Modernizing Medicare: CMS Expands Reimbursement for Virtual Care and Telehealth

As part of the 2019 Medicare Physician Fee Schedule Final Rule (Final Rule) published on November 23, 2018,¹ the Centers for Medicare & Medicaid Services (CMS) took significant steps toward modernizing Medicare to expand reimbursement for virtual care, telehealth coverage and care coordination. In the Final Rule, CMS expands reimbursement for “virtual care” patient services, adds services to the telehealth list, and removes geographic limitations for using telemedicine to treat substance abuse disorders, acute stroke and end-stage renal disease (ESRD) as mandated by the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act) and the Bipartisan Budget Act of 2018.²

“Virtual Care” Services

To increase Medicare beneficiaries’ access to physicians’ services that routinely involve the use of communication technology, CMS created two newly defined types of physicians’ services: (1) brief communication technology-based services and (2) remote evaluation of recorded video and/or images submitted by a patient. CMS also created a code to allow rural health clinics and federally qualified health centers to bill for the same “virtual care” services.³ Additionally, CMS established values for six Healthcare Common Procedure Coding System (HCPCS) codes for interprofessional telephone/internet consultations to further comprehensive patient-centered care management.  Only practitioners who are qualified to bill for evaluation and management (E&M) services are eligible to perform and bill for these services.

While these changes are certainly forward thinking, the scope of newly covered services is narrow and the reimbursement is modest at best. CMS is unsurprisingly cautious and concerned about potential overutilization and abuse of these newly covered services. As a result, CMS intends to monitor the utilization closely. Therefore, practitioners should carefully consider how they will capture and maintain supporting documentation showing appropriate use of the virtual care codes and their medical necessity.

In creating these new types of services, CMS explained that they are not “Medicare telehealth services” subject to the limitations in section 1834(m) of the Social Security Act (the Act) because they are not substitutes for in-person services already covered under the Physician Fee Schedule.⁴ As a result, the “virtual care” services are not subject to the restrictions that apply to telemedicine relating to geography (e.g., services are covered mainly just in rural or healthcare shortage areas), patient-originating site locations (e.g., hospitals, nursing homes, physician offices), and type of furnishing practitioner – making these services more widely available to beneficiaries.

Communication Technology-Based Services: Virtual “Check-ins”⁵

New HCPCS code, G2012, will provide reimbursement based on 0.25 wRVU for a non-face-to-face communication “check-in” between a physician and patient that is used to evaluate whether an office visit or other service is warranted.⁶ Traditionally, such communications were always bundled into the payment for the office visit itself. However, in this Final Rule CMS recognized that practitioners could now leverage technology to potentially avoid the need for an office visit, resulting in fewer billable services. Recognizing the potential effectiveness of such check-ins for addressing patient concerns and promoting efficient care, CMS finalized its proposal to separately pay for medically necessary virtual check-in services provided by a billing practitioner to an established patient.

In order to bill G2012, the patient must consent, verbally or in writing; and, that consent must be noted in the patient’s medical record.  In addition, the check-in cannot be associated with any E&M service provided within the previous seven days; nor, can the check-in lead to an E&M service or procedure within the next 24 hours or at the “soonest available appointment.” CMS expects the “soonest available appointment” language to deter potential abuse typical of a purely time-based standard, e.g., scheduling appointments after the 25^th hour.  In doing so, however, CMS acknowledged it may be challenging on an individual case basis to prove whether or not other appointments were available prior to the actual visit, even noting that “beneficiary convenience is also presumably a factor for when appointments are scheduled.” CMS did not offer any guidance to practitioners on how they can prove they met this standard.⁷

CMS is not prescriptive about the technology, but indicates that the code covers real-time direct interaction with the practitioner (e.g., audio-only telephone interactions and synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission). CMS emphasized that telephone calls with clinical staff are not covered by G2012: “the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.”⁸

