Medicare Compliance & Reimbursement

Keep an eye out for 8 new CPT^® codes to get deserved telehealth reimbursement.

If you’re one of the many healthcare providers who’ve been wishing for more Medicare coverage for services you deliver via telehealth, the Centers for Medicare & Medicaid Services (CMS) has heard your pleas loud and clear. You’ll soon earn Medicare pay for providing three additional types of services.

Good News: Get Paid for 3 Types of Services

On July 7, CMS announced the publication of the calendar year (CY) 2017 Medicare Physician Fee Schedule (MPFS) proposed rule. The rule contains a variety of program and reimbursement changes, one of the most significant proposed provisions being an expansion of telehealth services.

CMS is proposing to add several codes to the list of eligible telehealth services, including:

• End-stage renal disease (ESRD) related services for dialysis;
• Advance care planning services; and
• Critical care consultations.

CMS proposed new Medicare G-codes for billing critical care consultations furnished via telehealth. Also, the proposed rule contains payment policies for using new place of service (POS) codes specifically designed to report services delivered via telehealth (see “Pay Attention to Future POS Code Changes for Telehealth” on page 123).

Telehealth Reimbursement Still Subject to Coverage Criteria

The expansion of telehealth services in the proposed rule is CMS’ response to outcry from various stakeholders, according to attorneys Marshall Jackson, Jr. and Dale Van Demark of McDermott, Will & Emery. Pursuant to Section 1834(m) of the Social Security Act, for Medicare to reimburse providers for telehealth services under the PFS, the service must be:

• a) On the list of Medicare telehealth services as a defined set of services, including consultations, office visits, pharmacological management, and individual and group diabetes self-management training services;
• b) Provided at an approved “originating site” (e.g., physician offices, hospitals, skilled nursing facilities);
• c) Provided by an approved provider (e.g., physicians, nurse practitioners, clinical psychologists); and
• d) Provided using certain telecommunications technologies.

“As telehealth has grown in popularity as a means of delivering healthcare to patients, CMS has recognized its value by continuing to add related services to the list of services eligible for Medicare reimbursement,” Jackson and Van Demark note.

Bad news: But despite adding the three sets of new services in the proposed rule, CMS considered but ultimately rejected a number of other services for Medicare reimbursement. These include:

• Observation codes;
• Emergency department services;
• Psychological testing;
• Physical therapy;
• Occupational therapy; and
• Speech-language pathology services.

Why? CMS decided not to propose telehealth coverage of observation, emergency department, and psychological testing services because it concluded that there is insufficient evidence showing that the use of telehealth produces similar diagnoses or therapeutic interventions as would face-to-face delivery of these services, Jackson and Van Demark explain.

“Additionally, CMS stated that because physical therapists, occupational therapists, and speech-language pathologists are not authorized practitioners of telehealth under Section 1834(m)(4)(E) of the Act, as defined in Section 1842(b)(18)(C), such services provided by these providers should not be added to the list of Medicare-reimbursable telehealth services,” Jackson and Van Demark state.

Get to Know 8 New CPT^® Codes

CMS proposed eight new Current Procedural Terminology (CPT) codes for Medicare Part B telehealth physician and practitioner services that, if finalized, would be effective for services beginning on Jan. 1, 2017, according to the American Telemedicine Association (ATA).

Physicians and practitioners would use the new temporary codes GTTT1 and GTTT2 to bill for critical care evaluation and management services delivered via telehealth, the ATA says. The proposed codes for ESRD services, which are comparable to already covered services, are as follows:

• 90967: 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;
• 90968: 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;
• 90969: 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; and
• 90970: 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.

CMS proposed two additional codes for advanced care planning including the explanation and discussion of advance directives:

99497: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; first 30 minutes, face-to-face with the patient, family member(s), or surrogate(s); and

99498: Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified healthcare professional; each additional 30 minutes (list separately in addition to code for primary procedure).

What’s more: “In addition, CMS proposes lessening CPT^® code 99490 requirements for the initiating visit, 24/7 access to care and continuity of care, format and sharing of the care plan and clinical summaries, beneficiary receipt of the care plan, beneficiary consent, and documentation,” the ATA states. “CMS believes the 99490 code is underutilized with 275,000 beneficiaries served [on] an average of three months in 2015.”

Bottom line: CMS’ expansion of reimbursable telehealth services in the proposed rule doesn’t necessarily represent a significant change from its historical policies regarding telehealth reimbursement, Jackson and Van Demark note. But the proposed rule, especially in conjunction with other recently proposed legislation, “shows CMS’ continued careful accommodation and encouragement of the use of telehealth technologies as a method of delivering healthcare services to patients,” they add.

Resources: You can view the CY 2017 Physician Fee Schedule proposed rule in the July 15 Federal Register at https://federalregister.gov/a/2016-16097. The rule is open to public comments until Sept. 6. For additional information on the proposed rule, go to www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/PFS-Federal-Regulation-Notices-Items/CMS-1654-P.html.