Tech & Innovation in Healthcare

“Whole-person care means moving towards a health-care system that recognizes each unique aspect of a person and their wellbeing, including physical health, behavioral health, oral health, social determinants of health, and caregiving supports, and it all starts first with a foundation of primary care that can integrate these components,” said Meena Seshamani, MD, PhD, Deputy CMS Administrator and Director of the Center for Medicare. “We are taking lessons learned from numerous CMS Innovation Center models to strengthen primary care teams and accountable care organizations, allowing them to better meet the unique needs of every person with Medicare.”

Here’s an overview of what might be coming our way in 2025.

Could Digital Mental Health Treatment Devices Receive Reimbursement?

CMS is proposing payment for healthcare providers who use digital mental health treatment (DMHT) devices as part of established behavioral health treatment. “This new pathway is a major step in the right direction for reimbursement of digital therapeutics interventions more broadly,” writes Carrie Nixon, Esq, co-founder and managing partner of Nixon Gwilt Law, in online analysis.

The agency proposes reimbursement tied to following new G codes:

• GMBT1 (Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan)
• GMBT2 (First 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment (DMHT) device that augments a behavioral therapy plan, physician/other qualified health care professional time reviewing data generated from the DMHT device from patient observations and patient specific inputs in a calendar month and requiring at least one interactive communication with the patient/caregiver during the calendar month)
• GMBT3 (Each additional 20 minutes …)

The codes listed above are crosswalked to 98980 (Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; first 20 minutes) and +98981 (… each additional 20 minutes (List separately in addition to code for primary procedure)).

CMS proposes that the healthcare providers that could order and bill GMBT1-GMBT3 are those “who are authorized to furnish services for the diagnosis and treatment of mental illness.” Patients can use a DMHT device at home or in a medical office or outpatient setting as long as the device has received FDA clearance for use under 21 CFR 882.5801 (describing computerized behavioral therapy device for psychiatric disorders).

Currently, several restrictions exist for FDA-cleared DMHT devices, and in the proposed rule, FDA clearance under 21 CFR 882.5801 only applies substance abuse disorder, insomnia, and depression.

“Even a clinically safe and effective [digital therapeutics] product developed for mental health treatment would not qualify for reimbursement under the DMHT device supply code unless it had gone down the FDA clearance pathway. Such a restriction could pose a significant barrier to adoption, effectively excluding various devices and behavioral health conditions from reimbursement under the new DMHT codes,” Nixon writes.

Will G0511 Receive the Axe After 1 Year?

In 2025, CMS is proposing to eliminate G0511 (Rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month) and instead let Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs) bill with existing care management CPT® and HCPCS Level II codes. These codes could include proposed Advanced Primary Care Management (APCM) codes, if the MPFS is finalized.

The 2024 MPFS finalized adding remote physiologic monitoring (RPM) and remote therapeutic monitoring (RTM) services billed by RHCs and FQHCs with G0511 to the care management services list. During this calendar year, RHCs and FQHCs can submit G0511 to report several care management services, including RPM, RTM, chronic care management (CCM), and principle care management (PCM). However, billing G0511 multiple times in a calendar month for different services caused confusion among stakeholders.

Even though the proposal of having RHCs and FQHCs billing care management CPT^® codes could clarify which specific services were performed, providers could face reduced reimbursement since the combined rate under G0511 is higher than the individual services.

Understand Evolution of Telehealth Flexibilities

During the COVID-19 public health emergency (PHE), CMS produced some waivers that expanded access to telehealth services. Many of such flexibilities, which were extended temporarily, are set to expire at the end of 2024. CMS is proposing to continue to permit some practitioners to virtually supervise auxiliary personnel. CMS is also proposing that practitioners will be able to use their enrolled practice location instead of their home address when providing telehealth services from their home.

However, CMS warns that the statutory restrictions on geography, site of service, and practitioner type in place before the COVID-19 PHE will go back into effect Jan. 1, 2025, unless Congress acts. The agency says they’ll be requesting information to consider whether and how to expand services under the primary care exception umbrella in future rules.

Beware Grim Realities

If this rule is finalized, it will mark the fifth consecutive year that CMS has reduced its payments. Meanwhile, predictions about the Medicare Economic Index (MEI), which is a measure of practice cost inflation, show it may increase by 3.6 percent, further widening the gap between the cost of delivering care versus what Medicare pays for that care.

“Physician practices cannot continue to absorb rising costs while their payment rates dwindle. The Medicare Physician Payment Advisory Commission (MedPAC) and the Medicare Trustees have issued warnings about the dangers of repeated Medicare cuts and how they threaten access to care. As one of the only Medicare providers without an inflationary payment update, physicians have waited patiently for this change. Medicare physician payment declined 29 percent from 2001 to 2024, adjusted for inflation,” says Bruce A. Scott, MD, president of the American Medical Association (AMA), in a release about the proposed rule.

You can read the entire proposed rule and submit public comment through September 9.

Rachel Dorrell, MA, MS, CPC-A, CPPM