Remote Patient Monitoring, Telehealth expansions reflect CMS focus on digital medicine as the future of health care

The 2018 Medicare Physician Fee Schedule Final Rule (“2018 MPFS” or “Final Rule”) went into effect on January 1st. Marked by new additions to the Telehealth codes and the un-bundling of Remote Patient Monitoring code CPT 99091, the 2018 MPFS provides plenty of opportunities for providers to grow their practice through digital medicine. This article outlines key changes to the new Rule. 

1.    Rates, generally.

The overall payment update for 2018 is +0.31 percent. This reflects the +0.5 percent Statutory Update Factor included in the Medicare Access and CHIP Reauthorization Act, reduced by 0.09 percent to account for the mis-valued code target recapture amount required by the Achieving Better Life Experience (ABLE) Act of 2014, and an additional 0.1 percent to account for the RVU Budget Neutrality Adjustment. The final conversion factor is $35.99, up slightly from the 2017 conversion factor of $35.89. Non-excepted off-campus hospital outpatient provider-based departments are taking a big hit this year with a 20 percent reduction in rates. Last year, these services were paid at a rate of 50 percent of the Hospital Outpatient Prospective Payment System (OPPS) payment. That percent is reduced to 40 percent of OPPS payment for 2018. 

2.    Telehealth wins out with a number of new codes, elimination of the GT modifier, and an update to the originating site facility fee payment amount.

CMS introduced several new telehealth codes in the 2018 MPFS. First, they implemented four add-on codes that describe additional elements of services that are currently on the telehealth list. These services are only considered telehealth services when billed with a base code that is also on the telehealth list.

  • CPT codes 96160 and 96161 (Administration of patient-focused and caregiver-focused health risk assessment instruments with scoring and documentation)
  • HCPCS code G0506 (Comprehensive assessment of and care planning for patients requiring chronic care management (CCM) services)
  • CPT code 90785 (Interactive Complexity)

CMS also introduced some standalone codes, including:

  • HCPCS code G0296 (Visit to determine Low Dose Computed Tomography eligibility)
  • CPT codes 90839 and 90840 (Psychotherapy for crisis)

Additionally, CMS eliminated the required reporting of the GT modifier in order to reduce administrative burden on practitioners because it was redundant with the Place of Service (POS) code that is required on professional claims for all telehealth services. 

Finally, each year the telehealth originating site facility fee is increased by the percentage increase in the Medicare Economic Index (MEI). The originating site facility fee for telehealth services for CY 2017 is $25.40 and the MEI for 2018 is 1.4 percent. Therefore, the payment amount for the telehealth originating site facility fee (HCPCS Code Q3014) for 2018 is 80 percent of the lesser of the actual charge or $25.76. 

3.    Remote Patient Monitoring and the unbundling of CPT 99091.

As an acknowledgment to the value of monitoring services as a significant part of ongoing medical care, CMS unbundled CPT 99091 and activated it for separate payment in the Final Rule. CMS noted that Remote Patient Monitoring (RPM) under CPT 99091 is not a telehealth service, and therefore the additional requirements that apply to telehealth services do not apply to RPM. CMS also noted that the activation of CPT 99091 is a temporary measure until new CPT codes can be valued, which will likely come as part of the 2019 MPFS. 

CPT 99091 allows providers to bill separately for the “collection and interpretation of physiological data digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional.” This code can be billed once per patient in a 30-day period, and can be billed in conjunction with Chronic Care Management (CCM) and Transitional Care Management (TCM) codes, so long as the requirements for each are met separately. 

For more information about how to get reimbursed under CPT 99091, read our recent blog post on the topic.

4.    Separate payment for insertion, removal, and removal with reinsertion of subdermal implants for the treatment of opioid addiction.

In the wake of the national opioid crisis, CMS met with the American Society of Addiction Medicine (ASAM) in 2016 to discuss separating payment for insertion and removal of buprenorphine hydrochloride in the treatment of opioid addiction. The 2018 MPFS finalized three separate codes for this process.

  • HCPCS code G0516 (Insertion)
  • HCPCS code G0517 (Removal)
  • HCPCS code G0518 (Removal with reinsertion) 

5.    Opportunity to boost Merit-Based Incentive Payment System (MIPS) Score Using Appropriate Use Criteria (AUC) Program.

Section 281(b) of the Protecting Access to Medicare Act of 2014 (PAMA) promulgated a new requirement that CMS establish a program to promote the use of AUC for advanced diagnostic imaging services. PAMA defines AUC as evidence-based (to the extent possible) criteria that assist professionals who order and furnish applicable imaging services to make the most appropriate treatment decisions for a specific clinical condition. 

The program was first introduced in the 2016 MPFS Final Rule. In the 2018 MPFS, CMS again delayed the implementation of the program, this time until 2020, at which time CMS will deny payment for advanced imaging services unless the ordering professional consults AUC. CMS is, however, implementing a voluntary reporting period beginning July 2018 and continuing through the end of 2019. To incentivize early use of CDSMs to consult AUC (i.e. to motivate physicians to participate in the voluntary reporting period), CMS established consultation of specified AUC through qualified Clinical Decision Support Mechanisms (CDSMs) as a high-weight improvement activity for the MIPS performance period beginning January 1, 2018. To assist ordering professionals in finding CDSMs, CMS released a list of qualified CDSMs for consulting applicable AUC in conjunction with the 2018 Physician Fee Schedule Proposed Rule. The list is available here.

6.    Retroactive reduction of Physician Quality Reporting System (PQRS) and Meaningful Use (MU) reporting requirements finalized

Even though the PQRS data submission period for CY 2016 reporting period has already ended, CMS revisited that criteria to better align with MIPS quality reporting requirements. The revised criteria under the Final Rule lower the PQRS and MU reporting requirements from nine measures across three domains to only six measures with no domain or cross-cutting measure requirement. This change applies to the following reporting mechanisms: Claims, qualified registry (except for measures groups), QCDR, direct EHR product and EHR data submissions vendor product. With these new reporting requirements, more physicians will be able to avoid 2018 downward payment adjustments. Specifically, CMS predicts this change will reduce aggregate 2018 payment penalties for physicians by approximately $22 million. 

CMS has made it clear with these updates that they are still focused on the shift to value-based care, and that they expect digital medicine to play a large part in that shift. We expect to see further guidance from CMS on new codes released under the 2018 MPFS, particularly relating to CPT 99091, and we will keep you apprised of any new developments. In the meantime, if you are interested in how you can grow your practice through digital medicine and value-based care, contact a Nixon Law Group attorney today