

Annual Wellness Visit, includes a personalized prevention plan of

service (PPPS) first visit

G0438

Annual Wellness Visit, includes a personalized prevention plan of

service (PPPS) subsequent visit

G0439

Telehealth Consultation, Critical Care, initial, physicians typically

spend 60 minutes communicating with the patient and providers

via telehealth

G0508

Telehealth Consultation, Critical Care, subsequent, physicians

typically spend 50 minutes communicating with the patient and

providers via telehealth

G0509

Counseling visit to discuss need for lung cancer screening using

low dose CT scan (LDCT) (service is for eligibility determination

and shared decision making

G0296

Interactive Complexity Psychiatry Services and Procedures 90785

Health Risk Assessment 96160, 96161

Comprehensive assessment of and care planning for patients

requiring chronic care management

G0506

Psychotherapy for crisis 90839, 90840

Prolonged preventive services G0513, G0514

A physician, NP, PA, or CNS must furnish at least one ESRD-related “hands on visit” (not telehealth)

each month to examine the beneficiary’s vascular access site.

TELEHEALTH SERVICES BILLING AND PAYMENT

Submit professional telehealth service claims using the appropriate CPT or HCPCS code.

If you performed telehealth services “through an asynchronous telecommunications system”, add the

telehealth GQ modifier with the professional service CPT or HCPCS code (for example, 99201 GQ).

You are certifying the asynchronous medical file was collected and transmitted to you at the distant

site from a Federal telemedicine demonstration project conducted in Alaska or Hawaii.

Submit telehealth services claims, using Place of Service (POS) 02-Telehealth, to indicate you

furnished the billed service as a professional telehealth service from a distant site. As of January 1,

2018, distant site practitioners billing telehealth services under the CAH Optional Payment Method II

must submit institutional claims using the GT modifier.

CPT only copyright 2018 American Medical Association. All rights reserved.

Page 7 of 9 ICN MLN901705 March 2020

Telehealth Services MLN Booklet

Bill covered telehealth services to your Medicare Administrative Contractor (MAC). They pay you the

appropriate telehealth services amount under the Medicare Physician Fee Schedule (PFS). If you are

located in, and you reassigned your billing rights to, a CAH and elected the Optional Payment Method

II for outpatients, the CAH bills the telehealth services to the MAC. The payment is 80 percent of the

Medicare PFS facility amount for the distant site service.

TELEHEALTH ORIGINATING SITES BILLING AND PAYMENT

HCPCS Code Q3014 describes the Medicare telehealth originating sites facility fee. Bill your MAC for

the separately billable Part B originating site facility fee.

Note: The originating site facility fee does not count toward the number of services used to determine

payment for partial hospitalization services when a CMHC serves as an originating site.

RESOURCES

Telehealth Services Resources

For More Information About… Resource

Telehealth Services CMS.gov/Medicare/Medicare-General-Information/Telehealth/

Telehealth-Codes.html

CMS.gov/Medicare/Medicare-General-Information/Telehealth

CMS.gov/Regulations-and-Guidance/Guidance/Manuals/

Downloads/clm104c12.pdf

Physician Bonuses CMS.gov/Medicare/Medicare-Fee-for-Service-Payment/

HPSAPSAPhysicianBonuses

CMS.gov/Outreach-and-Education/Medicare-Learning-

Network-MLN/MLNProducts/MLN-Publications-Items/

CMS1246598.html

Hyperlink Table

Embedded Hyperlink Complete URL

Health Professional Shortage Area https://www.cms.gov/Medicare/Medicare-Fee-for-Service-

Payment/HPSAPSAPhysicianBonuses

Medicare Telehealth Payment

Eligibility Analyzer

New Modifier for Expanding the

Use of Telehealth for Individuals

with Stroke

Learning-Network-MLN/MLNMattersArticles/Downloads/

MM10883.pdf

Substance Use-Disorder Prevention

that Promotes Opioid Recovery and

Treatment (SUPPORT) for Patients

and Communities Act

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Telehealth Services MLN Booklet

HELPFUL WEBSITES

American Hospital Association Rural

Health Care

Critical Access Hospitals Center

Critical-Access-Hospitals-Center.html

Disproportionate Share Hospitals

Service-Payment/AcuteInpatientPPS/dsh.html

Federally Qualified Health Centers Center

Federally-Qualified-Health-Centers-FQHCCenter.

html

Health Resources and

Services Administration

Hospital Center

Hospital-Center.html

Medicare Learning Network®

National Association of Community

Health Centers

National Association of Rural Health Clinics

National Rural Health Association

Rural Health Clinics Center

Health-Clinics-Center.html

Rural Health Information Hub

Swing Bed Providers

Service-Payment/SNFPPS/SwingBed.html

Telehealth

General-Information/Telehealth

Telehealth Resource Centers

U.S. Census Bureau

REGIONAL OFFICE RURAL HEALTH COORDINATORS

To find contact information for CMS Regional Office Rural Health Coordinators who provide technical,

policy, and operational assistance on rural health issues, refer to CMS.gov/Outreach-and-Education/

Outreach/OpenDoorForums/Downloads/CMSRuralHealthCoordinators.pdf.

Medicare Learning Network® Product Disclaimer

The Medicare Learning Network®, MLN Connects®, and MLN Matters® are registered trademarks of the U.S.

Department of Health & Human Services (HHS).

Page 9 of 9 ICN MLN901705 March 2020

The post The Center for Medicaid and Medicare Services (CMS) – 2020 Medicare Learning Network Telehealth Services Booklet appeared first on mTelehealth.

