CMS has proposed three new codes for RPM services, retitled “Chronic Care Remote Physiologic Monitoring,” which do a far better job reflecting how providers can more effectively and efficiently use RPM technology to monitor and manage patient care needs, including chronic care management.  If finalized, these three codes would go live January 1, 2019.

CMS’ explanation for its bold, new proposal: “We now recognize that advances in communication technology have changed patients’ and practitioners’ expectations regarding the quantity and quality of information that can be conveyed via communication technology. From the ubiquity of synchronous, audio/video applications to the increased use of patient-facing health portals, a broader range of services can be furnished by health care professionals via communication technology as compared to 20 years ago.”

Medicare’s Current Remote Patient Monitoring Code

Medicare already offers separate reimbursement for RPM services billed under CPT code 99091.  That service is defined as the “collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.”  It went live for the first time earlier this year (effective January, 2018).

Why the New Codes?

While industry advocates generally applauded CMS for activating RPM reimbursement, they simultaneously recognized CPT 99091 fails to optimally describe how RPM services are furnished using current technology and staffing models.  This failure may be due to the fact that CPT 99091 is 16 years old and had never before been a separately payable service.  (It is an older code CMS “unbundled” and designated as a separately-payable service.)  Indeed, the AMA’s CPT Editorial Panel developed and finalized a set of three new RPM codes in late 2017.  These codes (CPT 990X0, 990X1, and 994X9) are what CMS recently proposed activating effective in 2019.  The new codes do a far better job accurately reflecting contemporary RPM services.

What Are the New RPM Codes?

The new Chronic Care Remote Physiologic Monitoring codes are:

• CPT code 990X0: “Remote monitoring of physiologic parameter(s) (e.g, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.”
• CPT code 990X1: “Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.”
• CPT code 994X9: “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.”

The biggest takeaways from the proposed 2019 Medicare Physician Fee Schedule and Quality Payment Program with regard to remote patient monitoring (Chronic Care Remote Physiologic Monitoring):

The three biggest takeaways from the new RPM codes that differ from the current CPT 99091 are as follows:

1. Less treatment time required to qualify for reimbursement. CPT 99091 requires at least 30 minutes per 30-day period, whereas CPT 994X9 requires only 20 minutes per calendar month.  The new code is much easier to track on a monthly basis, and requires 33 percent less time.

2. Separate payment for initial set-up and patient education. CPT 99091 does not offer additional reimbursement for the time spent setting up the RPM equipment or educating the patient on its use.  The new codes offer separate reimbursement for the work associated with onboarding a new patient, setting up the RPM equipment and training the patient on same. This is a very helpful move to further incentivize providers to start using these technologies with their patients. In addition, this separate payment is different from how Medicare reimburses Durable Medical Equipment (DME) suppliers (e.g., CPAP, oxygen, etc.). CMS requires the DME supplier to set up the equipment at the patient’s home and educate the patient on how to use the equipment, but does not offer separate payment for that work.
3. Clinical staff allowed. CPT 99091 is limited only to “physicians and qualified health care professionals” and does not expressly allow the RPM service to be delivered by clinical staff (e.g., RNs, medical assistants, etc.). This means the physician or qualified health care professional must perform the full 30 minutes per 30-day period, which is a lot of time for these highly trained professionals. For some providers, this is too resource-intensive to justify the $58.68 per month reimbursement rate.  The new code allows RPM services to be performed by clinical staff.

The only manner in which a Medicare provider could potentially use clinical staff for CPT 99091 is by complying with all the requirements for “incident to” billing, which – among other things – requires that auxiliary personnel be under the direct supervision of the physician. Under Medicare rules, direct supervision means the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel is performing services.

Most RPM services are best provided via general supervision, which does not require the physician and auxiliary personnel to be in the same building at the same time, and the physician could instead exert general supervision via telemedicine. This is a huge difference in operations and business models, but in order for CMS to make these new RPM codes work in the real world, it is near-essential that CMS allow RPM to be delivered “incident to” under general supervision.

Chronic Care Remote Physiologic Monitoring is Not a Telehealth Service

Providers frustrated with the labyrinthine and narrow Medicare coverage of telehealth services can take comfort in the fact that RPM is not considered a Medicare telehealth service.  Instead, like a physician interpretation of an electrocardiogram or radiological image that has been transmitted electronically, RPM services involve the interpretation of medical information without a direct interaction between the practitioner and beneficiary.  As such, Medicare pays for RPM services under the same conditions as in-person physicians’ services with no additional requirements regarding permissible originating sites or use of the telehealth place of service (POS) 02 code.  This means Chronic Care Remote Physiologic Monitoring does not require the use of interactive audio-video, nor must the patient be located in a rural area or a qualified originating site.  Patients can even receive RPM services in their homes.

Healthcare providers should begin launching RPM programs:

Healthcare providers service Medicare patients should consult with companies, such as Dr. Miltie, to deliver RPM services to patients, similar to what we have seen with Chronic Care Management (CCM) companies. This is because the new codes expressly allow the use of “clinical staff” to help fulfill part of the 20 minutes per month. Current CMS guidance on CCM services expressly contemplates and allows third-party companies to contract with Medicare providers to help deliver CCM services. In order to further enable that, CMS created an exception allowing a Medicare provider to bill CCM services as “incident to” under general supervision. Normally, most services billed incident to must be provided under the direct supervision of the provider.

Healthcare providers should prepare for these new opportunities:

The first thing is to take the time to truly understand, with precision, the billing and supervision rules fundamental to a compliant RPM service model. Providers should not focus too much on the technology and business development until they are confident the model they are “selling” or delivering does, in fact, comply with Medicare billing requirements.

Second, providers should take time to develop a model business-to-business RPM contract with Dr. Miltie, whether this is technology-only, support services-only or a combination of both.

