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CMS reimbursement changes to include expansion for telehealth platforms

Posted: Thursday, June 13, 2019

By Dereck Tatman, AristaMD President and COO

With healthcare spending in the United States projected to continue to rise through 2027, innovations designed to improve access to healthcare while reducing costs are more crucial now than ever. Virtual care is one such innovation. By making access to specialty care more convenient and reducing the cost of care, virtual care is empowering the modern patient population to be more proactive in managing their health; thus, improving population health metrics. Yet telehealth adoption has lagged disproportionately despite the positive impact it has across the healthcare sphere.

Reasons for the lag are multi-faceted, but studies are showing that lack of financial support for telehealth is a major factor. According to a survey by Reaction Data, 63 percent of health systems surveyed said improved federal support would speed implementation of virtual care services or increase use. Indeed, healthcare experts have noted that providers aren’t adopting connected health resources without reassurance that they will receive compensation for this new technology. Meanwhile, finance decision-makers insist on supporting these technologies only once they produce improved outcomes and reduced waste. This apprehension on both sides has created an impasse.

However, there is good news—positive support for connected health was included in the 2019 CMS fee structure change objectives. These objectives aim to modernize the healthcare system and help “restore the doctor-patient relationship” by reducing administrative burden. The changes related to telehealth both expand Medicare telehealth services and communicate a new interpretation of remote communication technologies. These changes to the CMS fee structure have made several telehealth services reimbursable for physicians, including virtual check-ins, eConsults, and remote patient evaluation. Here are the details on the proposed changes.

New telehealth reimbursements

  1. Virtual Check-ins

Virtual check-ins refer to brief non-face-to-face interactions with patients via communication technology, often via telephone. This virtual care technology is generally used to assess whether a patient’s condition necessitates an office visit.

Previously, virtual check-ins were not reimbursed by CMS. For phone calls resulting in an office visit, the time spent on check-ins would be made up for by the payment for the resulting visit. However, check-ins not resulting in visits would result in no payment—and thus, lost time and effort on behalf of the physician. CMS has proposed reimbursing virtual check-ins by making these interactions billable under HCPCS G2012, the criteria for which are detailed below.

Virtual check-ins are an effective way of mitigating unnecessary office visits and improving healthcare efficiency as a result. Adding reimbursement conditions for virtual check-ins makes adopting this procedure more viable for physicians.

CPT Code Description Amount Reimbursed
G2012 Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, not originating 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; 5-10 minutes of medical discussion $14.78
  1. Interprofessional Internet Consultations (eConsults)

Treating practitioners often require input from specialist healthcare professionals to provide adequate care to their patients. Because time spent consulting specialists has not historically been reimbursed, the general practice has been to refer patients so that they can schedule a separate appointment. Patients often experience difficulty in scheduling appointments with these healthcare professionals, creating access issues for the patient as well as overburdening specialists— whom are already facing heavy workloads due to severe specialist shortages within the workforce.

Telehealth technologies, such as eConsults, can assist in these situations. In order to cover the time spent using these services, CMS has proposed new reimbursement codes. The proposed codes are: 99451 and 99452. The codes 99446 and 99449 existed but the new fee structure included a revised description and reimbursement. In particular, CPT codes 99451 and 99452 are worth highlighting. Under these codes, Medicare eConsults are now reimbursable under Original Medicare, and some Medicare Advantage patients may be eligible as well. eConsults increase access and improve quality of care for patients with low-acuity conditions who can be treated without an in-person specialist visit. As a downstream effect, these platforms also help to increase appointment availability for patients who urgently need to schedule appointments with specialists.

A patient’s Medicare eligibility can be verified through the Medicare Administrative Contractor (MAC)’s portal, which shows the type of Medicare coverage a patient has. eConsults for all Traditional or Original Medicare patients are reimbursed as long as the patient qualifies under considerations, listed below under ‘Important Considerations’.

