On November 15, 2017, the Centers for Medicare & Medicaid Services (“CMS”) issued its Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program Final Rule (the “Final Rule”), which among other things, adds additional codes to the Medicare list of covered telehealth services, makes remote patient monitoring separately payable (through Medicare), and eliminates utilization of the GT modifier on Medicare telehealth claims. Historically, Medicare has paid for a limited number of telehealth services, and the Final Rule implements a welcomed expansion to the list of reimbursable telehealth services as telehealth services continue to expand across the country. The Final Rule became effective on January 1, 2018.
By way of background, Medicare pays for telehealth services if the following are satisfied:
- The service is listed on the approved list of covered Medicare telehealth services;
- The service is provided via the use of an interactive telecommunications system (e.g., audio and video equipment permitting two-way, real-time interactive communication between the patient at the originating site and the practitioner at the distant site site);
- The service is provided by a physician or other authorized practitioner;
- The service is provided to an eligible telehealth individual (e.g., an individual whom is enrolled in Medicare Part B); and
The individual receiving the service must be located in a telehealth originating site (an originating site means the location at which the eligible Medicare beneficiary is located at the time the service is furnished via a telecommunications system (which must be: i) located in a county outside of a Metropolitan Statistical Area (“MSA”); ii) an area designated as a rural Health Professional Shortage Area (“HPSA”) in a rural census tract; or iii) through an entity participating in a federal telemedicine demonstration project that has been approved by (or receives funding from) the by the Secretary of Health and Human Services (the “Secretary”).
Provided that the forgoing requirements are satisfied, Medicare pays a facility fee to the originating site (where the patient is located) and makes a separate payment to the distant site practitioner whom provided the service.
CMS’ Process to Review Proposed Changes:
Section 1834 of the Social Security Act (the “Act”) requires the Secretary to establish a process by which, on an annual basis, telehealth services can be added or deleted. Although Medicare adds services upon its own initiative from time to time, the Calendar Year 2003 Physician Fee Schedule memorialized the process by which telehealth services can be added or deleted from the list of approved Medicare telehealth services and the public has an opportunity to submit requests for adding services throughout the year in connection with such process. Upon receipt of requests to add telehealth services from industry stakeholders, CMS assigns requests to the following two (2) categories for consideration:
- Category 1: Services that are similar to services that are currently on the Medicare list of telehealth services. Upon receipt of requests to add services that are similar to those that are on the current list of approved telehealth services, CMS identifies similarities between the suggested services and current telehealth services for the interactions among the parties to the telehealth encounter, as well as the telecommunications system that will be utilized to perform the service.
- Category 2: Services that are dissimilar to telehealth services that are currently on the Medicare list of telehealth services. Upon receipt of requests to add services that are dissimilar to those that are on the current list of approved telehealth services, CMS analyzes whether the code accurately describes the proposed service and CMS also considers whether the telecommunications system will provide a clinical benefit to the patient. CMS notes that submissions should demonstrate clinical studies on how the proposed telehealth service will improve the diagnosis or treatment of an injury or illness (or functioning of a malformed body part) and any supporting peer review publications that are applicable to the proposed service. In analyzing whether the service provides a clinical benefit, CMS may consider how medical conditions can be diagnosed without in-person diagnostic services, how the patient population will receive treatment without in-person treatment options, how complications can be mitigated, how recovery periods will be reduced, how future physician and hospital visits will be reduced, etc.
New Codes for CY 2018:
For Calendar Year 2018, CMS added several codes to the approved list of telehealth services on a Category 1 basis (based on submissions from industry stakeholders):
- HCPCS Code G0296 (Lung cancer counseling visit to discuss lung cancer screening using low dose CT scan). CMS determined that this proposed (and now accepted) service can be furnished via telehealth as the code was similar to office visits on the approved list of telehealth services and the core elements of the service (such evaluating the patient’s risk for lung cancer, shared decision making, and counseling regarding the risk and benefit of low dose CT scans) can be provided through interactive telecommunications systems.