CMS has released its final rule for the 2020 Physician’s Fee Schedule.

We have previously covered how one can set up a chronic care management program in 5 steps. We have also covered the available CPT codes that can be used to bill for chronic care management, which also includes remote patient monitoring. If you want a condensed version of all that, 

The great news is none of the existing CPT codes have been modified for 2020! So a provider organization or practice can use those codes to finance their CCM and RPM programs. Especially those who have not gotten into the habit of using those CPT codes, now would be the time, as they have remained the same for the next year. So this 2019 Reimbursement Guide is still applicable, which covers both Chronic Care Management (CCM) and Remote Patient Monitoring (RPM). It will allow you to better understand the nature of those two programs. But to see exactly what changes have been made, and what it means for the reimbursement amounts for 2020, see this guide. 

For a more detailed breakdown of that guide, keep on reading.

The only changes that have happened for 2020 are the inclusion of other codes to bill extra periods of time worked on a patient and making the RPM codes furnishable via general supervision. It was only possible to furnish them via direct supervision prior.

Both changes are extremely beneficial. First, they do not displace any existing codes, thus organizations and clinicians alike do not need to relearn anything. The only thing they need to do is start familiarizing themselves with the existing CPT codes(as found on the reimbursement guide), and begin using them.

Second, the new changes make it easier to implement the codes because of a more relaxed stance on supervision. They also allow more options when providing care as far as the time allotted to patient goes. We cover the changes below. Going forward in 2020, one can bookmark this page to see all CPT codes that are available to them (existing ones and new ones included). 

2020 Reimbursement Scenarios   

Before covering all reimbursement scenarios, let’s cover some definitions first. 

General Supervision: “General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required”. 

Qualified Healthcare Professionals (QHP): “A qualified healthcare professional is an individual who is qualified by education, training, and licensure/regulation and/or facility privileges (when applicable) who performs a professional service within his or her scope of practice, and independently reports that professional service.”  

Examples of QHPs who can bill for CCM: Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists and Certified Nurse-Midwives.  

Clinical Staff: “A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service but who does not individually report that professional service.” 

Examples of clinical staff: Licensed practical nurses, medical assistants,  and registered nurses.

Looking at the language of how everything is framed, there seem to be two general options available for reimbursement strategies. 1)With Clinical Staff 2) Without Clinical Staff. Hiring clinical staff is obviously an expense that must be considered. It especially makes sense when there is a large number of patients involved.

If you Have Clinical Staff 

1st Year

*Optional Codes dependent on if the patient requires more time.

G0438 initial visit ($164)- For new first-time patients who have been enrolled with Medicare for more than one year. 

CPT 99490 ($42 for non-facility/ $32 for facility) “Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. Assumes 15 minutes of work by the billing practitioner per month.” 

*G2058 ($38 for non-facility/ $29 for facility )(reportable a maximum of two times within a given service period for a given beneficiary) – “Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.” 

CPT code 99453 ($19): “Remote monitoring of physiologic parameter(s) (e.g, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.” 

CPT code 99454 ($64): “Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.” 

CPT code 99457($52 for non-facility/ $32 for facility): “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.” 

*CPT code 99458 ($42 for non-facility/$26 for facility):  “Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes.”

Minimum Annual Revenue Per Patient= $[164+(42 x 12) + 19+ (64 x 12) +(52 x 12)]= $2079

For 40 minutes of general supervision monthly.

Revenue will increase if a patient needs more time.

2nd Year

Everything remains the same except G0438 is switched with G0439, and there is no need for CPT99453 as set up is already done.

G0439 subsequent visit ($109)- For returning patients who have had the AWV before. A patient is only eligible for a subsequent visit a year after the initial visit. 

Minimum Annual Revenue Per Patient= $[109+(42 x 12) + (64 x 12) +(52 x 12)]= $2005

For 40 minutes of general supervision monthly.

Revenue will increase if a patient needs more time.

If you Don’t Have Clinical Staff 

1st Year

*Optional Codes dependent on if the patient requires more time.

G0438 initial visit ($164)- For new first-time patients who have been enrolled with Medicare for more than one year. 

CPT 99491($84 for non-facility and facility) “Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month.” 

*G2058($38)( reportable a maximum of two times within a given service period for a given beneficiary) – “Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.” 

CPT code 99091($58 for non-facility and facility): “Collection and interpretation of physiologic data (e.g. ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days.” 

*CPT code 99458 ($42):  “Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes.”

Minimum Annual Revenue Per Patient= $[164+(84 x 12) + (58 x 12)]= $1868

For 60 minutes of work monthly.

Revenue will increase if a patient needs more time.

2nd Year

Everything remains the same except G0438 is switched with G0439.

G0439 subsequent visit ($109)- For returning patients who have had the AWV before. A patient is only eligible for a subsequent visit a year after the initial visit. 

Minimum Annual Revenue Per Patient= $[109+(84 x 12) + (58 x 12)]= $1813

For 60 minutes of work monthly.

Revenue will increase if a patient needs more time.

Besides the choice of operating with or without clinical staff, there is another great fork in the road which shapes your strategy.

It is the complexity of the patient cases. Again, by the way, the language is structured in the CMS rule book, it is apparent that there is a difference between low complexity cases (non-complex CCM), and moderate to high complexity cases (complex CCM).

The complexity of the case is determined by the number of problem points and data points. 

(Taken from EM University, 2019)

 Our 2020 Reimbursement guide considers both the staffing situation and the complexity of care when coming out with different care scenarios. Download it.

Get Started!