The post 2019 Medicare Physician Fee Schedule and Quality Payment Program – CMS Proposed Rule – CPT Codes 990X0, 990X1, and 994X9 – Everything You Need to Know appeared first on Dr. Miltie.

Monday, July 30, 2018

Where Things Stood

Understanding the impact of what we have seen so far this year first requires an understanding of where we were at the end of 2017, with respect to both Medicare reimbursement and provider adoption of telehealth solutions.

Hospitals and health systems have long understood that digital health technologies allow patients to be active participants in their health while also allowing health care providers to intervene before costs and complications escalate. At the close of 2017, direct-to-consumer telehealth companies had matured and were working closely with commercial payors to deliver telehealth services to plan beneficiaries. Reports on digital therapeutic tools, artificial intelligence applications and other digital health tools were in the media daily, and use cases continued to create evidence of both the efficacy and efficiency of digital health tools.

Under value-based reimbursement models, health care providers are penalized when patient care, particularly for chronic conditions, is not effectively managed. In order to manage the population now considered within their scope of care, and in anticipation of the rising care needs of the retiring baby boomer population, in 2017 providers were actively leveraging tools to help them succeed. In fact, a 2017 study reported that 73 percent of health care organizations use technology for monitoring and maintenance, with the most common use being patient monitoring at 64 percent.

Provider action tends to follow reimbursement dollars, however, and while Medicare has reimbursed for telehealth services for many years, the rules and restrictions associated with telehealth reimbursement have resulted in very limited utilization and actual Medicare reimbursement.

Prior to 2018, Medicare covered only real-time, audiovisual consultations with patients for a limited number of Medicare Part B services, and only when certain geographic, provider type and facility type criteria were met, with the exception of federal demonstration programs.  The biggest challenge was that reimbursement could only occur when the originating site (i.e., the patient’s location) was located either in a federal demonstration program, a rural Health Professional Shortage Area or a county outside of any Metropolitan Statistical Area, as defined by the Health Resources and Services Administration and the US Census Bureau.  This geographic restriction limited Medicare reimbursement to services provided to patients of health care facilities located in rural areas, and prevented reimbursement of services to patients outside of a medical facility (e.g., at home or at a workplace) or located in urban areas.  The restriction also undermined the broader implementation of telehealth programs because health systems could only develop programs for these specific use cases.

Indeed, the diversity of telehealth and digital health solutions continues to be one of the most difficult practical challenges associated with broad adoption. So while there is a patient care incentive to utilize digital health tools, there has been very little Medicare reimbursement incentive to provide services using digital health solutions—until now.

2018 and Beyond: A New Era?

In 2018 Medicare reimbursement has undergone massive expansion through a series of rules and laws, including a proposed rule promulgated in July 2018.

Unbundling of CPT Code 9901

CMS took a major step towards aligning patient care expectations with provider reimbursement in the revisions to the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program Final Rule (published on November 15, 2017) (Final Rule).  The Final Rule began taking effect January 1, 2018.

Of particular note, CMS unbundled CPT code 99091, which allows providers to bill for remote patient monitoring (RPM), fundamentally changing the scope of Medicare reimbursement for remote care. As the Connected Health Initiative stated, “[u]ntil now, connected health technologies have been effectively locked out of the most important part of America’s healthcare system, Medicare and Medicaid.” With this change, CMS not only provided an added incentive for providers to take advantage of digital health tools to benefit patients, but improved the business case for providers who have already invested in those tools to leverage them for patient care via RPM.

Prior to the adoption of the Final Rule, CMS rules prohibited billing certain remote care tasks for a patient during the same service period as many of the treatments that commonly use RPM services. Specifically, this category includes chronic care management (CCM) codes 99487, 99489 and 99490 (which include management of cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes and hypertension, among others); transitional care management (TCM) codes 99495 and 99469 (which include services for the time between a patient’s discharge from the hospital, rehab, nursing or similar facility and the patient’s return home or admission to an assisted living facility); and general behavioral health integration (BHI) code 99484.  Thus, if a provider used RPM for a patient with COPD receiving services billable under any of the above CCM codes, then the provider would receive no reimbursement for the RPM services. However, with the adoption of the Final Rule, RPM services that are billable under 99091 can be billed once during the same 30-day service period as any CCM,  TCM or BHI  codes discussed.

The Final Rule states that CPT code 99091 is for “collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.” Providers can use the code for time spent accessing data, reviewing or interpreting the data, and making any necessary modifications to the care plan that result, including communication with the patient and caregiver and any associated documentation.

CPT code 99091 is payable in both facility and non-facility settings, but there are other specific eligibility requirements. In addition to the requirement that the code be billed once per 30-day service period per patient, the provider must obtain advance beneficiary consent for the service and document the consent in the patient medical record. For new patients or patients who have not been seen by the billing provider within one year, the provider and patient must also have a face-to-face consultation. The unbundled code is applicable to physicians, physician assistants, nurse practitioners, certified nurse midwives, clinical nurse specialists and their teams. The services are ineligible if provided via subcontractor, however, which has discouraged collaborations between health care providers and RPM technology companies that desire to offer remote monitoring services. While providers can take advantage of digital health tools to support their RPM services, the analytic tasks must be provided by the clinical care team. Comments submitted to CMS expressed concern that the current code may not optimally describe the services furnished using current technology. However, CMS indicated that the unbundling of 99091 is an interim measure for reimbursement of RPM services while new, more specific RPM codes are developed. As CMS stated, “separate payment for this code will not mitigate the need for coding revisions.”

Other Notable 2018 Fee Schedule Final Rule Changes

In addition to unbundling code 99091, the Final Rule also expands allowable telehealth reimbursement and permits virtual sessions in certain circumstances under the Medicare Diabetes Prevention Program Expanded Model (MDPP), as we reported here.

