On July 27, 2018, the Centers for Medicare & Medicaid Services (CMS) published its proposed annual update to the Medicare Physician Fee Schedule, which includes proposals that would give a big boost to telehealth services starting January 1, 2019. Under the proposed rule, CMS would begin covering certain types of telehealth services as standard physician services, not as “Medicare telehealth services,” meaning that the services will be eligible for reimbursement regardless of whether they qualify as “Medicare telehealth services” under Section 1834(m) of the Social Security Act. In addition, the proposed rule would add prolonged consultations and services and stroke treatment to the list of eligible “telehealth services.”

Coverage of Telehealth as a Standard Physician Service

In its CY2018 Physician Fee Schedule rulemaking process, CMS sought comment and suggestion on ways to expand access to telehealth services within the current statutory authority of Section 1834(m), which includes limitations related to geography, patient setting, and type of furnishing practitioner. The proposed rule recognizes that medical practice has evolved in ways that regularly utilize a variety of audio/visual technology, but that application of the limitations contained in Section 1834(m) would create barriers to payment in many circumstances. 

The proposed rule offers a partial resolution to this conflict through statutory interpretation. CMS begins by distinguishing between services that traditionally have been provided through face-to-face patient-physician encounters but now can be provided through the use of audio/visual technology, and those services that "are defined by and inherently involve the use of communication technology.” CMS interprets Section 1834(m) to apply only to the former, not the latter. Thus, CMS concludes, the limitations contained in Section 1834(m) do not constrain CMS’s rulemaking authority to provide reimbursement for services that inherently involve communication technology, just as CMS is authorized to do for other types of physician services. In addition to supporting reimbursement for the services identified in the proposed rule, CMS’s rationale may well support further expansion of reimbursement for other services that inherently involve communication technology.

Here are highlights of three types of services that CMS is proposing to cover as standard physician services beginning January 1, 2019:

1. The Virtual Check-In

The Service: “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.” 

Proposed HCPCS Code: GVC11, Brief Communication Technology-Based Service

Key Elements of Service:

• Services are limited to five to 10 minutes of evaluation and management (E/M).
• Services must be provided to an established patient.
• Services may not originate from a related E/M service provided within the previous seven days. Such services should be bundled with the prior service.
• Services may not relate to an E/M service or procedure to be provided within the next 24 hours or at the soonest available appointment. Such services should be bundled with the future service.

Pricing: CMS intends to price this service at a lower rate than existing E/M in-person visits “to reflect the low work time and intensity and to account for the resource costs and efficiencies associated with the use of communication technology.”

Requested Comments: CMS is seeking comments on a number of issues related to this proposed change, including the types of technology involved in providing the services, whether audio-only interactions are sufficient, whether there should be limits for the number of times this code can be used with a single patient, and the appropriateness of time limits.

2. Photo and Video Evaluations

The Service: “[T]he remote professional evaluation of patient-transmitted information conducted via pre-recorded . . . video or image technology.”

Proposed HCPCS Code: GRAS1, Remote Evaluation of Pre-Recorded Patient Information

Key Elements of Service:

• Services are distinct from “The Virtual Check-in,” which occurs in real time and does not involve the transmission of recorded images.
• Services are subject to the same bundling rules applicable to “The Virtual Check-in.” They must be bundled when related to an E/M service provided within the previous seven days or to be provided within the next 24 hours or at the soonest available appointment.
• Evaluation that results in an in-person E/M office visit with the same physician or qualified healthcare professional should be bundled with the resulting visit and not separately billed.

Requested Comments: CMS is seeking comments on the whether this service should be limited to established patients, and whether there are practice areas in which this service would be appropriate for new patients.

3. Interprofessional Consultations

The Service: CMS will separately reimburse for certain existing CPT codes related to physician consultation with other physicians by phone, internet, or other electronic communication. These codes were formerly bundled with other services. CMS will establish two new CPT codes for this purpose as well.

CPT Codes:

• The following existing CPT codes are affected by the change: 99446, 99447, 99448, and 99449. All of these codes are for 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 Health Care Professional. Each code reflects a different period of consulting time (e.g., five to 10 minutes of medical consultative discussion and review, etc.).
• The following new CPT codes will be established: 994X0 and 994X6.

• Code 994X0 is Interprofessional Telephone/Internet/Electronic Health Record Referral Service(s) Provided by a Treating/Requesting Physician or Qualified Health Care Professional, 30 Minutes.

• Code 994X6 is 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 Health Care Professional, 5 or More Minutes of Medical Consultative Time.

Rationale: By bundling the resource costs for these services instead of providing separate payment, input from consulting physicians that could be obtained through a phone or email interaction often occurs through a separate appointment. Providing separate payment is an effort by CMS to match regulations to medical practice trends in patient care.

Requested Comments: CMS is seeking comments on how these services can be distinguished from activities that primarily benefit the practitioner (e.g., information shared simply for professional courtesy), how to ensure that services billed under these codes are reasonable and necessary, and whether CMS should require treating practitioners to obtain verbal consent from beneficiaries in advance to be sure that the patient is aware of the additional expense.

Coverage of New “Telehealth Services”

1. Prolonged Preventative Service Visits

CMS is proposing to add HCPCS codes G0513 and G0514 to cover prolonged preventative service visits that require direct patient contact beyond the typical service time of the primary procedure.  Code G0513 covers the first 30 minutes of the prolonged period, and Code G0514 covers each additional 30 minutes.

2. Clinical Assessments for End-Stage Renal Disease Patients

CMS is proposing to reimburse providers for telehealth services provided to end-stage renal disease patients receiving home dialysis. CMS will cover monthly clinical assessments delivered via telehealth, provided patients receive a face-to-face visit once a month for the first initial three months of home dialysis and at least once every three consecutive months afterward. For this specific service, the proposal includes (1) adding renal dialysis facilities and an individual’s home as telehealth originating sites, and (2) removing the telehealth geographic requirements.

In sum, these proposals are a notable step by CMS to keep up with trends, and overall, a welcome change for providers using technology to meet patient needs.

CMS is accepting comments on the proposed rule until September 10, 2018.