We can help get you up and running – or customize aTouchAway for your organization.  Just get in touch!

The post The Chronic Care Management (CCM) – Remote Patient Monitoring (RPM) – Reimbursement Guide – Coverage Year 2020 appeared first on mTelehealth.

CARE MANAGEMENT SERVICES

CMS is taking steps to further refine the codes for transitional care management (TCM) and chronic care management (CCM). They have also created new codes for principal care management (PCM) services for patients that have only one serious condition.

Transitional Care Management (TCM)

CMS has finalized their proposal to allow for concurrent billing with TCM services in the following code families:

• Prolonged services without direct patient contact
• Home and outpatient international normalized ration monitoring services
• End stage renal disease services
• Interpretation of physiological data (RPM)Chronic care management
• Complex chronic care management services
• Care plan oversight services.
• See the full text for list of specific codes.

Chronic Care Management (CCM)

CMS had proposed to adopt two new G codes with new increments of clinical staff time instead of the existing single CPT code (99490), and two additional G codes to be used to establish and revise a comprehensive care plan. However, in response to commenters concerns that the temporary G codes replacing most of the CCM code set would create administrative burden, CMS has chosen to only finalize one code (G2058 – the add-on code for additional clinical staff time), because it addresses the need for a code to bill for additional time increments for non-complex CCM. G2058 could be reported a maximum of two times within a given service period for a given beneficiary.

Principal Care Management (PCM)

CMS has finalized their proposal to establish separate coding and payment for principal care management (PCM) services, which describes care management services for one serious chronic condition (as opposed to the multiple chronic conditions covered by CCM). A qualifying condition would be expected to last between 3 months and a year or until death, may have led to a recent hospitalization and/or place the patient at significant risk of death, acute exacerbation, decompensation or functional decline. The services would include coordination of medical and/or psychosocial care related to the single complex chronic condition, provided by a physician or clinical staff under the direction of a physician or other qualified health professional.

Due to the similarity between the description of the PCM and CCM services, both of which involve non-face-to-face care management services, the full CCM scope of service requirements would apply to PCM, including documenting the patient’s verbal consent in the medical record. PCM could not be billed by the same practitioner for the same patient concurrent with certain other care management services, such as CCM, behavioral health integration services and monthly capitated ESRD payments.

New Principle Care Management Codes:

HCPCS code G2064 – Comprehensive care management services for a single high-risk disease, e.g., Principal Care Management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

HCPCS code G2065 – Comprehensive care management for a single high-risk disease services, e.g. Principal Care Management, at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month with the following elements: one complex chronic condition lasting at least 3 months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been cause of a recent hospitalization, the condition requires development or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.

CMS expressed concerns that this separate coding could result in a patient with multiple chronic conditions having their care managed by multiple practitioners, each only billing for PCM, which could potentially result in fragmented patient care, overlaps in services, and duplicative services. They are finalizing a requirement that ongoing communication and care coordination between all practitioners furnishing care to the beneficiary must be documented by the practitioner billing for PCM in the patient’s medical record.

CHRONIC CARE REMOTE PHYSIOLOGIC MONITORING SERVICES

One of the codes established in Sept. 2018 CPT Editorial Board for remote physiologic monitoring was 99457. Effective for CY 2020, the code has been revised, still with 99457 as the base code that describes the first 20 minutes of treatment management services, but then allows for use of an add on code, for subsequent 20 minute intervals (99458). The codes now only require that these services be delivered with general supervision of auxiliary personnel by a physician or other qualified healthcare professional, as opposed to direct supervision, as previously required. 

CMS also clarified that RPM services are not separately billable for FQHCs and RHCs because it is included in the RHC All-Inclusive Rate (AIR) or FQHC Prospective Payment System (PPS) payment.

CONSENT FOR COMMUNICATION TECHNOLOGY-BASED SERVICES

In the CY 2019 PFS, CMS finalized payment for a number of communication technology-based services, including brief virtual check in services and interprofessional consultation. Currently consent is required for each service delivered through communication technology-based services, in part to ensure that patients are aware of any fee sharing they may be responsible for. However, based on feedback CMS received that obtaining consent for each and every one of these services is burdensome, they have revised this policy for CY 2020 to only require consent once a year for technology-based services.

ONLINE DIGITAL EVALUATION SERVICE (E-VISIT)

CMS is finalizing their proposal to create new G-codes that describe the performance of an online “assessment” rather than an “evaluation” so that qualified non-physician health care professionals that fall outside the category of a practitioner able to bill for “evaluation codes”, may bill for those services.

The new codes are as follows:

G2061 – Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes.

G2062 – Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes.

G2063 – Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.

These codes would be valued at a lower rate than when the service is furnished by a physician because the work is likely less, due to the acuity of the patient.

ORIGINATING SITE FACILITY FEE

For CY 2020 the payment amount for HCPCS code Q3014 (the telehealth originating site facility fee) will be 80% of the lesser of the actual charge or $26.56.

© 2019 Public Health Institute Center for Connected Health Policy

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12 August 2019 Health Care Law Today Blog Authors: Emily H. WeinNathaniel M. Lacktman

On July 29, the Centers for Medicare and Medicaid Services (CMS) issued its proposed 2020 Physician Fee Schedule rule, which contains new telehealth services covered under Medicare. Surprisingly, CMS did not receive any provider requests to add new telehealth services this year. Fortunately, CMS took it upon itself to propose three new codes. This article discusses the proposed new codes, explains how to submit public comments on the proposed rule, and describes how to submit requests for new telehealth services. The public comment period is open through September 27, 2019.