New and add-on services

CMS evaluates requests for the addition of telehealth services on the basis of two categories: (1) services that are similar to services already on the list, and (2) services that are not similar to services already on the list. An evaluation of a category 2 service requires CMS to assess, based on the submission of evidence, whether the use of a telecommunications system to furnish the service “produces demonstrated clinical benefit to the patient.”

Upon review of several public requests, CMS determined that the following services met the category 1 requirement:

• Healthcare Common Procedure Coding System (HCPCS) code G0296 – counseling visit to discuss the need for lung cancer screening
• Current Procedural Technology (CPT) codes 90839 and 90840 – psychotherapy for crisis

Payment for these services is conditioned upon the distant site practitioner having the ability to mobilize originating site resources to diffuse a crisis and restore safety, when applicable.

The following four add-on (category 2) CPT and HCPCS codes were also added:

• CPT code 90785 – interactive complexity
• CPT codes 96160 and 96161 – administration of patient-focused health risk assessment instrument, and administration of caregiver-focused health risk assessment instrument
• HCPCS code G0506 – comprehensive assessment or/and care planning for patients requiring CCM services

In instances where CMS is unable to confirm whether all components of a service may be performed via telehealth, an explicit condition of payment may be added alongside the code to ensure that all CPT (or other) prefatory requirements are met.

Medicare diabetes prevention program virtual sessions

MDPP is a “structured behavior change intervention” designed to prevent type 2 diabetes among Medicare beneficiaries with an indication of prediabetes. MDPP consists of 16 sessions that integrate a Centers for Disease Control and Prevention-approved curriculum in an in-person, “group-based, classroom-style setting.” The curriculum provides practical training in dietary changes, increased physical activity and strategies to control weight. Under the Final Rule, MDPP beneficiaries may make up a limited number of sessions “virtually” at the request of the individual beneficiary. The virtual sessions may include furnishing behavioral change programs online (e.g., via a connected smart phone, tablet, computer, laptop); furnishing coaching programs online with other means of support by the coach (e.g., via telecommunications, video conferencing); or distance learning that does not require online connectivity (e.g., via phone). The sessions will be billed using a modifier for CMS’s tracking purposes. MDPP services that are exclusively furnished virtually or using remote technologies (without in-person attendance) will not be reimbursed.

2018 Quality Payment Program Final Rule

In tandem with the Final Rule, CMS released the 2018 Quality Payment Program Final Rule. Physicians and other eligible practitioners who participate in the Merit-Based Incentive Payment System must attest to their participation in two “High” weighted activities and four “Medium” weighted activities, or a combination, to obtain the maximum performance score. By changing the classification of the Improvement Activity Performance Category called “Engage Patients and Families to Guide Improvement in the System of Care” from Medium to High, CMS incentivized providers to use RPM technologies that provide real-time feedback to patients and their care team. The updates require providers to leverage platforms and devices using an active feedback loop to provide real-time, or near real-time, patient-generated health data to the care team or clinically endorsed feedback from the provider to patients.

In combination with the Fee Schedule changes, including changes to CPT code 99091, this change further demonstrates that CMS is getting behind digital health initiatives in a real way.

The Bipartisan Budget Act of 2018

The Bipartisan Budget Act of 2018 passed in February includes significant expansion of direct reimbursement for telehealth services by incorporating provisions of the CHRONIC Care Act, which had, in different forms, passed both houses of Congress in 2016. These provisions represent the first significant legal expansion of Medicare reimbursement of telehealth services since Medicare first started to reimburse telehealth services.

Expanded access to telehealth stroke services

Beginning in 2019, Medicare will reimburse telehealth consultations with neurologists with respect to patients presenting with stroke symptoms at hospitals or mobile stroke units. The provision eliminates the current geographic restriction that limits originating sites to rural areas. This allows distant site providers delivering telestroke services to receive a professional fee for delivering the consultation to patients located anywhere in the United States, provided that the other Medicare telehealth coverage requirements are satisfied (e.g., type of provider, type of technology).

Expanded telehealth services for chronically ill Medicare Advantage enrollees

Beginning in plan year 2020, Medicare Advantage (MA) plans can offer expanded telehealth services as a basic benefit to chronically ill enrollees. MA enrollees would have the option to receive these additional benefits through telehealth or in person. However, a plan that fails to provide in-person access to a certain type of physician specialist cannot meet network adequacy requirements by providing solely telehealth access to such providers. HHS is required to solicit public comment before November 30, 2018, with respect to the types of telehealth services that should be considered and the requirements for providing those services.

Expanded telehealth opportunities for Accountable Care Organizations (ACOS)

Beginning in 2020, certain ACOs will have an increased opportunity to provide Medicare reimbursable telehealth services with the removal various barriers. The changes allow a beneficiary’s home to qualify as an originating site, and eliminate the geographic component of the originating site requirement. Not surprisingly, the provision eliminates the originating site fee if the service is furnished in the patient’s home. This additional telehealth flexibility is available for Next Generation ACOs and for additional ACOs, including MSSP Track II (if the ACO remains at two-sided risk and chooses prospective assignment), MSSP Track III, and two-sided risk ACO models with prospective assignment tested or expanded through the Innovation Center.

The Secretary was asked to study the implementation of this provision and report to Congress before January 1, 2026 with an analysis of the utilization of and expenditures for telehealth services under this section and recommendations for any appropriate legislation and administrative action.

CMS Proposed Rule (Physician Fee Schedule) Released July 12, 2018

CMS’s Notice of Proposed Rulemaking, Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019 (Proposed Rule) would expand reimbursement for physicians and other qualified health care providers under a variety of specific circumstances. Comments on the Proposed Rule may be submitted until September 10, 2018.

