Healthcare Leaders Praise Telehealth Advancements, Delayed E&M Coding Changes in Recent CMS Rule

Nov. 6, 2018
Starting in 2019, for the first time, CMS will reimburse providers for virtual check-ins with patients, regardless of the patient’s location—a move that drew praise from many healthcare leaders.

For the first time, starting in 2019, the Center for Medicare & Medicaid Services (CMS) will reimburse healthcare providers for certain virtual care visits with patients, regardless of the patient’s location—a move that drew praise from many healthcare leaders as helping to advance telehealth.

On Nov. 1, CMS published its final rule providing updates to the Physician Fee Schedule (PFS) and calendar-year 2019 Quality Payment Program (QPP), and while there were no big surprises as many of CMS’ changes and updates were originally proposed in the agency’s draft rule, published back in July, healthcare industry groups quickly praised the virtual visit provisions contained in the final rule—specifically, reimbursing doctors for virtual check-ins, remote image evaluation, and other technology-enabled services.

Healthcare Informatics covered the core takeaways from these proposals, particularly for how they impact the health IT community, in a story following the prosed rule’s release in July.

In the 2,379-page final rule, CMS is making sweeping changes to Medicare Incentive-based Payment Program (MIPS) measures, Evaluation and Management (E&M) coding and telemedicine reimbursement. Last week, CMS officials said changes to the Medicare PFS and QPP will shift clinicians’ time from completing unnecessary paperwork to providing innovative, high-quality patient care. The proposals in the final rule “address provider burnout and provide clinicians immediate relief from excessive paperwork tied to outdated billing practices,” CMS said in a press release. A fact sheet on the final rule published Nov. 1 can be accessed here.

“The final 2019 Physician Fee Schedule (PFS) and the Quality Payment Program (QPP) rule released today also modernizes Medicare payment policies to promote access to virtual care, saving Medicare beneficiaries time and money while improving their access to high-quality services, no matter where they live,” CMS stated. “It makes changes to ease health information exchange through improved interoperability and updates QPP measures to focus on those that are most meaningful to positive outcomes.”

The QPP changes, set to take place in year three of the program, in 2019, would make changes to quality reporting requirements to focus on measures that most significantly impact health outcomes, CMS said, and the changes will encourage information sharing among healthcare providers electronically. The QPP final rule will make changes to the MIPS “Promoting Interoperability” performance category to support greater EHR interoperability and patient access to their health information, as well as to align this clinician program with the “Promoting Interoperability” program for hospitals, which was published as a final rule in August.

Health IT Now (HITN), a broad-based coalition of patient groups, provider organizations, employers, and payers supporting the use of data and health information technology to improve healthcare, praised the incentives in the CMS policy to promote interoperability across the healthcare continuum. However, Joel White, HITN Executive Director, said, “As we noted in our comments on the proposed rule, barriers to interoperability remain due to the lack of clear rules regarding harmful information blocking practices as required under the 21st Century Cures Act. We appreciate administration officials' update earlier this fall that a proposed information blocking rule is under review at OMB and we eagerly await its swift release."

As it relates to virtual care, CMS officials said that provisions in the CY 2019 Physician Fee Schedule would support access to care using telecommunications technology. Under the final rule, Medicare will pay providers for new communication technology-based services, such as brief check-ins between patients and practitioners, and pay separately for evaluation of remote pre-recorded images and/or video. CMS is also expanding the list of Medicare-covered telehealth services.

During a press call last week, CMS Administrator Seema Verma said, “This provides opportunities for patients around communicating with providers remotely. We’ve never had this in the program at large. There has been a telehealth benefit mostly for rural providers, but access to care is not just a rural issue, it’s something that patients struggle with across the country,”

She continued, “This is an historic change in terms of increasing access and it’s also a great example of some of the efforts that we’re trying to make around supporting innovation. This has been happening in the private market and I think the opportunities and the impact could be tremendous. We’re excited to be able to harness this innovation for Medicare beneficiaries.”