How Medicare Defines Telehealth Services

Under Medicare, the term “telehealth services” refers to a specific set of services practitioners normally furnish in-person, but for which CMS will make payment when they are instead furnished using interactive, real-time telecommunication technology. The Social Security Act governs what telehealth services are, and are not, covered under Medicare. Generally, there are five statutory conditions required for Medicare coverage of telehealth services:

1. The beneficiary (patient) is located in a qualifying rural area;
2. The beneficiary is located at one of eight types of qualifying originating sites;
3. The services are provided by one of ten categories of distant site practitioners eligible to furnish and receive Medicare payment for telehealth services;
4. The beneficiary and distant site practitioner communicate via an interactive audio and video telecommunications system that permits real-time communication between them; and
5. The Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCs) code for the service itself is named on the list of covered Medicare telehealth services.

Provided the distant site practitioner complies with each of the above requirements, the telehealth service furnished via an interactive telecommunications system will substitute for an in-person encounter, and it should meet the requirements for Medicare coverage assuming other standard coverage and payment provisions are met.

How Does CMS Assess New Telehealth Services?

There is a specific process to request additions or deletions from the list of covered telehealth services. Initially, CMS assigns each proposed code to one of two categories. Category 1 is for those services similar to professional consultations, office visits, and office psychiatry services currently on the list of telehealth services. Category 2 is for those services not similar to those on the current list of telehealth services. Proposals that fall into Category 2 undergo a more exacting review, including whether the proposed service will produce demonstrated clinical benefit for patients. When submitting a proposal to request coverage of a new service/code, it is necessary to first determine in which category the service will be considered, so that the type of clinical and nonclinical support documentation CMS expects will accompany the submission.

When Does CMS Accept Requests for New Telehealth Services?

CMS accepts requests for additions or deletions to the Medicare telehealth services list until February 10th of each calendar year. This deadline aligns with the deadline for receipt of code value recommendations from the Relative Value Scale Update Committee.

What Telehealth Services Will CMS Add for 2020?

Particularly surprising was that this year, there were no requests that CMS add new codes to the telehealth services list. It is unclear why providers failed to make such requests, but CMS speculated that the vast majority of existing services that can be appropriately delivered via telehealth are reflected by codes that are already on the list. 

Despite the absence of requests, CMS proposed adding three codes to the covered Medicare telehealth service list:

1. HCPCS code GYYY1: Office-based treatment for opioid use disorder, including development of the treatment plan, care coordination, individual therapy and group therapy and counseling; at least 70 minutes in the first calendar month.
2. HCPCS code GYYY2: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; at least 60 minutes in a subsequent calendar month.
3. HCPCS code GYYY3: Office-based treatment for opioid use disorder, including care coordination, individual therapy and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes (List separately in addition to code for primary procedure).

These three services are sufficiently similar to services already on the list of Medicare telehealth services, so CMS classified them as Category 1. Accordingly, a streamlined review process took place. Subject to public comment, these services are expected to be added to the list of Medicare telehealth services when the final rule is published, and would go into effect January 1, 2020.

CMS also noted how the SUPPORT Act statutorily removed the geographic limitations for telehealth services furnished to individuals diagnosed with a substance use disorder (SUD) for the purpose of treating the SUD or a co-occurring mental health disorder. The change also allows telehealth services for treatment of a diagnosed SUD or co-occurring mental health disorder to be furnished to individuals at any telehealth originating site (other than a renal dialysis facility), including in a patient’s home. No originating site facility fee is paid when the beneficiary’s home is the originating site. These changes became effective July 1, 2019.

How to Submit Comments on the Proposed Rule

Providers, technology companies, and entrepreneurs interested in telehealth should consider submitting comments to the proposed rule anonymously or otherwise – via electronic submission at this link. CMS is soliciting comments on the proposed rule until 5:00 p.m. on September 27, 2019. Alternatively, commenters may submit comments by mail to:

• Regular Mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1715-P, P.O. Box 8016, Baltimore, MD 21244-8016.
• Express Overnight Mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1715-P, Mail Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850 (for express overnight mail).  

If submitting via mail, please be sure to allow time for comments to be received before the closing date.

How to Request Additional Medicare Telehealth Services 

Interested parties need not wait on Congress or CMS to act; anyone may send CMS a request to add services (HCPCS codes) to the list of covered Medicare telehealth services. This can include medical specialty societies, individual physicians or practitioners, entrepreneurs, hospitals, state and federal agencies, telehealth companies, vendors, and even patients. Requests may be submitted at any time on an ongoing basis. The requests will be consolidated and considered during the CMS rulemaking cycle.

Each request should address the following:

• Requestor Name(s), address, and contact information.
• The HCPCS code(s) that describes the service(s) proposed for addition or deletion to the list of Medicare telehealth services. If the requestor does not know the applicable HCPCS code, the request should include a description of services furnished during the telehealth session.
• A description of the type(s) of medical professional(s) providing the telehealth service at the distant site.
• A detailed discussion of the reasons the proposed service should be added to the definition of Medicare telehealth service.
• An explanation as to why the requested service cannot be billed under the current scope of telehealth services, for example, the reason why the HCPCS codes currently on the list of Medicare telehealth services would not be appropriate for billing the service requested.
• Evidence that supports adding the service(s) to the list on either a Category 1 or Category 2 basis as explained in the section labeled “CMS Criteria for Submitted Requests.”