Brief (5–10 minute) virtual visits by qualified providers with existing patients

The Proposed Rule would reimburse virtual care services between visits to determine whether a patient’s condition requires an office visit. Reimbursement for virtual visits would be billed using HCPCS code GVCI1 at a rate of $14 per visit, which is much lower than the cost of an E/M visit, and would be available only with respect to existing patients of the practitioner. This change could potentially result in cost savings to Medicare if it effectively reduces unnecessary office visits by allowing providers to use technology to communicate with their patients to assess their patients’ needs (in a rather common-sense way). Currently, CMS does not separately cover these types of check-ins between providers and patients, but dedicated providers across the country have offered this type of assistance regardless.

If the virtual care service originates from a related E/M service delivered at some point within the prior seven days, the virtual care service would not be separately reimbursable, as the follow-up visit would be “bundled” into the Medicare payment for the previous E/M service. Similarly, if the virtual care service leads to an E/M service with the same physician, the virtual care service would be “bundled” into that E/M service and would not be separately reimbursable.

CMS believes that this approach could be beneficial in a variety of ways. For example, it notes that this could assist in the treatment of opioid use disorders and other substance use disorders “since there are several components of Medication Assisted Therapy (MAT) that could be done virtually, or to assess whether the patient’s condition requires an office visit.” At the same time, CMS recognizes that it may need to address a few concerns. Specifically, CMS is seeking comments on whether a frequency limitation should be imposed and also what sort of documentation regarding medical necessity would be appropriate, among other things.

Review of patient images or video (store and forward)

The Proposed Rule provided that HCPCS GRAS1 code (Remote Evaluation of Pre-Recorded Patient Information) be used for reimbursement for reviewing “recorded video and/or images captured by a patient in order to evaluate the patient’s condition” and to determine whether the patient requires an in-person office visit. This proposed change would apply to all providers, which would be significant given that “store and forward” telehealth services are currently only reimbursed by Medicare in very limited circumstances.

As with the virtual visits described above, this service would not be separately reimbursable if it results from an E/M service provided within seven days prior, or leads to E/M services. CMS is seeking comment on whether this service should be limited to existing patients “or whether there are certain cases, like dermatological or ophthalmological services, where it might be appropriate for a new patient to receive these services.”

Provider-to-provider consultations

Codes 994X6, 994X0, 99446, 99447, 99448 and 94449 may be used to reimburse provider-to-provider consults in the context of care management or care coordination activities. These codes may be used for “assessment and management services conducted through telephone, internet, or electronic health record consultations furnished when a patient’s treating physician or other qualified healthcare professional requests the opinion and/or treatment advice of a consulting physician or qualified healthcare professional with specific specialty expertise to assist with the diagnosis and/or management of the patient’s problem without the need for the patient’s face-to-face contact with the consulting physician or qualified healthcare professional.”

This expansion of reimbursement (away from a service that would otherwise be bundled through face-to-face encounters) is derived from CMS’s recognition that current coding does not accurately reflect trends in medical practice. Specifically, CMS believes that “making separate payment for interprofessional consultations undertaken for the benefit of treating a patient will contribute to payment accuracy for primary care and care management services.” Nonetheless, CMS is concerned about program integrity and is seeking comments on how CMS might be able to evaluate whether the services are reasonable and necessary under the circumstances.

Cost

Crucially, CMS is cognizant of the impacts these changes may have on Medicare cost with respect to utilization and avoidable utilization of other services. Its analysis is that because reimbursement is generally low for these services, utilization will be fairly low, but could increase to upwards of 19 million visits per year. CMS also expects that the number of additional services resulting from these new services will outweigh avoided utilization. Accordingly, CMS expects that the financial impact of paying for the communication-technology-based services will be an increase in Medicare costs. Unfortunately, this does not bode well for reimbursement generally: “In order to maintain budget neutrality in setting proposed rates for CY 2019, we assumed the number of services that would result in a 0.2 percent reduction in the proposed conversion factor.”

CMS Proposed Rule (Home Health) Released July 2, 2018

In an effort to encourage more home health agencies (HHAs) to adopt RPM, the CMS Proposed Changes to the Home Health Prospective Payment System released July 2, 2018, propose the inclusion of RPM costs on the HHA cost report as an allowable cost. Allowing HHAs to report the costs of RPM on the HHA cost report as part of their operating expenses means these costs would then be factored into the costs per visit, which has important implications for purposes of assessing HHA costs relevant to payment, including HHA Medicare margin calculations. CMS is soliciting comments on the proposed definition of remote patient monitoring under the Home Health Agency Prospective Payment System to describe the telecommunication services that are used by HHAs to augment the patient’s plan of care during a home health episode. In addition, CMS has requested comments regarding additional opportunities to use telehealth technologies for consideration in future rulemaking, which further evidences CMS attention to how telehealth can improve the delivery of home health services.

CMS Proposed Rule (Outpatient Hospital Services) Released July 25, 2018

In the CMS Proposed Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs released on July 25, 2018, CMS has asked members of the public to submit their ideas on ways to promote the interoperability and electronic information exchange, and potential revisions to CMS patient health and safety requirements for hospitals and other Medicare- and Medicaid-participating providers and suppliers “to fully understand all of these health IT interoperability issues, initiatives, and innovations through the lens of its regulatory authority.” CMS is “particularly interested in identifying fundamental barriers to interoperability and health information exchange, including those specific barriers that prevent patients from being able to access and control their medical records.”

Don’t Get Too Excited

Reimbursement for services delivered via digital health solutions should continue to improve beyond 2018, based on Congress’ and CMS’s desire to identify additional appropriate uses of telehealth and to reevaluate the current Medicare coverage requirements, CMS’s recent expansions of and proposed changes to the list of covered services, and the fact that Medicare and Medicaid payments for telehealth services are at an all-time high. However, this must be understood in context.

