Nov 7, 2018
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Digital Health Updates in the 2019 Physician Fee Schedule (PFS) Rule

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CMS has finalized the adoption of multiple CPT codes in the CY 2019 PFS that create more opportunities for providers and digital health companies to collaborate on chronic care management business models in the fee-for-service market.

Virtual Check-Ins

CMS finalized the creation of a new code to reimburse providers for brief “check-in” services conducted using communications technology by creating HCPCS code G2012, defined as “[b]rief communication technology-based service, e.g. virtual check-in.”

  • Who can bill? Services must be conducted by a physician or other qualified health care professional who can independently report evaluation and management (E/M) services. CMS states its recognition of the important role that others on the care team, such as nurses and other clinical staff, but suggests that any non-face-to-face time spent coordinating care is more appropriately billed under other care management codes (for example, such time may be more appropriate under Chronic Care Management (CCM)).
  • Timeframe: The service cannot originate from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or “soonest available appointment.”
  • Technology: Both “audio-only, real-time telephone interactions” and “synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission” are included services under this code, as long as they involve direct interaction between the patient and the provider. CMS did not address whether automated technologies, such as AI-powered messaging or chatbots, were included in the definition.
  • Established patients only: Services must only be provided to an established patient. The CPT defines established patients as those who have “received professional services from a physician or qualified health care professional or another physician or qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.”
  • Consent: CMS requires verbal patient consent, noted in the medical record, for each billed service.
  • Co-Pay: CMS reiterates that beneficiaries must participate in cost-sharing for this service (despite multiple commenters suggesting that this may not make sense for the virtual check-in workflow) citing statutory restrictions on waiving cost sharing.
  • Medical discussion: A required part of this service is 5-10 minutes of medical discussion. While CMS did not elaborate on this requirement, we interpret this language to mean 5-10 minutes of discussion between the provider and the patient.

CMS chose not to impose limitations as to how many times a provider could bill for these services, but promises to monitor utilization of G2012 to determine whether such a limitation should be required in the future.

Remote Evaluation of Pre-Recorded Patient Information

CMS also finalized new HCPCS code G2010, defined as “[r]emote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward).”

  • CMS chose not to impose limitations as to how many times a provider could bill for these services, but promises to monitor utilization of G2012 to determine whether such a limitation should be required in the future.
  • Service description: The provider delivers an interpretation of the patient-submitted video or image, and follows up with the patient within 24 business hours.
  • Timeframe: The service cannot originate from a related E/M service provided within the previous 7 days nor lead to an E/M service or procedure within the next 24 hours or soonest available appointment.
  • Technology: The required follow-up between provider and patient can take place via phone call, audio/video communication, secure text messaging, email, or patient portal communication – it does not need to be verbal. However, CMS specifically notes that compliance with HIPAA and all relevant laws is necessary. If the quality of the submitted video or image is insufficient for the provider to make an interpretation, billing for this code would be inappropriate and CMS would urge the provider to obtain a higher-quality transmission or suggest other appropriate alternatives.
  • Established patients only: Similar to its rationale with virtual check-in, CMS states that since this service should be within an existing patient-clinician relationship.
  • Consent: Beneficiary consent that could be verbal or written, including electronic confirmation that is noted in the medical record for each billed service for HCPCS code G2010.
  • Co-Pay: Beneficiary cost-sharing also applies to services billed under this code.

Interprofessional Internet Consultations

CMS has also finalized the establishment of separate payment for the following six CPT codes for interprofessional consultation services – where a treating physician or other qualified healthcare professional requests the opinion and/or treatment advice of a consulting physician or qualified healthcare professional who has “specific specialty expertise to assist with the diagnosis and/or management of the patient’s problem:” 99451, 99452, 99446, 99447, 99448, and 99449. CPT codes 99446, 99447, 99448, and 99449 were previously treated as bundled with other reimbursable services, so their separate payment, combined with the establishment of two new codes, is a significant shift from prior CMS policy.

  • Who can bill? Each of the CPT codes specifies whether the treating provider or the consulting provider can bill. We note that for CPT codes 99451 and 99452 is that both the patient’s treating physician and the consulting physician can bill for equal RVUs associated with the service (0.5).
  • Service description: The six codes describe “assessment and management services conducted through telephone, internet, or electronic health record consultations,” without the patient being present. CMS believes that they will be primarily used for the ongoing evaluation and management of the patient, including collaborative medical decision making among practitioners, but will monitor utilization for program integrity purposes.
  • Timeframe: CMS imposes no timeframe restrictions.
  • Technology: All six codes allow for the services to be furnished via telephone or internet, but CPT codes 99446-99449 require the consulting physician or other qualified health professional to provide a verbal and written report to the treating provider or qualified health professional to claim reimbursement. CPT codes 99451 and 99452 provide that the consultation can be done via the EHR, but CPT code 99452 requires the consulting physician to provide a written report to the physician as well.
  • Consent: A beneficiary’s verbal consent is required to be documented within the medical record for each interprofessional consultation service consistent with the policy for HCPCS G2012 above, but commenters noted that it might be difficult to obtain consent in critical care or emergency settings.
  • Co-Pay: Even though commenters recommended that CMS waive beneficiary cost-sharing for this code to obviate the need for consent to proceed with these services, CMS determined that it did not have the authority to do so.  For several years, industry stakeholders have been working to develop new, updated codes to describe remote patient monitoring activities and enable health care providers to get reimbursed for the time spent setting up and interacting with remote monitoring data analytics – also sometimes referred to as “patient generated health data.” As a result of these efforts, CMS has finalized its reimbursement for a set of three new CPT codes:

Remote Patient Monitoring

For several years, industry stakeholders have been working to develop new, updated codes to describe remote patient monitoring activities and enable health care providers to get reimbursed for the time spent setting up and interacting with remote monitoring data analytics – also sometimes referred to as “patient generated health data.” As a result of these efforts, CMS has finalized its reimbursement for a set of three new CPT codes:

  • 99453 – Remote monitoring of physiologic parameter(s): Initial set-up time, including patient education on use of equipment. This is a practice expense only code.
  • 99454 – Remote monitoring of physiologic parameter(s): Initial device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. This is a practice expense only code.
  • 99457 – Remote physiologic monitoring treatment management services: 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.

Devices used to collect this physiologic data must be medical devices as defined by the FDA. Beneficiary co-pays are required for remote monitoring services.

  • Who can bill? Multiple commenters urged CMS to allow other clinical staff, such as care navigators or case managers, to bill for their time “incident to” a billing practitioner’s services. Nevertheless, CMS states that CPT code 99457 “describes professional time and therefore cannot be furnished by auxiliary personnel incident to a practitioner’s professional services.” Billing practitioners must be authorized to bill Medicare for their services. The Medicare Claims Processing Manual contains more details on who can bill for E/M services under Medicare, including certain non-physician professionals such as nurse practitioners, certified nurse midwives, and physician assistants.
  • Technology: Commenters asked for specific examples of technology that could be included, such as smart phones, FitBits, or AI messaging. While the agency did not opine on which types of technologies were in or out at this time, CMS plans to issue future guidance to inform practitioners and stakeholders on these issues.

CMS has determined that these above services are inherently not delivered “face-to-face” and thus, are not subject to the statutory restrictions applicable to “Medicare telehealth services” under section 1834(m) of the Social Security Act. The new codes demonstrate that CMS recognizes the need to provide separate reimbursement for medical care delivery beyond traditional in-person visits between patients and providers to promote true care coordination.



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