- CPT Codes 90839 and 90840 (Psychotherapy for Crisis; first 60 minutes) and (Psychotherapy for Crisis; each additional 30 minutes). CMS determined that these codes aligned with the psychotherapy services that were on the previous telehealth list although the new codes relate to more urgent care and psychotherapeutic interventions. In order for such codes to be reimbursable, the distant site practitioner must be able to “mobilize resources [(i.e., communicate with staff)] at the originating site to defuse the crisis and restore safety.”
CMS also added the following four (4) add-on codes that are only considered telehealth services when they are billed as add-ons with other existing and approved telehealth services:
- CPT Code 90785 (Interactive Complexity).
- CPT Codes 96160 and 96161 (Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument) and (Administration of caregiver-focused health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument).
- HCPCS Code G0506 (comprehensive assessment of and care planning for patients requiring chronic care management services).
- For CPT Codes 96160 and 96161 and HCPCS Code G0506, CMS notes that these codes are not always provided in person with a physician or billing practitioner. These services are only deemed Medicare telehealth services when they are billed with a base code that is also on the approved Medicare telehealth list (i.e., the foregoing codes would not be considered approved Medicare telehealth services when billed with other services that are not on the approved Medicare telehealth list). For administrative efficiencies, CMS added these codes as they could be reported with a base visit code (for services provided via telehealth) and place of service identifier.
New Separate Payment for Remote Patient Monitoring:
In addition to the addition foregoing codes, CMS will now make a separate payment for remote patient monitoring—CPT Code 99091 (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 health care professional requiring a minimum of 30 minutes of time)—although remote patient monitoring is not generally considered Medicare telehealth services under Section 1834 of the Act as it involves interpretation of medical information without a direct practitioner/patient interaction. In connection with making CPT Code 99091 separately payable, and as patient-generated and submitted data is typically considered under the umbrella of chronic care management (“CCM”), CMS is requiring that practitioners secure advance beneficiary consent for the service (which must be documented in the patient’s medical record) and for new patients, or patients who the practitioner has not seen during the one (1) year prior to billing CPT Code 99091, the service must be initiated during a face-to-face visit with the billing practitioner (i.e., at an Annual Wellness Visit, Initial Preventive Physical Exam, or other face-to-face visit). In making CPT Code 99091 separately payable, CMS is limiting the reporting to no more than once in a thirty (30) day period and it can be billed once per patient during the same service period as CCM, transitional care management, and behavioral health integration. CMS recognizes that it may make additional CPT coding changes to more accurately describe remote patient monitoring in practice and streamline billing requirements.
Elimination of GT Modifier:
For CY 2018, practitioners will no longer be required to submit claims for telehealth professional services with the telehealth “GT” modifier. In the CY 2017 Physician Fee Schedule final rule (effective as of January 1, 2017), CMS required utilization of the Place of Service (“POS”) code, which: i) details the location at which the telehealth services were provided; ii) certifies that the professional services were provided via telehealth; and iii) that the telehealth requirements have been satisfied. Upon review of CMS’ payment policies, CMS identified that use of both the GT modifier and POS code was redundant. Thus, CMS removed the requirement that the distant site provider report the GT modifier on professional claims.
While the CY 2018 Final Rule demonstrates CMS’ incremental efforts to expand covered telehealth services, Medicare’s reimbursement of telehealth services is still limited in comparison to commercial payors. Although telehealth is a valuable means of providing patient care—as it enables patients in remote locations to receive healthcare that is typically available in urban areas—CMS has historically taken a careful approach to adding covered services over time. Additionally, as with other covered services, Medicare is also aware that some telehealth services are not appropriate for reimbursement (for various reasons, such as use of an inappropriate originating site, inappropriate telecommunications system, etc.), and thus, the U.S. Department of Health and Human Services, Office of Inspector General (“OIG”) has advised that it will conduct audits to confirm that claims (and services provided) are appropriate. In fact, in the current OIG Work Plan, the OIG specifically advised that it, “will review Medicare claims paid for telehealth services provided at distant sites that do not have corresponding claims from originating sites to determine whether those services met Medicare requirements.” Thus, it is important for providers to properly structure telehealth arrangements, ensure that services are provided in a compliant manner, and address overall compliance considerations prior to entering into a telehealth arrangement or performing telehealth services.
This bulletin is for general informational purposes only, and does not constitute legal advice.