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.