For Medicare Advantage beneficiaries, reimbursement rates may differ from those offered to Original Medicare beneficiaries. Further, the availability of reimbursement may depend on the state of residence for the patient’s plan and the provider’s contract status. The patient’s Medicare Advantage eConsult eligibility can be confirmed with the Medicare Advantage administrator (for example, Humana or Anthem Medicare).

For Medicaid programs, eConsults are explicitly covered under CPT codes 99451 and 99452 in Connecticut, Kentucky, Michigan, Minnesota, Montana, Nebraska, and Utah. States where eConsults are not covered include Indiana, Maryland, Mississippi, Missouri, Texas, West Virginia, and the District of Columbia. All other states either have yet to release their 2019 fee schedule or do not list information about eConsult coverage.

CPT Code Description Amount Reimbursed
99451 Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified healthcare professional; 5 or more minutes of medical consultative time $37.48
99452 Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified healthcare professional; 30 minutes $37.48

Important considerations

There are several important considerations for codes 99451 and 99452, which are new for 2019:

  • Code 99451 should only be billed by the consultative physician and 99452 by the treating and requesting physician.
  • A written report from the consultative physician is required to fulfill CPT code 99451; code 99452 should be billed when the referring physician spends at least 16 minutes preparing the information for the referral.
  • None of these codes require any interactive communication involving the patient and are intended to be used between professionals only.
  • For telehealth reimbursements, it is important to be aware that modifiers and specific place of service codes may be needed to bill these services properly. However, this does not apply for CPT Code 99452—the eConsult reimbursement for the referring provider—which should only be billed as exactly 99452.
  1. Remote Evaluation of Pre-recorded Patient Information

Technology for forwarding patient information via video or images, often referred to as “store-and-forward,” has been useful in facilitating remote triage, diagnosis, and treatment. This has generally not been reimbursable under the Medicare telehealth benefit, but CMS has proposed a new code to address this: HCPCS G2010.

This reimbursement is only available for the treatment of established patients, and informed consent is required. CMS has proposed Pre-recorded Patient Information as a billable service. There are; however, two exceptions. If the patient information originates from an E/M service in the last seven days by the same treating healthcare professional, or if the information leads to an immediate (next available) in-person visit with the same healthcare professional.

CPT Code Description Amount reimbursed
G2010 Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with verbal follow-up with the patient within 24 business hours, not originating 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 12.61
  1. Remote Patient Monitoring

CMS has added additional codes for reimbursement of remote patient monitoring (RPM) of certain physiological parameters. These new codes are CPT 99453, 99454, and 99457, the details of which can be found in the table below.

Patients with chronic conditions often face many challenges in receiving quality care, with the largest obstacles being the high cost of repeated office visits for monitoring of physiological data and the ability to receive care in a timely fashion. With added reimbursement codes to facilitate the adoption of RPM by increasing numbers of physicians, these patients will see a large increase in the quality, timeliness, and affordability of their care.

CPT Code Description Amount Reimbursed
99453 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 $19.46
99454 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 $64.15
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 $51.54

In conclusion

The rising cost of healthcare in the United States is a burden not only on patients, but on healthcare professionals as well. With constant spending increases, it’s imperative that stakeholders pursue innovative technologies for improving efficiency and quality of care. Virtual health and eConsult technologies are critical for improving healthcare providers’ ability to provide quality care, and their rate of adoption depends on viability for patients and physicians alike.

The good news is that certain technologies, such as eConsults, have gained traction. A recent American College of Physicans (ACP) survey found that eConsults were used by 33 percent of respondents, the highest figure for any telehealth technology. By adding new opportunities for reimbursement of eConsults and other telehealth tools, CMS is making it more feasible than ever before for healthcare professionals to leverage these technologies, improving efficiency and broadening access to healthcare for the modern patient population.

Learn more about how to access AristaMD’s eConsult platform and get reimbursed for eConsults.

GET REIMBURSED FOR MEDICARE eCONSULTS

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