Remote Evaluation of Patient-Submitted Video and/or Images⁹

In the Final Rule, CMS also acknowledged stakeholder requests for separate Medicare payment for “store and forward” communication services – when a physician uses a patient-recorded video and/or image in order to evaluate the patient’s condition – and established coverage for these services in certain circumstances. Specifically, HCPCS code G2010¹⁰ will allow for separate payment for remote professional evaluation of patient-transmitted information conducted via pre-recorded “store and forward” video or image technology. Following the evaluation, the healthcare professional’s follow-up with the patient may take place via phone call, audio/video communication, secure text messaging, email, or patient portal communication. CMS assigned 0.18 wRVUs to G2010.

Similar to the virtual check-in service, the remote evaluation is to be used for determining whether or not an in-person office visit is necessary. If the service results in an E&M office visit or procedure within 24 hours or at the soonest available appointment; or, there has been a related E&M office visit within the previous seven days, the remote evaluation is not separately payable. Also mirroring the virtual check-in service requirements, G2010 may be billed only for established patients and requires verbal or written consent noted in the patient’s medical record for each billed service. CMS will monitor utilization of the G2010 code to consider if any future adjustments to the billing rules or valuation of the service are necessary.

Interprofessional Internet Consultation¹¹

CMS established Medicare payments for the level I HCPCS codes 99451 (0.70 wRVU),¹² 99452 (0.70 wRVU)¹³, 99446 (0.35 wRVU)¹⁴, 99447 (0.70 wRVU)¹⁵, 99448 (1.05 wRVU)¹⁶, and 99449 (1.40 wRVU)¹⁷ describing remote consultations between a treating practitioner and a specialist provided for varying amounts of time. In establishing payment rates for these codes, CMS recognized the practical result of not covering these types of services would be patients being asked to schedule a separate patient visit with a specialist when a phone or internet-based interaction between the physicians is sufficient and more efficient.

More specifically, these codes cover “assessment and management services conducted by telephone, internet, or electronic health record consultations that are furnished when a patient’s treating practitioner requests the opinion and/or advice of a consulting practitioner, with specific specialty expertise to assist with the diagnosis and/or management of the patient’s problem.”¹⁸ Each service requires the patient’s verbal consent to be noted in the medical record and may only be billed by practitioners that can bill Medicare independently for E&M services.

Telehealth List Additions¹⁹

CMS finalized its proposal to add two services to its list of covered telehealth services because they are sufficiently similar to office visits currently on the telehealth list and could be furnished via interactive telecommunications technology. Beginning in calendar year 2019, HCPCS codes G0513 and G0514 will be payable as telehealth services. HCPCS code G0513 should be billed for the first 30 minutes of “Prolonged preventive service(s) (beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service,” and should be listed separately in addition to the code for the preventive service. HCPCS code G0514 should be billed for each additional 30 minutes of preventive service, beyond the first 30 minutes, and should be listed separately in addition to code G0513. CMS assigned 1.17 wRVUs each for G0513 and G0514.

Expanded Access to Telehealth Services²⁰

The SUPPORT Act

As part of the Final Rule, CMS updated – on an interim final basis – its regulations to implement expanded coverage of telehealth services for substance abuse treatment and related services as mandated by the recently passed SUPPORT Act.²¹ Effective July 1, 2019, Medicare’s telehealth statute will no longer contain restrictive geographic requirements for telehealth services provided to individuals receiving substance use disorder and co-occurring mental health disorder treatment, now allowing a patient’s home to be a permissible originating site and no longer limiting the coverage to primarily healthcare shortage and rural areas. In addition, the updates remove any originating site fee when the patient’s home is the originating site. The interim final rule makes corresponding changes to the regulations,²² which are subject to a 60-day comment period as part of the Final Rule.

For more information on the SUPPORT for Patients and Communities Act, please see our November 16, 2018 summary available here.

Bipartisan Budget Act of 2018²³

The Bipartisan Budget Act of 2018 expanded certain telehealth services furnished on or after January 1, 2019. Accordingly, in the Final Rule, CMS updated its regulations to reflect these expansions.