First, it is important to note that although Congress has significantly improved the financial environment for telehealth through the Bipartisan Budget Act, it has not altered in any fundamental way the very restrictive structure for telehealth reimbursement. With the exception of broadening the flexibility for MA Plans, the Bipartisan Budget Act essentially creates very specific exceptions to that structure by waiving certain, but not all, of its requirements, and then only under specific circumstances. This seems to be consistent with the approach suggested by the Medicare Payment Advisory Commission in its report to Congress on telehealth issued as required by the 21st Century Cures Act: “[P]olicymakers should take a measured approach to further incorporating telehealth into Medicare by evaluating individual telehealth services to assess their capacity to address the Commission’s three principles of cost reduction, access expansion, and quality improvement.” Accordingly, we should not expect significant or unbridled congressional efforts to expand telehealth coverage under Medicare.

Second, as demonstrated by the reference to a likely fee schedule offset in the Proposed Rule, we should recognize that even though CMS is interested in expanding telehealth reimbursement, it remains focused on the bottom line of Medicare reimbursement as a whole. Accordingly, while digital health reimbursement expansion may be more likely in the future, broad support for these efforts may be tempered by the possibility of financial offset in other reimbursement areas.

Finally, the OIG’s addition of Medicaid and Medicare telehealth payment audits to the 2018 Work Plan and recent reports indicating high billing errors demand that telehealth providers fully understand and develop procedures for complying with the associated regulatory and compliance requirements in advance. One key step in this process requires that providers review and update their corporate compliance programs—particularly billing, coding and documentation policies—to confirm that the provider and any partners properly bill for services, and that the compliance program effectively prevents, identifies and offers pathways for addressing billing compliance issues. With the changes in 2018, this task has simply gotten harder.

Although these comments may reflect a tempering of expectations and a word of caution relative to enforcement, they are also indicative of a very positive trend for telehealth. The Medicare reimbursement regime’s efforts to expand reimbursement for certain telehealth services, focus on its role within larger policy goals and concerns related to fraud also reflect the government’s perspective that these services are no longer a novelty and deserve attention.

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CMS’ explanation for its bold, new proposal: “We now recognize that advances in communication technology have changed patients’ and practitioners’ expectations regarding the quantity and quality of information that can be conveyed via communication technology. From the ubiquity of synchronous, audio/video applications to the increased use of patient-facing health portals, a broader range of services can be furnished by health care professionals via communication technology as compared to 20 years ago.”

The biggest takeaways from the proposed 2019 Medicare Physician Fee Schedule and Quality Payment Program with regard to remote patient monitoring (Chronic Care Remote Physiologic Monitoring):

CMS introduced three new RPM codes, retitled “Chronic Care Remote Physiologic Monitoring,” which largely adopt the new codes created by the American Medical Association in 2017.  The codes (CPT 990X0, 990X1, and 994X9) are intended to better reflect how RPM services can be delivered to patients.

Even before these new codes were proposed, separate billing Medicare for RPM has been allowed using CPT 99091, defined as:  “Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (where applicable) requiring a minimum of 30 minutes of time.”

The three biggest takeaways from the new RPM codes that differ from the current CPT 99091 are as follows:

1. Less treatment time required to qualify for reimbursement. CPT 99091 requires at least 30 minutes per 30-day period, whereas CPT 994X9 requires only 20 minutes per calendar month.  The new code is much easier to track on a monthly basis, and requires 33 percent less time.

2. Separate payment for initial set-up and patient education. CPT 99091 does not offer additional reimbursement for the time spent setting up the RPM equipment or educating the patient on its use.  The new codes offer separate reimbursement for the work associated with onboarding a new patient, setting up the RPM equipment and training the patient on same. This is a very helpful move to further incentivize providers to start using these technologies with their patients. In addition, this separate payment is different from how Medicare reimburses Durable Medical Equipment (DME) suppliers (e.g., CPAP, oxygen, etc.). CMS requires the DME supplier to set up the equipment at the patient’s home and educate the patient on how to use the equipment, but does not offer separate payment for that work.
3. Clinical staff allowed. CPT 99091 is limited only to “physicians and qualified health care professionals” and does not expressly allow the RPM service to be delivered by clinical staff (e.g., RNs, medical assistants, etc.). This means the physician or qualified health care professional must perform the full 30 minutes per 30-day period, which is a lot of time for these highly trained professionals. For some providers, this is too resource-intensive to justify the $58.68 per month reimbursement rate.  The new code allows RPM services to be performed by clinical staff.

The only manner in which a Medicare provider could potentially use clinical staff for CPT 99091 is by complying with all the requirements for “incident to” billing, which – among other things – requires that auxiliary personnel be under the direct supervision of the physician. Under Medicare rules, direct supervision means the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel is performing services.

Most RPM services are best provided via general supervision, which does not require the physician and auxiliary personnel to be in the same building at the same time, and the physician could instead exert general supervision via telemedicine. This is a huge difference in operations and business models, but in order for CMS to make these new RPM codes work in the real world, it is near-essential that CMS allow RPM to be delivered “incident to” under general supervision.

Healthcare providers should begin launching RPM programs:

Healthcare providers service Medicare patients should consult with companies, such as Dr. Miltie, to deliver RPM services to patients, similar to what we have seen with Chronic Care Management (CCM) companies. This is because the new codes expressly allow the use of “clinical staff” to help fulfill part of the 20 minutes per month. Current CMS guidance on CCM services expressly contemplates and allows third-party companies to contract with Medicare providers to help deliver CCM services. In order to further enable that, CMS created an exception allowing a Medicare provider to bill CCM services as “incident to” under general supervision. Normally, most services billed incident to must be provided under the direct supervision of the provider.  

Healthcare providers should prepare for these new opportunities:

The first thing is to take the time to truly understand, with precision, the billing and supervision rules fundamental to a compliant RPM service model. Providers should not focus too much on the technology and business development until they are confident the model they are “selling” or delivering does, in fact, comply with Medicare billing requirements.

