Medicare Compliance & Reimbursement

New federal rules put telemedicine front and center.

As technology takes healthcare in directions never thought possible, the feds want to harness new products and options to streamline everyday medical processes. Looking to the future, recent CMS proposals and final rules expand telehealth and virtual care to deliver more efficient care nationwide in 2019 and beyond.

Read on to find out new, updated, and proposed virtual care options slated for use or finalization in 2019.

CMS Finalizes Virtual Care Options

CMS released its Medicare Physician Fee Schedule (MPFS) final rule for CY 2019 on Nov. 1 with several technology-centered code choices. The final rule is scheduled for publication on Nov. 23 in the Federal Register.

Back in July, CMS proposed two HCPCS codes — GVCI1 and GRAS1 — for virtual check-ins and remote evaluation of patient videos and images. According to the agency, these proposals were “placeholders” for the end codes, which will pay separately and use “communication technology” for physicians’ services.

Here is an overview of the two finalized HCPCS code choices:

• G2012 (Brief communication technology-based service, e.g. virtual check-in...). This code was originally referred to as “GVCI1” in the CY 2019 MPFS proposed rule.
• G2010 (Remote evaluation of recorded video and/or images submitted by an established patient...). This code was originally referred to as “GRAS1” in the CY 2019 MPFS proposed rule.

Important: These virtual service codes aim to assist physicians in determining “whether or not an office visit or other service is warranted,” indicates CMS in the final rule. Though they bolster more efficient care, these non-face-to-face codes come with a laundry list of documentation rules (i.e. patient must be established, service cannot lead to an E/M visit, and so on) that show medical necessity and are meant to curb “overutilization,” warns the agency. It plans on “monitoring” providers’ usage closely, CMS notes in the MPFS guidance.

Interprofessional Services Get Revisions, New Codes

You’ll have some changes to interprofessional telephone/Internet services in the new year that were recently finalized in the CY 2019 MPFS as well.

Revisions: The revisions focus mainly on the inclusion of “electronic health record” into the descriptor. Moreover, according to the final rule, these previously bundled codes will now be paid separately, too. The CPT^® codes are as follows:

• 99446 — Interprofessional telephone/Internet/electronic health record 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; 5-10 minutes of medical consultative discussion and review
• 99447 — … 11-20 minutes of medical consultative discussion and review
• 99448 — … 21-30 minutes of medical consultative discussion and review
• 99449 — … 31 minutes or more of medical consultative discussion and review.

New codes: Meanwhile, you can add the following two codes to your CPT^® checklist that primarily focus on a written report and referral service:

• 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, 5 minutes or more of medical consultative time
• 99452 — Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or other qualified healthcare professional, 30 minutes.

“It remains to be seen if payers will reimburse for these services, as generally a face-to-face encounter is usually required; however, some specialties might in fact benefit,” says Melanie Witt, RN, MA, an independent ob-gyn coding consultant in Guadalupita, New Mexico. However, “if the payer currently does not reimburse for interprofessional services, it is probably an indication that they will also not pay for these two new services,” she adds.

Caution: The finalized policy will “require the patient’s verbal consent,” which must be “noted in the medical record for each interprofessional consultation service” code, CMS says. “Cost sharing will apply for these services,” too, and the codes are only an option for providers who “can bill Medicare independently for E/M services,” the final rule advises.

BBA 2018 Telehealth Requirements Fulfilled

Effective Jan. 1, 2019, the Bipartisan Budget Act of 2018 (BBA 2018) mandated CMS expand telehealth services for beneficiaries with end-stage renal disease (ESRD) receiving home dialysis and for beneficiaries with acute stroke, reminds the CMS fact sheet on the CY 2019 fee schedule final rule. The agency obliged and added these two HCPCS codes to the telehealth services list:

• G0513 — 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; first 30 minutes ...
• G0514 — 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; each additional 30 minutes ....

Reminder: “You can only use these codes in the office or other outpatient setting,” explains Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians. “G0513 is added to the preventive service, and G0514 is added to G0513.” Moore goes on to add, “CMS will only permit you to bill these services with Medicare-covered preventive services.”

Opioid Treatment Comes Under Telehealth Umbrella

Last month, Congress passed the “Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act,” or “SUPPORT Act” for short. President Trump signed the bill on Oct. 24, which was the culmination of years-long bipartisan efforts aimed at combating the opioid abuse crisis.

“The Act attempts to tackle the epidemic from multiple angles, including via telehealth and telemedicine,” stress attorneys Margaret L. Power, MPH, CHES and Daniel S. Zinsmaster of regional law firm Dinsmore & Shohl, LLP in legal analysis of the legislation. “The Act expands access to treatment by eliminating geographic restrictions on reimbursement and directing the attorney general to promulgate rules regarding a special telehealth registration.”

Review the SUPPORT Act at www.congress.gov/bill/115th-congress/house-bill/6/text.

Medicare Advantage Gets a Telehealth Booster

With a nod toward more flexibility, CMS proposed to expand telehealth options in a Medicare Advantage (MA) proposed rule, published in the Federal Register on Nov. 1, 2018.

Admitting that MA plans need a technological makeover, the “proposed changes are a major step towards expanding access to telehealth services” since the rule hopes to remove roadblocks evident under current MA plans, allows a CMS fact sheet on the subject. The proposals offer more flexibility and funding for MA providers to better serve their beneficiaries no matter the location, and also cover “clinically-necessary telehealth benefits not otherwise available to Medicare beneficiaries,” the guidance suggests.

“Proposed changes would give Medicare Advantage plans more flexibility to innovate in response to patients’ needs,” said CMS Administrator Seema Verma in a release on the telehealth proposals. “I am especially excited about proposed changes to allow additional telehealth benefits, which will promote access to care in a more convenient and cost-effective manner for patients.”

Resources: Read the 2,378-page MPFS CY 2019 final rule at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24170.pdf.

Review the Medicare Advantage proposed rule at www.federalregister.gov/documents/2018/11/01/2018-23599/medicare-and-medicaid-programs-policy-and-technical-changes-to-the-medicare-advantage-medicare.