What Does 2019 Hold for Telehealth and Related Services?

Historically, payment for Medicare “telehealth services” has been constrained by a number of geographic and other limitations, but there are several new reimbursement opportunities for physicians and other health care practitioners beginning this year. Here we explore the expansion of traditional Medicare “telehealth services” under the Bipartisan Budget Act of 2018 (“BBA 2018”)1 and the SUPPORT for Patients and Communities Act (the “SUPPORT Act”)2, certain newly recognized and separately payable communication technology-based services (which look like telemedicine3 but do not constitute Medicare “telehealth services”), and how Blue Cross and Blue Shield of Alabama (“BCBSAL”) telemedicine policies stack up against Medicare’s new policies for 2019.

Medicare “Telehealth Service” Limitations; Expansion Under BBA 2018 and the SUPPORT Act

Medicare recognizes payment for certain “telehealth services” provided through interactive audio and video communications in certain situations where the service would otherwise ordinarily be furnished in-person (e.g., an evaluation and management or “E/M” visit). Medicare “telehealth services” are limited to beneficiaries located in rural areas, must be performed from certain originating sites (physician/practitioner office, hospital, skilled nursing facility, rural health clinic, etc.4), and may only be performed by certain practitioners (physicians, physician assistants, nurse practitioners, clinical psychologists, etc.5). The pervasiveness of conditions such as acute stroke and substance use disorders and the suitability of treating such conditions through telemedicine recently led to a statutory reduction of many restrictions on the provision of Medicare “telehealth services” in an effort to better control these health conditions at lower costs. Several of these changes resulted from the BBA 2018 and the SUPPORT Act.

The BBA 2018 expanded the availability of reimbursement for telehealth services, especially for end-stage renal disease (“ESRD”) and stroke patients. Specifically, ESRD patients may now receive monthly ESRD-related clinical assessments via telehealth, provided they receive a face-to-face (non-telehealth) visit/assessment at least monthly during the initial three months of home dialysis treatment and at least once every three months thereafter. The BBA 2018 also includes non-hospital-related renal dialysis facilities, and the patient’s home as eligible originating sites and removes the geographic location (i.e., rural area) requirements for monthly ESRD-related clinical assessments provided via telehealth services at the foregoing originating sites.

Medicare “telehealth services” provided “for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke” (“acute stroke telehealth services”) are now subject to special (and less restrictive) rules implemented pursuant to the BBA 2018. CMS added mobile stroke units to the list of eligible originating sites for providing acute stroke telehealth services and removed geographic limitation (i.e., rural area) for acute stroke telehealth services.6 Similarly, under the SUPPORT Act, the geographic limitation (i.e., rural area) is removed and the patient’s home is added as an eligible originating site for purposes of treating individuals diagnosed with a substance use disorder or a co-occurring mental health disorder.

For any of the foregoing Medicare “telehealth services,” it should be noted that no facility fee will be paid where the patient’s home is the originating site. In addition, practitioners will be limited to providing services, which are on the approved list of Medicare “telehealth services,” and must decide whether it is clinically appropriate to treat the underlying condition via “telehealth services.” However, the Centers for Medicare and Medicaid Services (“CMS”) has also expanded opportunities for some services that look like telemedicine but are not classified as Medicare “telehealth services.”

New Communication Technology-Based Services

In the 2019 Physician Fee Schedule Final Rule7, CMS defined a new set of separately reimbursable communication technology-based services, including virtual check-ins, remote evaluation of pre-recorded patient information, and interprofessional internet consultations. CMS does not consider these services to be Medicare “telehealth services” because the services typically would not otherwise be performed at an in-person visit, and therefore, they are not subject to the same geographic, provider-type, and originating site requirements for Medicare “telehealth services.”

Virtual Check-Ins. Until this year, CMS considered any routine non-face-to-face communication that occurs before or after an in-person visit to be bundled into the payment for the visit itself. Starting in 2019, CMS will separately reimburse for “virtual check-ins” (new HCPCS code G2012) used to determine whether an office visit or other service is warranted for an established patient.8 A virtual check-in should include five to 10 minutes of medical discussion and must be provided by a physician or other practitioner who could bill for an E/M service.9 The virtual check-in may be provided by audio-only telephone encounters10, but there must be real-time interaction with the patient. CMS emphasized the importance of obtaining patient consent for virtual check-in services and noted patients are expected to initiate virtual check-ins. Patient consent may be verbal but must be documented in the medical record for each billed service. Practitioners must document the virtual check-in is medically reasonable and necessary, but otherwise, CMS is not imposing any service-specific documentation requirements for the virtual check-in service. CMS is not limiting the frequency with which practitioners may provide and bill for virtual check-in services. However, virtual check-ins that result from a related E/M service in the previous seven days or that lead to an E/M service by the same practitioner or other qualified health care professional in the next 24 hours will be bundled in with the related service instead of being reimbursed separately.

Remote Evaluation of Pre-Recorded Patient Information. CMS has also provided separate reimbursement, starting in 2019, when a physician uses pre-recorded video or images11 captured by a patient to evaluate an established patient’s condition and determine whether an office visit or other service is necessary (new HCPCS code G2010). It is expected the practitioner will review the video or images and follow up with the patient within 24 business hours (verbally via phone call or audio/video communication, or through secure text messaging, email, or secure patient portal). However, if the video or images are of insufficient quality for the practitioner to assess whether an office visit or service is necessary, the practitioner could not bill for the service. Similar to the virtual check-in, if the remote evaluation results from a related service in the previous seven days or leads to an E/M service in the next 24 hours, it will be considered bundled with the related service and will not be reimbursed separately.

