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Recognizing the potential for virtual care to expand access to healthcare for Medicare and Medicaid beneficiaries, the Centers for Medicare and Medicaid Services (CMS) is increasingly facilitating reimbursement of virtual services outside of traditional care settings. In recent weeks, CMS has significantly expanded reimbursement of virtual services, particularly for beneficiaries with chronic conditions and substance use disorders. With this expansion, CMS is seeking to modernize its programs in response to the increasing availability of technology in the healthcare space. As 2019 approaches, we will be watching a number of “telehealth” trends and related effects on industry stakeholders.

Separate Payment for Communication Technology-Based Services

Beginning on January 1, 2019, CMS will separately pay for virtual check-ins under new HCPCS code G2012. This will facilitate separate reimbursement for physicians’ and other qualified healthcare professionals’ virtual (i.e., non-face-to-face) communications with established patients other than in connection with an office visit. In a Final Rule dated November 23, 2018 (Final Rule), CMS clarifies that providers may receive separate reimbursement only for virtual communications with established patients who provide verbal consent for the communication, as noted in the patient’s record. Communications must be five to ten minutes in length and provided via telephone or video. If a communication is preceded by a related service within the previous seven days, or leads to a service or procedure within the next 24 hours, or soonest available appointment, the communication is not separately billable and will be bundled into the related office visit.1  

Also beginning on January 1, 2019, CMS will separately pay for a physician or qualified healthcare professional’s evaluation of recorded video or images submitted to the provider by an established patient. HCPCS code G2010 provides that such evaluation must include follow up with the patient within 24 hours and, like the virtual check-ins described above, must not be preceded by an office visit within the previous seven days or lead to a service or procedure within the next 24 hours, or soonest available appointment. Follow-up communications between a provider and a patient must occur via phone call, audio/video communication, secure text messaging, email, or patient portal communication. Patients must provide verbal or written consent for a provider’s evaluation of recorded video or images, as documented in the medical record.2

Finally, in recognition of the increasing management of patients’ chronic conditions through a team-based approach, CMS is finalizing separate payment for CPT codes 99451, 99452, 99446, 99447, 99448, and 99449 for peer-to-peer consults of various lengths in time, for the patient’s treating/requesting physician, or other qualified healthcare professional, as well as for the consulting physician. Consults may be conducted through telephone, internet, or electronic health record communications and, like virtual check-ins and evaluations of recorded video or images, must have the patient’s verbal consent, as documented in the medical record.3

In the Final Rule, CMS is careful to distinguish the communication technology-based services described above from the telehealth services set forth in Section 1834(m) of the Social Security Act (Act). Because CMS views virtual check-ins, evaluations of recorded video or images, and peer-to-peer consults as services that are not provided face-to-face, CMS does not consider such services to be telehealth services. Such services, therefore, are not included in CMS’s listing of telehealth services set forth in the Act and are not subject to related originating site or geographic requirements limiting the availability of related reimbursement to rural and healthcare professional shortage areas.4

Expanding List of Telehealth Services

Effective in calendar year 2019, CMS will add two new HCPCS codes – G0513 and G0514 – to the list of telehealth services set forth in the Act. These codes relate to prolonged preventive services in an office or other outpatient setting for an initial period of thirty minutes (G0513) and each additional period of thirty minutes (G0514). In adopting these new HCPCS codes, CMS reasoned that the related services were sufficiently similar to office visits currently on the list of telehealth services and could appropriately be furnished via interactive telecommunications technology. Separately, CMS is accepting comments for the list of telehealth services effective in calendar year 2020 until February 10, 2019.5

Telehealth for Substance Use Disorder Treatment

In the last quarter of 2018, CMS loosened restrictions on the use of telehealth services to treat substance abuse through several revisions to Section 1834(m) of the Act. The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act (SUPPORT Act), signed into law on October 24, 2018, adds the home of an individual as a permissible originating site for telehealth services furnished for substance use disorder treatment or treatment of co-occurring mental health disorders. In an Interim Final Rule dated November 23, 2018, CMS clarifies that providers will remain responsible for assessing whether an individual has a substance use disorder and whether it would be clinically appropriate to treat such disorder via telehealth services. This provision of the SUPPORT Act will become effective on July 1, 2019, subject to a 60-day comment period that closes on December 31, 2018.6

Telehealth for Home Dialysis and Stroke Care

CMS is also expanding telehealth services for beneficiaries with end-stage renal disease (ESRD) who receive home dialysis and beneficiaries who have experienced acute stroke. This expansion comes through CMS’s implementation of the requirements of the Bipartisan Budget Act of 2018 (BBA), via amendment of Section 1834(m) of the Act, and provides for the homes of ESRD patients and mobile stroke units as originating sites, effective January 1, 2019. CMS will not subject related services to originating site or geographic area requirements, even though such services will be considered telehealth services.7

Telehealth for Medicare Advantage Beneficiaries

In a Proposed Rule dated November 1, 2018 (Proposed Rule) that also responds to the BBA, CMS proposed allowing Medicare Advantage (MA) plans to expand telehealth benefits for MA beneficiaries beginning in plan year 2020. Under the Proposed Rule, MA plans would be permitted to offer additional telehealth benefits beyond what is currently allowable as part of their basic benefits packages. CMS anticipates that MA plans would offer beneficiaries telehealth services at home and allow supplemental benefits (not covered by original Medicare) via remote access or telemonitoring services, akin to the communication technology-based services described above. CMS anticipates that changes in MA funding under the Proposed Rule would generate $4.5 billion in savings over ten years and facilitate increased access to healthcare services. CMS is soliciting comments on this proposal until December 31, 2018.8

As we keep an eye on telehealth trends in 2019, we anticipate that patients, providers, payors, and other industry stakeholders will increasingly recognize the potential for telehealth and other virtual services to foster patient access and provider efficiency in the provision of healthcare. Providers who historically have been reluctant to offer virtual services may be comforted by CMS’s requirement that certain virtual services be provided to established patients only. Patients who typically rely on face-to-face communications with their providers may be encouraged to communicate with those same providers from the comfort of their own homes. As CMS rings in the new year with a more modern view of virtual services, we anticipate that industry stakeholders will embrace telehealth trends and opportunities for expanded coverage of related services.

  1. 83 Fed. Reg. 59269, 59483-86 (Nov. 23, 2018).
  2. Id. at 59486-89.
  3. Id. at 59489-91.
  4. Id. at 59483.
  5. Id. at 59492.
  6. Id. at 59496 – 98.
  7. Id. at 59494 – 96.
  8. 83 Fed. Reg. 54982, 54982-83 (Nov. 1, 2018).