First, CMS finalized a new modifier and revised 42 CFR §§ 410.78 and 414.65 to implement amendments to acute stroke telehealth services. Section 1834(m)(6)(B) of the Act, as amended, now allows for acute stroke telehealth services to be furnished in any hospital, critical access hospital, mobile stroke units, or any other site determined appropriate by the Secretary, in addition to the current telehealth originating sites. CMS explained that practitioners and the originating site would append the new modifier to the HCPCS code used to bill for an acute stroke telehealth service or an originating site facility fee, respectively. The use of the modifier will also allow CMS to track and analyze utilization of acute stroke telehealth services.

Second, CMS revised 42 CFR § 410.78 to add a renal dialysis facility and the home of an individual as Medicare telehealth originating sites for the purpose of a home dialysis monthly ESRD-related clinical assessment. Further, CMS revised the regulation to reflect that the section 1834(m) telehealth services’ geographic requirements would not apply to services furnished on or after January 1, 2019 for the purpose of the monthly ESRD-related clinical assessment, where the originating site for the assessment is a hospital-based or critical access hospital-based renal dialysis center, a renal dialysis facility, or the home of an individual. CMS also revised 42 CFR §  414.65(b)(3) to reflect that if the originating site for this telehealth service is the patient’s home, then there is no originating site facility paid.

Conclusion

In expanding payment under the Physician Fee Schedule for virtual and technologically delivered services, CMS appears to be recognizing advances in technology and shifting trends in medical practice toward patient-centered care through more cost-effective and practical means. The changes also demonstrate alternative means for separate payment of telehealth-like services outside of the more restrictive section 1834(m) and telehealth services list.

¹ 83 Fed. Reg. 49,451 (Nov. 23, 2018).

² Bipartisan Budget Act of 2018, Pub. L. 115-123, February 9, 2018.

³ 83 Fed. Reg. 59,683-59,688.

⁴ 42 U.S.C. 1395m.

⁵ 83 Fed. Reg. at 59483-59486.

⁶ HCPCS G2012: Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified healthcare professional who can report evaluation and management services, provided to an established patient, not originating from a related E&M service provided within the previous seven days nor leading to an E&M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

⁷ 83 Fed. Reg. at 59845.

⁸ 83 Fed. Reg. at 59484.

⁹ 83 Fed. Reg. at59486-59489.

¹⁰ HCPCS G2010: Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E&M service provided within the previous seven days nor leading to an E&M service or procedure within the next 24 hours or soonest available appointment.

¹¹ 83 Fed. Reg. at 59489-59491.

¹² 99451: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified healthcare professional, five or more minutes of medical consultative time).

¹³ 99452: Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified healthcare professional, 30 minutes.

¹⁴ 99446: Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 5-10 minutes of medical consultative discussion and review.

¹⁵ 99447: Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 11-20 minutes of medical consultative discussion and review.

¹⁶ 99448: Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 21-30 minutes of medical consultative discussion and review.

¹⁷ 99449: Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 31 minutes or more of medical consultative discussion and review.

¹⁸ 83 Fed. Reg. at 59489.

¹⁹ 83 Fed. Reg. at 59491-59494.

²⁰ 83 Fed. Reg. 59496.

²¹ Substance-Use Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, H.R. 6, 115th Cong. (2018), available at https://www.congress.gov/bill/115th-congress/house-bill/6.

²² Amending 42 CFR § 410.78(b)(3) to add 42 CFR §410.78(b)(3)(xii), adding the home of an individual as a permissible originating site for telehealth services; amending 42 CFR § 414.65(b)(3) to reflect that there is no originating site fee paid when the originating site for these services is the individual’s home; adding 42 CFR § 410.78(b)(4)(iv)(C) to specify that the geographic requirements at section 1834(m)(4)(C)(i) of the Act do not apply to these telehealth services.

²³ 83 Fed. Reg. at 59494-59496.