Recent Legislative Impacts to Telemedicine in Care Delivery

Legislative support is growing for the reimbursement of care delivery via telemedicine. The Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG) have recently made final and proposed rule changes to stimulate greater use and access for telemedicine delivery. These changes mean that for healthcare providers all around the United States, telemedicine will become a greater strategic focus.

Three major areas of telemedicine impacted are Remote Patient Monitoring Services (RPM), Chronic Care Management (CCM), and Opioid Use Disorder (OUD) treatment. Here we highlight the most significant changes that will impact providers in 2020 and beyond.

Remote Patient Monitoring Services (RPM) 

Until recently, this contributing technology for telemedicine has been hampered by murky details within existing law. It is now, however, the area of the industry experiencing the most significant changes in recent rulemaking.

RPM involves the development and use of technology to gather, monitor, and interpret patient vitals and other metrics. These data points can lead to further development of patient care plans. One critically impactful benefit of RPM is the ability to determine the need for acute hospitalization. This use of RPM for telemedicine is also a major factor in the technology succeeding under Alternative Payment Models (APMs) set forth by the CMS. 

Reimbursable procedure codes were introduced for RPM services under the release of code 99091 in January 2018. However, confusion around the billing of the code has led to extremely low uptake. Also hindering its use is the stipulation for direct physician time without the use of clinical staff.

Code 99457 was then released in 2019, allowing for clinical staff time but the service was not rolled under the veil of “designated care management.” This meant physicians must still be located on the same premises as the clinical staff performing an interaction with the patient/caregiver.

In the 2020 Medicare Physician Fee Schedule (MPFS), the new final rule now allows RPM as “designated care management” and thus only requires general supervision. This means physicians can now communicate with clinical staff via live video without being in the same building. As long as there is use of a secure connection, they can oversee the interactions with clinical staff from any location.

Another change in 2020 is a code for an additional 20 minutes of time per calendar month: code 99458. The table below provides a timeline of the changes.

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Chronic Care Management (CCM)

Due to rapid growth in the 65+ population, in 2020 CMS is furthering incentives to manage patients with two or more chronic conditions. The first codes for Chronic Care Management were implemented in 2015, and CMS has rightfully been concerned with the lack of uptake in managing high-risk patients.

In 2019 CMS released two new Alternative Payment Models (APM) - Direct Contracting Model and Primary Care First - aimed at shoring up the divide in advanced primary care. CMS has also continued work to ease the administrative burden for correctly billing CCM services. Now, in the 2020 MPFS, CMS is explicitly listing what constitutes a typical care plan, plus easing restrictions on reporting of community resources and outreach.

Another significant change in 2020 is the addition of two new designated care management codes for Principal Care Management. Principal Care Management is defined as management of a patient with only one high-risk condition expected to last at least three months and putting the patient at risk of hospitalization. Code G2064 requires direct physician or other qualified health professional time, while G2065 allows for clinical staff time under general supervision. A significant step towards enhancing primary care to reduce acute hospitalization, this code also allows specialists to bill for care management and the development of a disease-specific care plan.

A Physician Safe Harbor Proposed by the Office of Inspector General 

A significant development came out of the Office of Inspector General (OIG) last month that could have a substantial impact on both RPM and CCM services. In the proposed revisions to the Anti-Kickback Statute and Civil Monetary Penalties Law, the OIG specifically identifies a proposal to waive beneficiary cost-sharing for RPM and CCM services. If enacted, a safe harbor would then exist for physicians to routinely waive copay and deductible amounts incident to the delivery of such services.

We see this as a potential game-changer, as the OIG has previously been completely unwilling to take such statutory measures in the past.

Opioid Use Disorder Treatment Implications

In the 2020 Medicare Physician Fee Schedule, CMS has finalized a set of codes that represent substantial effort to combat the opioid crisis through enhanced care delivery.

First, CMS established a monthly bundled payment for near comprehensive treatment of individuals with Opioid Use Disorder (OUD). The bundles include development of a treatment plan, care coordination, individual and group therapy, and counseling.

FDA approved medications will be paid under separate codes, thus the bundled payments only cover non-drug components. Separate payments are authorized for the initial month and subsequent months of treatment. There is also an add-on code for patients requiring greater resource utilization.

Another big allowance published in the 2020 final MPFS is the credentialing of Opioid Treatment Programs (OTPs) as Medicare providers. CMS has even added weekly bundled payment codes, which cover the dispensing of medication as well as substance abuse counseling, individual and group therapy, and toxicology testing. The payment for each bundle is dependent on the cost of medication. For weeks in which no medication is administered, there is a separate weekly bundle for non-drug services.

Partial episodes were originally in the Proposed Rule, however, CMS has elected in favor of full episodes only. Full payment bundles were thus added for in-take activities, certain take-home medications, periodic assessment of patient care plans, and counseling beyond the normal time required to manage a patient’s adherence to the care plan.

Just as noteworthy, effective as of July 2019, geographic site restrictions were removed for all OUD related, non-face-to-face billable procedures. Thus, all counseling and care coordination can occur with the originating site as the patient’s home. CMS has also exercised statutory authority to set copayments for OTP beneficiaries at 0 to facilitate better access to these facilities and further its goal of combating the crisis.

Future Implications for Care Via Telemedicine 

The above developments are hallmark efforts by CMS to spark provider uptake of telemedicine delivery. Each new Alternative Payment Model (APM) released by CMS over the last two years, as well as all 39 Bundled Payment Care Initiatives – Advanced (BPCI-A) episodes made available, provide telehealth waivers for patient site origination.

Now, most APMs allow for the patient’s home to be an originating site and all relieve geographic restrictions. This means CMS no longer requires the patient originating site to be in a rural area or a designated Health Professional Shortage Area.

For healthcare providers, this means telemedicine is an increasingly important delivery method to consider. As healthcare payors will continue to look towards better patient outcomes to determine full or enhanced reimbursement, a sound telemedicine strategy will be crucial to the success of a broad spectrum of healthcare providers.

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