Interprofessional Internet Consultation. CMS will also begin to reimburse for interprofessional internet consultations, represented by six newly-recognized CPT codes (99446, 99447, 99448, 99449, 99551 and 99452). The new consult codes recognize reimbursement for both the work of the treating/requesting physician in initiating the consult and the services of the consulting physician in providing consultative services and a verbal and/or written report (generally corresponding to the length of medical consultative discussion). The patient must first give verbal consent to the consultative services, which must include a discussion of applicable cost-sharing requirements, and the consent must be documented in the medical record. Allowing these interprofessional internet consultations should streamline patient care because a patient can receive consultative services without having to set up a separate appointment with the consulting physician, and the reimbursement also recognizes the services provided by both treating/referring physician and the consulting physician.

BCBSAL Telemedicine Policies

The telemedicine policies for BCBSAL are less restrictive than Medicare’s in some respects, but the policies have not been expanded to include the new types of communication technology-based services for which Medicare will provide reimbursement beginning this year. For instance, BCBSAL does not appear to limit telemedicine services to particular originating sites located in rural areas. However, it does require telemedicine services be provided via “two-way, real-time (synchronous), interactive, secured and HIPAA compliant, electronic audio and video telecommunications systems,” and the patient’s home is only approved as an originating site for behavioral health services.12 Practitioners must also obtain patient consent, including all information that pertains to routine office visits and a description of the potential risks, consequences, and benefits of telemedicine.

BCBSAL specifically notes a number of services not considered appropriate for telemedicine, including telephone conversations, video cell phone interactions, provider-to-provider consultations when the patient is not present, appointment scheduling, brief follow-up of a medical procedure to
confirm the stability of the patient’s condition, brief discussion to confirm the stability of the patient’s chronic condition, services that would not be charged during a regular office visit, requests for a referral, and information exchange leading to a subsequent face-to-face visit within 24 hours. As evidenced by this list (which is illustrative rather than exhaustive), BCBSAL arguably would not reimburse for the new communication technology-based services for which Medicare will now make payment, such as virtual check-in, remote evaluation of pre-recorded patient information, and interprofessional internet consult. As has been the case in the past, BCBSAL may follow Medicare reimbursement policies on these communication technology-based services – or something relatively similar – upon a study of how they are implemented in the Medicare program. However, for now, practitioners must continue to maintain and follow two separate policies (at least for billing and reimbursement purposes) for telemedicine services provided to Medicare and BCBSAL beneficiaries.

Conclusion

There are a number of new opportunities to provide patient care services through telemedicine and related means that will be reimbursable under the Medicare program. However, practitioners should note this new menu of services will be scrutinized by CMS in the coming years to ensure services are reasonable and necessary and are not being overutilized. It should also be noted other payors (e.g., BCBSAL) will not necessarily adopt similar payment policies. Practitioners should have policies and procedures to ensure proper use of these services for each applicable payor. If you have additional questions about the scope of telemedicine services reimbursable in your practice, please contact your counsel for assistance.

Article contributed by Christopher L. Richard with Gilpin Givhan, P.C. Gilpin Givhan, P.C., is an official partner with the Medical Association.

References

1. Pub. L. 115-123 (Feb. 9, 2018).
2. Pub. L. 115-271 (Oct. 24, 2018).
3. It is important to note the difference between the general conception of telemedicine and the narrower subset of telemedicine services which constitute Medicare “telehealth services” and are subject to more extensive restrictions.
4. The full list of eligible originating sites includes: physician/practitioner office, critical access hospital (“CAH”), rural health clinic, Federally qualified health center, hospital, hospital-based or CAH-based renal dialysis center, skilled nursing facility, and community mental health center. Social Security Act, Section 1834(m)(4)(C)(ii) (42 U.S.C. § 1395m(m)(4)(C)(ii)).
5. The full list of practitioners who may provide Medicare “telehealth services” includes: physicians, physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, certified nurse-midwives, clinical social workers, clinical psychologists, and registered dieticians or nutrition professionals. Social Security Act, Section 1834(m) (42 U.S.C. § 1395m(m)).
6. CMS will require practitioners to bill a new modifier to indicate that the services provided are acute stroke telehealth services.
7. 83 Fed. Reg. 59452 (Nov. 23, 2018), available at https://www.govinfo.gov/content/pkg/FR-2018-11-23/pdf/2018-24170.pdf.
8. CMS determined it would not allow payment for a virtual check-in for a new patient. An established patient is one who has received professional services from the health care practitioner or another health care practitioner in the exact same specialty or subspecialty who belongs to the same group practice, within the past three years.
9. CMS specifically noted a virtual check-in could not be billed if performed by clinical or billing staff only (and did not involve a physician or other health care practitioner who can bill for E/M services).
10. Communications technology involving both audio and video components can be used as well, but the payment rate will not vary based on the additional video component.
11. CMS specifically excluded evaluation of other types of patient-generated information, such as information from heart rate monitors or other devices, because these services could potentially be reported with CPT codes describing remote patient monitoring.
12. BlueCross BlueShield of Alabama, Telemedicine Policy (last updated Nov. 2018).