Email your request to Telehealth_Review_Process@cms.hhs.gov with a subject line of “Telehealth Review Process.” Alternatively, you can mail the request to: Division of Practitioner Services, Mail Stop: C4-03-06, Centers for Medicare and Medicaid Services, 7500 Security Boulevard Baltimore, Maryland 21244-1850. Attention: Telehealth Review Process.

Conclusion

Continued expansions in Medicare reimbursement mean providers should make enhancements to telehealth programs now, both for the immediate cost savings and growing opportunities for revenue generation, to say nothing of clinical quality and patient satisfaction. We will continue to monitor CMS for any rule changes or guidance that affect or improve telehealth opportunities.

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On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) issued three proposed rules on payment updates and policy changes for calendar year 2020 under 1) the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System (the OPPS Proposed Rule);¹ 2) the Medicare Physician Fee Schedule (the PFS Proposed Rule);² and 3) the Medicare End Stage Renal Disease and Durable Medical Equipment, Prosthetics, and Orthotics (the DMEPOS Proposed Rule).³ Interested parties should submit comments to CMS for consideration during the rulemaking process by 5 p.m. EDT on September 27, 2019.

Below we summarize portions of each proposed rule that are particularly noteworthy.

The OPPS Proposed Rule

Payment Update. CMS proposes increasing OPPS payment rates by 2.7 percent.

Price Transparency. CMS proposes defining “standard charges” to include hospitals’ gross charges and payer-specific negotiated charges, and requiring hospitals to make public a machine-readable file that contains all standard charges. CMS also proposes requiring hospitals to provide a publically available list of 300 “shoppable” health care items and services—those items and services that are routinely provided in non-urgent situations that do not require immediate action or attention to the patient, thus allowing patients to price shop. Hospitals that fail to publish standard charges could be subject to monetary penalty of up to $300 per day.

Device Pass-Through Payment. CMS proposes an alternative pathway to the substantial clinical improvement criterion for devices approved under the FDA Breakthrough Devices Program to qualify for device pass-through status beginning with applications received on or after January 1, 2020. This proposal is similar to the one made in the FY 2020 Inpatient Prospective Payment System Proposed Rule. CMS is evaluating seven applications for device pass-through payments and is seeking public comments on whether these meet the criteria for device pass-through payment status.

340B-Acquired Drugs. CMS proposes to continue to pay Average Sales Price (ASP) minus 22.5 percent for drugs acquired under the 340B Program during CY 2020. CMS is soliciting public comments on the appropriate OPPS payment rate for 340B-acquired drugs, including retrospective remedy for CYs 2018 and 2019, in preparation for the outcome of an appeal to American Hospital Association et al. v. Azar et al. There, the District Court for the District of Columbia concluded that the Secretary exceeded statutory authority in adjusting Medicare payment rates for 340B-acquired drugs.

ASC Covered Procedures List. CMS proposes adding eight procedures to the ASC list of covered surgical procedures, including a total knee arthroplasty, a mosaicplasty, and six coronary intervention procedures. CMS is soliciting public comments on whether certain other surgical procedures related to the cardiovascular system should be added.

Supervision of Outpatient Therapeutic Services. CMS proposes lowering the minimum required level of supervision from direct to general supervision for all outpatient therapeutic services that hospitals and critical access hospitals provide, thus establishing a standard minimum level of supervision for each hospital outpatient service furnished incident to a physician’s service.

Prior Authorization Requirement for Certain Hospital Outpatient Department Services. CMS proposes establishing a prior authorization process as a means for controlling unnecessary increases in the volume of the following five categories of services: 1) blepharoplasty, 2) botulinum toxin injections, 3) panniculectomy, 4) rhinoplasty, and 5) vein ablation.

Cost Thresholds for Packaged Skin Substitutes. CMS proposes continuing the policy established in CY 2018 to assign skin substitutes to the low-cost or high-cost group. Any skin substitute product that was assigned to the high-cost group in CY 2019 would be assigned to the high-cost group for CY 2020. CMS proposes to continue determining the high-cost/low-cost status for each skin substitute product based on whether a product’s geometric mean unit cost (MUC) exceeds the geometric MUC threshold or the product’s per day cost (PDC) (the total units of a skin substitute multiplied by the mean unit cost and divided by the total number of days) exceeds the PDC threshold. CMS is proposing to assign each skin substitute that exceeds either threshold to the high-cost group. In addition, CMS is proposing to assign any skin substitute with a MUC or a PDC that does not exceed either threshold to the low-cost group.

The PFS Proposed Rule

Open Payments Program. CMS proposes the following changes to reduce burden under Open Payments, which would first impact data collected beginning in CY 2021 and reported in CY 2022: 1) expanding the definition of “covered recipient” to include the categories specified in the SUPPORT Act (i.e., to include physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, and certified nurse-midwife); 2) expanding the “nature of payment” categories by consolidating two categories for continuing education programs and by adding three new categories (to be applied prospectively): i) debt forgiveness (or transfers of value related to forgiving the debt of a covered recipient, a physician owner, or the immediate family of a physician owner or investor; ii) long-term medical supply or device loans (or loans of covered devices or medical supplies for longer than 90 days); and iii) acquisitions (or buyout payments made to covered recipients in relation to the acquisition of a company in which the covered recipient has an ownership interest); and 3) standardizing data on reported covered drugs, devices, biologicals, or medical supplies, including requiring the submission of device identifiers (DIs) and mandatory fixed portion of the unique device identifier (UDI) assigned to devices and clarifying that National Drug Codes (NDCs) are required for both research and non-research payments associated with applicable drugs and biologics in Open Payments reporting. If finalized, the NDC requirement will be effective 60 days following the publication of the final rule.