Second, providers should take time to develop a model business-to-business RPM contract with Dr. Miltie, whether this is technology-only, support services-only or a combination of both.

The post 2019 Medicare Physician Fee Schedule and Quality Payment Program – CMS Proposed Rule CPT Codes 990X0, 990X1, and 994X9 appeared first on Dr. Miltie.

The post New CMS Incentives for Remote Patient Monitoring and Patient Access appeared first on Dr. Miltie.

By Bruce Gosser

Overburdened and inefficient. An accurate description of today’s US healthcare system which wasn’t designed to handle the current population’s health needs. According to the Centers for Disease Control and Prevention (CDC), 68 percent of Americans aged 65 and older are living with multiple chronic conditions. With this expanding population of chronic patients, there’s a need to re-visit our current models.

Technology solutions in healthcare, such as remote patient monitoring (RPM), can help bridge the gap between the overtaxed medical resources and the growing demand for them. While virtual care technology like RPM has been around for years, there have been many barriers to adoption: clinician mindset, regulatory, technological/interoperability issues and most important: how to reimburse clinicians for care. However, current healthcare reforms are finally changing the game.

Value-Based Reimbursement Incentives
In January 2018, Centers for Medicaid and Medicare Services (CMS) announced changes to Medicare reimbursement for remote patient monitoring and telemedicine. By introducing the new CPT code 99091, clinicians can now bill separately for time spent on collection and interpretation of health data that is generated by patients remotely. Before January of this year, RPM services were only reflected as a part of other payments, such as an office visit or chronic care management or transitional care management. Now, physicians can bill for remote monitoring in addition to those other fees. This means significant new revenue for physicians and is clearly based on the return on investment for CMS and other payers when patients are remotely monitored for serious chronic conditions like hypertension, diabetes, congestive heart failure, etc.

This direct new 99091 code and its financial incentive may finally ignite more widespread use of virtual telehealth and RPM resulting in increased access to healthcare services for those that need it most, at a lower cost of care and increased quality. The benefits are many: identifying at-risk patients, improving outcomes, and ultimately becoming part of the standard of care that improves the health and efficiency for all. Virtual telehealth technologies let patients take an active role in their health and allow providers to detect problems early before costs and complications escalate. The new and changing payment for remote patient monitoring is expected to boost the efforts of physicians and health systems to improve the health of chronic patient populations. At last, physicians will have meaningful technology available to support their transition to value-based care.

CMS Financial Incentives are in Place – Now What?
With CMS financial incentives now in place, there are other fundamentals that healthcare organizations should look at when trying to roll out virtual care and RPM program. These include:

The Right Technology
First, it is important that healthcare organizations interested in embarking on telehealth initiatives implement technology that captures and communicates the right data between the patient and the care team. This technology needs to be easy to use, deploy, and maintain.

According to a 2017 Aruba report, almost 60 percent of healthcare organizations have introduced IoT devices into their facilities with 87 percent of planning to implement medical IoT devices by 2019. Seventy-three percent of healthcare organizations use IoT for monitoring and maintenance with the most common use being patient monitoring at 64 percent.

The medical device IoT explosion and proliferation of wireless networks offers an overwhelming array of data gathering and communication solutions for healthcare. Bluetooth-enabled blood pressure cuffs and weight scales, implantable continuous glucose monitors, and smartphone apps that assess mood, pain control, or medication side effects allow people with hypertension, diabetes, or depression to engage in care safely, effectively, and virtually. Analytic tools help care teams know which patients need attention when and why.

Questions to consider to ensure you’re implementing the right technology:

What data do care teams need in order to monitor patients outside of the hospital or provider office?
What is needed for patients and care teams to communicate in the simplest manner?
What infrastructure is required?

Patient Engagement
Patient engagement and adherence is one of the most essential steps for implementing a successful telehealth program. Virtual care offers the opportunity to engage people “in the wild,” wherever they are living, not only in the physical setting of a provider organization. Helping patients manage their diabetes while at home, surrounded by their own personal challenges like eating the right foods or finding time to exercise, can powerfully reveal the barriers patients face with diabetes control; however, this only helps if the patients are ready and able to take responsibility for self-management.

Questions to consider to promote engagement:

How will you organizations generate awareness for its telehealth program?
Will you post signs around the office?
Will you send an email blast, or add a message to the office voice mail?

A New Model of Healthcare
The Center for Disease Control and Prevention estimates that medications are not taken as prescribed by their doctor 50 percent of the time. Close to one-third of American patients choose to ignore their doctor’s orders and forgo even filling their prescription at their pharmacy. This lack of adherence causes roughly 125,000 deaths each year and costs healthcare professionals a fortune. How can we get patients to follow their medication guidelines?

Virtual care offers new ways for patients to engage with their care and care teams, offering opportunities for education, treatment, and coordination of care. However, for this to occur successfully, it’s important for healthcare organizations to implement new healthcare models that integrate and take advantage of the interdisciplinary patient interactions that occur with or without the face-to-face provider visit. Other industries such as banking and retail have been able to make the transition to remote based models, it’s time for the healthcare industry to do the same thing.

Questions to consider when integrating telehealth into your healthcare organization

What goals are you trying to accomplish with virtual telehealth/RPM?
What is your current workflow and how will you integrate telehealth into that workflow
How will you engage your staff and make sure they’re on board?

Virtual care is destined to be the standard of care in healthcare as more organizations get familiar with the new way of thinking, new models and technology. Telehealth technologies have become financially viable to rapidly proliferate and positively change the way healthcare is delivered. As primary care physicians and other practices couple the new virtual telehealth technologies code with the existing Chronic Care Management codes and the Transitional Care Management codes, the new revenue will significantly transform these practices in terms of revenue and resources to serve our communities.

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The Bipartisan Budget Act of 2018 was recently signed into law. Within the number of provisions is the use of telehealth and reimbursement for Part B Medicare beneficiaries using CPT code 99091.

