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Final Rule in 2018 Physician Fee Schedule Favors Telehealth

Posted by Michael Greiwe, MD | December 27, 2018 |
Michael Greiwe, MD

The final Medicare Physician Fee Schedule ruling for CY 2019 came out in November and it has some surprises in store for telehealth reimbursement. For telemedicine advocates like OrthoLive, it was a nice holiday gift that added to an exciting year of telehealth reimbursement breakthroughs.

While CMS shows no signs of backing off from loosening telehealth reimbursement restrictions in 2019, this latest round of changes to the Physician Fee Schedule is another positive sign that the technology is finally taking off into the mainstream of care delivery.

As we close out the year, let’s look at the latest round of CMS reimbursement changes scheduled to go into effect on January 1, 2019.

New Codes for Telehealth

The first exciting change loosened the restrictions requiring that the clinician must document medical necessity before conducting a virtual visit. In the case of established patients, the documentation should show what has changed since the last visit, and not recap medical necessity. Doctors will not have to reiterate the history already entered by ancillary staff for new patients, just indicate that they reviewed the data.

CMS also released some new codes tied to telehealth:

  • HCPCS G2012 covers using telehealth for a “brief communication” between a doctor or other healthcare professional with an established patient. This should not stem from an E/M service provided in the last seven days. It should also not lead to a related E/M service within 24-hours or the earliest available appointment following the virtual check-in. The code is perfect for those five to 10-minute check-ins with patients that may not typically be reimbursable. The code allows for audio-only real-time phone calls as well as synchronous telemedicine. Patient consent must be noted for each billed service.
  • HCPCS 62010 pays clinicians for the remote evaluation of recorded video or images from an established patient via store and forward or asynchronous telemedicine. The code allows for interpretation and follow-up with the patient within 24-business hours. Again, it should not originate from a related E/M service provided within the prior seven days or lead to an E/M procedure within 24-hours or the soonest available appointment. The code defines the patient follow-up visit as taking place via a phone call, video or audio communication, secure text messaging or email, or communication via a patient portal. Patient consent is required to be noted in the history for each billed service.

It should be noted that these final rule changes are in addition to a number of big improvements to telehealth reimbursement that came over the summer.


But Wait, There’s More – Telehealth Payments Improving

CMS already added a number of new reimbursement codes for remote patient monitoring, a type of telehealth service. We reported this exciting news in June, in the OrthoLive blog. The new codes focused primarily on long-term remote care management of chronic diseases, including:

  • HCPCS G0296 covers a telehealth counseling session to discuss the need for lung cancer screening with low dose tomography.
  • HCPCS GO506 reimburses for a virtual visit to discuss a care treatment plan for patients needing chronic disease management.
  • CPT 90785 is a payment under the concept of “interactive complexity” resulting from communication difficulties during psychiatric treatment.
  • CPT 90839 AND 90840 allows reimbursement for crisis psychotherapy while using telehealth technology.
  • CPT 96160 and 96161 reimburses for virtual health risk assessments.
  • CPT 99091 is unbundled so providers can receive reimbursement separately for remote patient monitoring. Key to this change was that RPM is not subject to the same barriers that stymie general telehealth; under this code, the geography is not limited to medically underserved areas or originating site restrictions. This code allowed remote patient monitoring from anywhere the patient is – a truly groundbreaking rule change this year!

To see the current list of CMS reimbursement codes correlated to telehealth, click here.

2019 Telehealth Reimbursement Predictions

The National Law Review concisely defines how CMS looks at telehealth:

Under Medicare, the term “telehealth services” refers to a specific set of services practitioners normally furnish in-person, but for which CMS will make payment “when they are instead furnished using interactive, real-time telecommunication technology.”

They point out that the Social Security Act of 1935 is the real governing legal document behind what telehealth services are covered under Medicare. The general requirements and restrictions as defined in the law include:

  • The patient must be located in a qualified rural area.
  • The patient must be located at one of eight different qualifying originating sites.
  • The services should be provided by one of ten distant site practitioners that qualify for Medicare telehealth reimbursement.
  • The patient and distant site practitioner communicate via an interactive real-time two-way video and audio telehealth tool.
  • The service can only be reimbursed if it falls under a reimbursable CPT/HCPCs code.

When we discuss the current barriers to telehealth, we typically cite the requirement for the service to occur in a rural area and originating site. The best news for 2018 was that there are signs these antiquated rules are shifting. With the final Medicare fee schedule changes now on the books, we can predict that 2019 will continue to chip away at some of the barriers to reimbursement when using telehealth technology.

Other organizations and healthcare executives mirror this optimism for the future of telemedicine. An athenahealth blog recently stated:

The proposed CMS changes for telehealth are a start. The broader umbrella of “Communication Technology” will allow healthcare organizations to think beyond just virtual visits to include mobile check-ins and push notifications, remote monitoring, preventive services, records reviews, and more – beginning the shift from telehealth to a true virtual care model.

We predict that telehealth reimbursement restrictions will continue to loosen as the service paradigm shifts from simple treatments to more proactive and preventative care to help manage chronic diseases. The locum tenens model will couple with telehealth to increase access to treatment while easing the burdens felt by a growing physician shortage. We also believe that companies will increasingly seek workers compensation models using telehealth services as a way to significantly cut costs and OSHA-reportable events while providing immediate care.

Will 2019 bring the launch of your own telehealth initiative? Talk to the OrthoLive team about how our service can help your practice stay competitive in the New Year.

Topics: "telehealth", "reimbursement", "telemedicine", technology, physician

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