Payment Update. Payments made under the PFS are based on the relative resources typically used to furnish the service, as reflected in Relative Value Units (RVUs) applied to each service for physician work, practice expense, and malpractice. CMS proposes increasing physician payment rates by 0.14 percent in 2020. After applying the budget-neutrality adjustment required by law, the proposed CY 2020 PFS conversion factor is $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.

Evaluation and Management (E/M) Coding and Payment. CMS proposes aligning E/M coding with changes laid out by the Current Procedural Terminology (CPT) Editorial Panel for office/outpatient E/M visits. Level 1 E/M visits would now only describe visits performed by clinical staff for established patients. Levels 2-5 E/M visits would be based on redefined medical decision making criteria or the total time personally spent by the practitioner during that visit. CMS proposes to establish a single add-on, CPT code that would only be reported when time is used for code level selection and the time for a level 5 office/outpatient visit (the floor of the level 5 time range) is exceeded by 15 minutes or more on the date of service. CMS also proposes adopting the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC)-recommended values for office/outpatient E/M visit codes for CY 2021.

Care Management Services. CMS proposes implementing a set of Medicare-developed HCPCS G codes for certain Chronic Care Management (CCM) services, which involve care coordination and management services for beneficiaries with multiple chronic conditions over a calendar month service period. CMS proposes replacing a number of the CCM codes with Medicare-specific codes to allow clinicians to bill incremental time and resources required in certain cases and to better distinguish complexity of illness. CMS also proposes creating new coding for Principal Care Management (PCM) services, which would allow clinicians to bill for care management for patients with a single serious and high-risk condition. CMS is also seeking comments on potential for duplicative payment between the proposed PCM services and other services, such as interprofessional consultation services (CPT codes 99446-99449), CPT code 99451, and CPT code 99452 or remote patient monitoring (CPT codes 99091, 99453, and 99457).

Remote Physiologic Monitoring (RPM) Services. CMS proposes adopting the CPT Editorial Panel’s revised structure for CPT code 99457. Effective beginning in CY 2020, CMS proposes the following new code descriptors: CPT code 99457 (remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; initial 20 minutes); and CPT code 994X0 (remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes). CMS also proposes that RPM services reported with CPT codes 99457 and 994X0 may be furnished under general supervision rather than the currently required direct supervision. CMS also solicits comments on whether a single advance beneficiary consent could be obtained for a number of communication technology-based services and the appropriate interval of time or number of services for which consent could be obtained.

The DMEPOS Proposed Rule

Comparable Item Analysis. CMS proposes a framework for Medicare pricing of novel DMEPOS. For DMEPOS without a pricing history, the proposal establishes five main categories of components or attributes (physical, mechanical, electrical, function and intended use, and additional attributes and features) that would be evaluated to determine if a new item is comparable to older existing items for gap-filling purposes. If the new DMEPOS proves comparable to older existing items, CMS is proposing to use the fee schedule amounts for the older items to establish fee schedule amounts for the new DMEPOS. If there are no comparable existing items, CMS proposes that the Medicare fee schedule amounts for the new DMEPOS would be based on other, more accurate sources of commercial pricing data—such as internet retail prices or information from supplier invoices—deflated to the fee schedule base period and updated by the covered item update factors. When needed, CMS proposes to use technology assessments that determine the relative costs of older existing item(s) compared with the new DMEPOS to establish the fee schedule amounts for the latter. In order to avert fee schedule inflation, a one-time downward adjustment would later be performed on initial fee schedule amounts determined by comparable item analysis. CMS invites comments on whether fee adjustments (upward or downward) should be introduced where supplier or commercial prices used to establish original gap-filled fee schedule amounts change by 15 percent or more afterward, and possible mechanisms for such a procedure.

Conditions of Payment for Certain DMEPOS. CMS proposes to streamline the requirements for ordering DMEPOS items and to prepare a single list of DMEPOS potentially subject to a face-to-face encounter and written orders prior to delivery, or prior authorization requirements. CMS previously established face-to-face examination and written order prior to delivery requirements for power mobility devices (71 FR 17021). CMS separately created a list of Specified Covered Items to be subject to face-to-face encounter and written order prior to delivery requirements, based on criteria outlined in 43 CFR § 410.38 (77 FR 68892). CMS also created a Master List of items that are potentially subject to prior authorization upon selection (80 FR 81674). The latest proposal would create one standardized set of required elements for all DMEPOS orders. The proposal would harmonize the three existing lists noted above and develop one Master List of items potentially subject to a face-to-face encounter and written orders prior to delivery, or prior authorization requirements. It would also update the prior authorization program to more nimbly adapt to changes in billing, and to recognize and offer relief for specific suppliers when they demonstrate billing compliance.

Melissa Hudzik, Jeff Weinstein, and Eva Yin contributed to the preparation of this WSGR alert.

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Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2020

On July 29, 2019, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2020.

The calendar year (CY) 2020 PFS proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a healthcare system that results in better accessibility, quality, affordability, empowerment, and innovation.

Background on the Physician Fee Schedule
Payment is made under the PFS for services furnished by physicians and other practitioners in all sites of service.  These services include, but are not limited to, visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services.

In addition to physicians, payment is made under the PFS to a variety of practitioners and entities, including nurse practitioners, physician assistants, and physical therapists, as well as radiation therapy centers and independent diagnostic testing facilities.

Payments are based on the relative resources typically used to furnish the service.  Relative Value Units (RVUs) are applied to each service for physician work, practice expense, and malpractice.  These RVUs become payment rates through the application of a conversion factor.  Payment rates are calculated to include an overall payment update specified by statute.