February 14, 2018 by Cafe Staff

If 2017 ended on a high for telehealth and remote patient monitoring, the start of 2018 also did not disappoint. Indeed, on Feb 9, the Bipartisan Budget Act of 2018 was signed into law. This bill, which provides a budget agreement for 2018-2019, also includes a number of policy provisions in support of telehealth, also opening the door to remote patient monitoring (RPM). This budget deal expands the use of telehealth for patients undergoing home dialysis by allowing Medicare beneficiaries to elect to receive monthly related clinical assessments through telehealth, and to those having suffered a stroke, it expands the possible locations where patients may receive a telehealth consultation. The use of telehealth was also expanded for Medicare Advantage (MA) plans and accountable care organizations (ACOs).

We are advancing to a new “personal health” paradigm.

Beginning in plan year 2020, a MA plan may provide additional telehealth benefits to its enrollees. The bill defines additional telehealth services as those “for which benefits are available under Medicare part B…” and “that are identified for such year as clinically appropriate to furnish using electronic information and telecommunications technology when a physician… or practitioner… providing the service is not at the same location as the plan enrollee.” I had mentioned above that the door was opened for RPM. And, as I reported before, the Centers for Medicare & Medicaid Services (CMS) started reimbursing RPM (code 99091 is now reimbursed in Part B Medicare), as such so that it is “available under Part B” (note the underlined text above) and therefore reimbursable as part of MA. Or, at least, this is our interpretation. In fact, CMS should issue a clarification in this respect to ensure plans start covering RPM.

As to the expansion of telehealth use by ACOs, the bill removes the restrictions (subject to some conditions) set by 1834(m) of the Social Security Act to a Medicare fee-for-service beneficiary of the ACO whereby the home of the beneficiary can be treated as an originating site (similar to the changes presented above for the treatment of stroke patients), and geographic limitations are lifted.

Intel has long believed that the old “mainframe health” paradigm (i.e., centralized, hospital-centric, expert driven, reactive, costly) is giving way to a new “personal health” paradigm (i.e., distributed, data rich, preventive, home- and consumer- centric, and efficiency-driven). An ingredient of this transformation is Intel’s Health Application Platform for remote healthcare. This application software platform enables a variety of remote care usage models. When coupled with an Intel architecture-based design specification, it can enable healthcare solution providers to securely deliver distributed services.

With the passing of this legislation, the US Congress showed bipartisan support for the expansion of technologies that support Medicare’s modernization. Patients will have more choices to access healthcare services, hopefully improving clinical outcomes, which is another step in the right direction for a more nimble, patient centric healthcare framework. Intel lauds this bipartisan agreement and the support for the expansion of telehealth. We will be now looking to CMS’ next steps to bring to fruition the possibilities opened by this legislation.

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New billing opportunities for providers and hospitals are available under CPT code 99091. 

February 12, 2018 by Foley & Lardner LLP

The new year continues to offer big opportunities for telemedicine and digital health companies, and one of the most notable developments is CMS’ decision to reimburse providers for remote patient monitoring (RPM).  Effective the Medicare program will  January 1, 2018, the Medicare program will pay providers for RPM services billed under CPT code 99091.   The service is currently defined as the “collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.”

It is great to see CMS agree with health innovation advocates that RPM services can be a significant part of ongoing medical care and that the Medicare program should recognize these services for separate payment as soon as practicable.  Providers and telehealth companies should act now to embrace this landmark shift by Medicare to directly pay for RPM services on a monthly recurring basis.

RPM is Not a Telehealth Service

RPM services are technically not considered a Medicare telehealth service.  Instead, like a physician interpretation of an electrocardiogram or radiological image that has been transmitted electronically, RPM services involve the interpretation of medical information without a direct interaction between the practitioner and beneficiary. As such, Medicare pays for RPM services under the same conditions as in-person physicians’ services with no additional requirements regarding permissible originating sites or use of the telehealth place of service (POS) 02 code.  RPM services do not require the use of interactive audio-video, nor must the patient be located in a rural area. The patient can even receive RPM services in their home.

CPT 99091 is not a newly-created code. Instead, Medicare “unbundled” it and designated it as a separately-payable service. Regardless of how CMS accomplished it, the final result is clear: Medicare will now pay providers a monthly fee for delivering RPM services.

Industry response was positive and telehealth advocates supported CMS’ action as another step in recognizing the increasing importance of RPM services.

Not All RPM Codes Made the Cut

When assessing whether or not Medicare should pay for RPM services, CMS also evaluated CPT 99090 as a potential covered service. That service is defined as the “analysis of clinical data stored in computers (e.g., ECGs, blood pressures, hematologic data).”  Unlike CPT code 99091, CPT code 99090 does not state that the RPM information must be interpreted by a physician or other qualified health care professional, nor does it specify a 30 minute minimum. After considering the differences, CMS elected to keep CPT 99090 “bundled” and not allow its use for separate payment.

What Does CMS Require for CPT 99091?

It is true that CPT 99091 fails to optimally describe how RPM services are furnished using current technology.  This may be due to the fact that the code description is years old and has never before been a separately payable service. The AMA’s CPT Editorial Panel is currently working on new codes intended to more accurately describe remote monitoring. But providers, patients, and CMS itself did not want to wait until those new codes were developed.  Until new codes are published and approved by CMS, providers should use the current CPT 99091 for billing RPM services. Here are some of the core requirements to bill Medicare for RPM services under CPT 99010:

• The practitioner must get the patient’s consent for RPM services and document it in the patient’s medical record.
• For new patients or patients not seen by the practitioner within one year prior to billing RPM, the practitioner must first conduct a face-to-face visit with the patient (e.g., an annual wellness visit or physical). E/M services levels 2 through 5 (CPT codes 99212 through 99215) should qualify for this face-to-face visit. Transitional care management (TCM) services should also qualify. However, services that do not involve a face-to-face visit by the billing practitioner or which are not separately payable under Medicare (e.g., online services, telephone and other E/M services) would not qualify as an initiating visit.
• CPT 99091 should be reported no more than once in a 30-day period per patient.
• The service must include the physician or other qualified health care professional time involved with data accession, review and interpretation, modification of care plan as necessary (including communication to patient and/or caregiver), and associated documentation.
• CPT 99091 can be billed once per patient during the same service period as chronic care management (CCM) services (CPT codes 99487, 99489, and 99490), TCM services (CPT codes 99495 and 99496), and behavioral health integration services (CPT codes 99492, 99493, 99494, and 99484). This is allowed because CMS recognizes the kind of analysis involved in furnishing RPM services is complementary to CCM and other care management services. However, time spent furnishing these services cannot be counted towards the required time for both RPM and CCM codes for a single month (i.e., no double counting).
• Because RPM services are not considered telehealth services under Medicare, the patient can be at his/her home, and need not be in a rural area or qualifying originating site.

Entrepreneurs and companies offering RPM technologies should take steps now to understand the new billing opportunities under Medicare. With the forthcoming new CPT codes for more RPM services, this looks to be an area of significant upside potential over the coming years.  Hospitals and providers using telehealth and non-face-to-face technologies to develop patient population health and care coordination services should take a serious look at RPM services billing opportunities, and keep abreast of developments that can drive recurring revenue and improve the patient care experience.

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Per CMS 2018 is the year for Telehealth Reimbursement!

December 8, 2017 by Shelby Buettner, Lisa Schmitz Mazur and McDermott Will & Emery

The Centers for Medicare & Medicaid Services (CMS) reiterated its commitments to expanding access to telehealth services and paying “appropriately” for services that maximize technology in the Medicare Program; Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program Final Rule published on November 15, 2017 (the Final Rule). Among many other developments, the Final Rule expands allowable telehealth reimbursement under the calendar year (CY) 2018 Physician Fee Schedule, List of Medicare Telehealth Services (list) and permits virtual sessions in certain circumstances under the Medicare Diabetes Prevention Program Expanded Model (MDPP, or the Program). The regulations are effective January 1, 2018.

“New” and “Add-On” Telehealth Services Slated for Reimbursement

CMS evaluates requests for the addition of telehealth services on the basis of two categories: (1) services that are similar to services already on the list and (2) services that are not similar to services already on the list. An evaluation of a category (2) service requires CMS to assess, based on the submission of evidence, whether the use of a telecommunications system to furnish the service “produces demonstrated clinical benefit to the patient.”

Upon review of several public requests, CMS determined that the following services were “sufficiently similar” to services already on the list, thereby meeting the category (1) requirement:

• Healthcare Common Procedure Coding System (HCPCS) code G0296—counseling visit to discuss the need for lung cancer screening
• Current Procedural Technology (CPT) codes 90839 and 90840—psychotherapy for crisis

Payment for these services is conditioned upon the distant site practitioner having the ability to mobilize originating site resources to diffuse the crisis and restore safety, when applicable.

The following four add-on CPT and HCPCS codes were also added:

• CPT code 90785—interactive complexity
• CPT codes 96160 and 96161—administration of patient-focused health risk assessment instrument, and administration of caregiver-focused health risk assessment instrument
• HCPCS code G0506—comprehensive assessment or/and care planning for patients requiring chronic care management services

Separate payment for CPT code 99091 was also added to reimburse providers for time spent collecting and interpreting patient-generated health data that is stored digitally and sent to the provider for review, which is considered by some to be a small but significant step toward Medicare reimbursement of remote patient monitoring services.

In instances where CMS is unable to confirm whether all components of a service may be performed via telehealth, an explicit condition of payment may be added alongside the code to ensure that all CPT (or other) prefatory requirements are met. CMS has provided a full list of reimbursable telehealth services.

Medicare Diabetes Prevention Program (Sometimes) Allows Virtual Sessions

MDPP is a “structured behavior change intervention” designed to prevent type 2 diabetes among Medicare beneficiaries with an indication of prediabetes. The Program consists of 16 sessions that integrate a Centers for Disease Control and Prevention (CDC)-approved curriculum in an in-person, “group-based, classroom-style setting.” The curriculum provides practical training in dietary changes, increased physical activity and strategies to control weight. Under the Final Rule, MDDP beneficiaries may make up a limited number of sessions “virtually” at the request of the individual beneficiary. The virtual sessions may include furnishing behavioral change programs online (e.g., via a connected smart phone, tablet, computer, laptop); furnishing coaching programs online with other means of support by the coach (e.g., via telecommunications, video conferencing); or distance learning that does not require online connectivity (e.g., via phone). The sessions will be billed using a modifier for CMS’ tracking purposes. MDDP services that are exclusively furnished virtually or using remote technologies (without in-person attendance) will not be reimbursed. The Program begins on April 1, 2018.

Concluding Thoughts: Two Steps Forward, One Step Back?

Congress’ desire to identify additional appropriate uses of telehealth and to reevaluate the current Medicare coverage requirements, CMS’ expansion of the list of telehealth covered services (albeit rather slowly), and the fact that Medicare and Medicaid payments for telehealth services are at an all-time high indicate that telehealth reimbursement will continue to improve in 2018 and beyond. That said, the US Department of Health and Human Services Office of Inspector General’s recent addition of Medicaid and Medicare telehealth payment audits to the 2018 Work Plan may cause telehealth providers to feel as if these small victories come at a cost. As a result, in conjunction with the exploration of telehealth reimbursement opportunities, telehealth providers should review and update their corporate compliance programs—particularly billing, coding and documentation policies—to confirm that the program effectively prevents, identifies and offers pathways for addressing compliance issues.

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