PAYMENT PROVISIONS

CY 2020 PFS Rate setting and Conversion Factor
We are proposing a series of standard technical proposals involving practice expense, including the implementation of the second year of the market-based supply and equipment pricing update, and standard rate setting refinements to update premium data involving malpractice expense and geographic practice cost indices (GPCIs). 

With the budget neutrality adjustment to account for changes in RVUs, as required by law, the proposed CY 2020 PFS conversion factor is $36.09, a slight increase above the CY 2019 PFS conversion factor of $36.04.

Medicare Telehealth Services
For CY 2020, we are proposing to add the following codes to the list of telehealth services: HCPCS codes GYYY1, GYYY2, and GYYY3, which describe a bundled episode of care for treatment of opioid use disorders.

Payment for Evaluation and Management (E/M) Services
Consistent with our goals of burden reduction, we are proposing to align our E/M coding with changes laid out by the CPT Editorial Panel for office/outpatient E/M visits.  The CPT coding changes retain 5 levels of coding for established patients, reduce the number of levels to 4 for office/outpatient E/M visits for new patients, and revise the code definitions.  The CPT changes also revise the times and medical decision making process for all of the codes, and requires performance of history and exam only as medically appropriate.  The CPT code changes also allow clinicians to choose the E/M visit level based on either medical decision making or time. 

We are proposing to adopt the AMA RUC-recommended values for the office/outpatient E/M visit codes for CY 2021 and the new add-on CPT code for prolonged service time.  The AMA RUC-recommended values would increase payment for office/outpatient E/M visits.  The RUC recommendations reflect a robust survey approach by the AMA, including surveying over 50 specialty types demonstrate that office/outpatient E/M visits are generally more complex and require additional resources for most clinicians. 

We are also proposing to consolidate the Medicare-specific add-on code for office/outpatient E/M visits for primary care and non-procedural specialty care that we finalized in the CY 2019 PFS final rule for implementation in CY 2021 into a single code describing the work associated with visits that are part of ongoing, comprehensive primary care and/or visits that are part of ongoing care related to a patient’s single, serious, or complex chronic condition.  We are also seeking more information and feedback from the public about the definition, application, and valuation of this code.

We are not proposing to make AMA RUC-recommended changes to global surgery codes as we are in the process of gathering information on global surgery.  We have had three reports prepared by RAND, which we release with the proposed rule.  We encourage stakeholders to comment on the reports.

Physician Supervision Requirements for Physician Assistants (PAs)
We are proposing to modify our regulation on physician supervision of PAs to give PAs greater flexibility to practice more broadly in the current health care system in accordance with state law and state scope of practice.  In the absence of State law governing physician supervision of PA services, the physician supervision required by Medicare for PA services would be evidenced by documentation in the medical record of the PA’s approach to working with physicians in furnishing their services.

Review and Verification of Medical Record Documentation
We’ve received feedback from the clinician community in response to our Patients Over Paperwork initiative request for information (RFI).  We’ve heard from multiple stakeholders that undue burden is created when physicians and other practitioners, including those serving as clinical preceptors for students, must re-document notes entered into the medical record by other members of the medical team.  

To reduce burden, we are proposing broad modifications to the documentation policy so that physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certified nurse-midwives could review and verify (sign and date), rather than re-documenting, notes made in the medical record by other physicians, residents, nurses, students, or  other members of the medical team.  

Care Management Services
We are proposing to increase payment for Transitional Care Management (TCM), which is a care management service provided to beneficiaries after discharge from an inpatient stay or certain outpatient stays.

We are also proposing a set of Medicare-developed HCPCS G codes for certain Chronic Care Management (CCM) services.  CCM is a service for providing care coordination and management services to beneficiaries with multiple chronic conditions over a calendar month service period.  We are proposing to replace a number of the CCM codes with Medicare-specific codes to allow clinicians to bill incrementally to reflect additional time and resources required in certain cases and better distinguish complexity of illness as measured by time.  We are also proposing to adjust certain billing requirements and elements of the care planning services.  These changes would also reduce burden associated with billing the complex CCM codes.

Recognizing that clinicians across all specialties manage the care of beneficiaries with chronic conditions, we are also proposing to create new coding for Principal Care Management (PCM) services, which would pay clinicians for providing care management for patients with a single serious and high risk condition.

Comment Solicitation on Opportunities for Bundled Payments under the PFS
We are seeking comment on opportunities to expand the concept of bundling to improve payment for services under the PFS and more broadly align PFS payment with the broader CMS goal of improving accountability and increasing efficiency in paying for the health care of Medicare beneficiaries.  We believe that the statute, while requiring CMS to pay for services on the basis of the resources required to furnish the service, allows considerable flexibility for improving the efficiency of health service delivery within the PFS.   

Medicare Coverage for Opioid Use Disorder Treatment Services Furnished by Opioid Treatment Programs (OTPs)
Section 2005 of the Substance Use–Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act established a new Medicare Part B benefit for opioid use disorder (OUD) treatment services, including medications for medication-assisted treatment (MAT), furnished by opioid treatment programs (OTPs).  To meet this statutory requirement, CMS is specifically proposing:

• Definitions of OTP and OUD treatment services;
• Enrollment policies for OTPs;
• Methodology and estimated bundled payment rates for OTPs that vary by the medication used to treat OUD and service intensity, and by full and partial weeks;
• Adjustments to the bundled payments rates for geography and annual updates;
• Flexibility to deliver the counseling and therapy services described in the bundled payments via two-way interactive audio-video communication technology as clinically appropriate; and
• Zero beneficiary copayment for a time limited duration.

CMS intends to implement this benefit beginning January 1, 2020, as required by the SUPPORT Act.

Bundled Payments under the PFS for Substance Use Disorders
In the CY 2019 PFS proposed rule, CMS sought comment on creating a bundled episode of care for management and counseling treatment for substance use disorders.  In response to comments received, CMS is proposing to create new coding and payment for a bundled episode of care for management and counseling for OUD.  The new proposed codes describe a monthly bundle of services for the treatment of OUD that includes overall management, care coordination, individual and group psychotherapy, and substance use counseling.  One code describes the initial month of treatment, which would include administering assessments and developing a treatment plan; another code describes subsequent months of treatment; and an add-on code describes additional counseling.  CMS is proposing that the individual psychotherapy, group psychotherapy, and substance use counseling included in these codes could be furnished as Medicare telehealth services using communication technology as clinically appropriate.  CMS is also seeking comment on bundles describing services for other SUDs and on the use of MAT in the emergency department setting, including initiation of MAT and the potential for either referral or follow-up care, as well as the potential for administration of long-acting MAT agents in this setting, to help inform whether we should consider proposing to make separate payment for such services in future rulemaking. 

Therapy Services
In the CY 2019 PFS final rule, in accordance with amendments to the Medicare law, we established modifiers to identify therapy services that are furnished in whole or in part by physical therapy (PT) and occupational therapy (OT) assistants, and set a de minimis 10 percent standard for when these modifiers will apply to specific services.  We also established that the statutory reduced payment rate for therapy assistant services, effective beginning for services furnished in CY 2022, does not apply to services furnished by critical access hospitals because they are not paid for therapy services at PFS rates. 

Beginning January 1, 2020, these modifiers are required by statute to be reported on claims.  We are proposing a policy to implement the modifiers as required by statute, and apply the 10 percent de minimis standard, while imposing the minimum amount of burden for those who bill for therapy services while meeting the requirements of the statute.

OTHER PROVISIONS

Ambulance Services
CMS is proposing to clarify that there is no CMS-prescribed form for physician certification statements (PCSs) for ambulance transports. So long as the elements required by regulation are clearly conveyed, ambulance suppliers and providers would be free to choose the format by which the information is displayed, and they may find that other forms that may be required by other legal requirements to perform the transport may also satisfy the function of the PCS.  CMS is also proposing to grant ambulance suppliers and providers greater flexibility around who may sign a non-physician certification statement in certain circumstances.  The proposal would also add licensed practical nurses (LPNs), social workers and case managers as staff members who may sign the non-physician certification statement if the provider/supplier is unable to obtain the attending physician’s signature within 48 hours of the transport.

Ground Ambulance Data Collection System
The Bipartisan Budget Act (BBA) of 2018 requires the Secretary to develop a data collection system to collect cost, revenue, utilization, and other information determined appropriate with respect to ground ambulance providers suppliers.  In the CY 2020 PFS proposed rule, CMS proposes the data collection format and elements, a sampling methodology that CMS would use to identify ground ambulance organizations for reporting each year through 2024 and not less than every 3 years after 2024, and reporting timeframes.  CMS is also proposing to reduce by 10% the payments that would otherwise be made to a ground ambulance organization that is identified for reporting but fails to sufficiently submit data, as well as a process under which a ground ambulance organization can request a hardship exemption that, if granted by CMS, would allow it to avoid the payment reduction.

Open Payments Program
CMS’s Open Payments program promotes a transparent and accountable healthcare system by annually publishing the financial relationships that physicians and teaching hospitals (known as “covered recipients”) have with applicable manufacturers and group purchasing organizations (GPOs). The program has been successful in disclosing over 64 million records since August of 2013. CMS continues to reduce the associated burden of reporting under Open Payments while also clarifying and making the data more useful to the public through minor reporting changes to the program. Therefore, CMS is proposing several changes to Open Payments: 1) expanding the definition of “covered recipient;” (as required by the SUPPORT Act) 2); modifying payment categories; and 3) standardizing data on reported medical devices.

Medicare Shared Savings Program
CMS is soliciting comment on how to potentially align the Medicare Shared Savings Program quality performance scoring methodology more closely with the Merit-based Incentive Payment System (MIPS) quality performance scoring methodology. We recognize that accountable care organizations (ACOs) and their participating providers and suppliers dedicate resources to performing well on quality metrics. We believe that aligning quality metrics across programs will reduce burden and will allow ACOs to more effectively target their resources toward improving care. In addition, we propose refining the Shared Savings Program measure set by: 1) removing one measure and adding another to the CMS Web Interface, to maintain alignment with proposals under the Quality Payment Program, and 2) reverting one measure to pay-for-reporting due to a substantive change made by the measure owner.

Stark Advisory Opinion Process
CMS issues written advisory opinions on a case-by-case basis about whether a physician referral for certain health services is prohibited under Section 1877 of the Social Security Act (the “Stark Law”). Last year, CMS issued a Request for Information (RFI) to gather public input on how to address unnecessary burden created by the physician self-referral law, focusing in part on how it may impede care coordination, a key aspect of value-based healthcare. In response to the RFI, many health systems and provider groups urged CMS to update the regulations governing its advisory opinion process on physician referrals to reduce provider burden and uncertainty around compliance with the Stark Law. Therefore, CMS is soliciting comment on potential changes to its advisory opinion process to address these stakeholder comments. Other comments in response to the RFI are expected to be addressed in separate rulemaking.

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