As Healthcare Informatics Contributing Editor David Raths noted in an article about the telehealth provisions in the proposed rule back in July, CMS can’t use its regulatory power to change the laws that restrict telehealth services paid for by Medicare to rural settings. However, the agency instead defined new “communication technology–based services” that could be used for virtual visits with established Medicare patients regardless of such patients’ location, effective Jan. 1, 2019.

HITN applauded the telehealth advances, noting that CMS is “leading the march toward a modernized Medicare program that helps its 59 million enrollees access care when and where they need it.”

“While much work remains to ensure that Medicare catches up with private payors in its coverage of telehealth services, this final rule marks progress,” White said in a statement. White also urged CMS to expand the policy beyond established patients. “Health IT Now further believes that CMS’s decision not to define these virtual services as ‘telehealth,’ so as to avoid running afoul of current inflexible telehealth restrictions, highlights the urgent need for Congress to do its part as well. We cannot fully realize the promise of telehealth in Medicare independent of Congressional action."

Nathaniel Lacktman, a partner and healthcare lawyer with Foley & Lardner, who chairs the firm’s Telemedicine and Digital Health Industry Team, said in a blog post that the new code represents a “sizeable change” to allow providers to efficiently use new technologies to deliver medical care. “By reimbursing for virtual check-ins, the new code exemplifies CMS’ renewed vision and desire to bring the Medicare program into the future of clinically-valid virtual care services,” he wrote.

Lacktman notes that the virtual “check-in” has to be conducted by the physician or a qualified healthcare professional, not office staff. What’s more, patient consent to use telehealth is required each time the provider connects with the patient. “Providers frustrated with the labyrinthine and narrow Medicare coverage of telehealth services can take comfort in the fact that virtual check-ins are not considered a Medicare telehealth service,” Lacktman wrote.

Mari Savickis, vice president, federal affairs at the Ann Arbor, Mich.-based College of Healthcare Information Management Executives (CHIME), also praised the virtual care provisions in the final rule. “[CMS] has done so many positive things here, that it's no longer one toe in the water; it’s definitely now one foot in the water. This is a great start for 2019, and it’s exceptionally promising that they are following through on many things we have seen from Congress.”

In an interview with Raths back in July, Krista Drobac, executive director of the Alliance for Connected Care, expressed both enthusiasm and concern about the virtual care provisions in the then-proposed rule. “What they have done is creative and brilliant, and it goes further than CMS has ever gone previously to ensure that seniors have services everyone else in the marketplace has,” Drobac said. On the other hand, she said that CMS paying for brief e-visits could create an environment where providers are going to weigh whether it is worth it to invest in telehealth systems. “What they will probably find is that the reimbursement is not enough to transform their practice and make telehealth part of their work flow,” she said.

Echoing White’s comments, Drobac said she believes CMS has gone as far as it can go within the existing law. She said Congress needs to give the Secretary the authority to waive the telehealth restrictions on all provider codes. “On the one hand, I am excited about the progress; on the other hand, it makes me even more determined that Congress act. CMS has gone as far as any of us could have asked on a regulatory level,” she said back in July.

The final update to the 2019 PFS and QPP also includes three new CPT (current procedural terminology) codes for reimbursement of remote patient monitoring. Those updated codes go live in January 2019. In a blog post, Lacktman wrote that the new RPM codes, officially titled “Chronic Care Remote Physiologic Monitoring,” incentivize providers to effectively and efficiently use RPM technology to monitor and manage patient care needs. 

E&M Coding Reforms

The PFS final rule addresses E&M documentation reform, and CMS noted that coding requirements for physician services known as E&M visits have not been updated in 20 years. The final rule simplifies and streamlines documentation, so doctors can spend more time with patients, CMS officials said.

The major E&M reforms include replacing the current E&M codes with a new, single blended payment rate for E&M office visit codes Level 2 through 4 visits, while maintaining the payment rate for E&M office/outpatient visit code level 5 in order to better account for the care and needs of complex patients.

This change will be effective in 2021 and marks a change from CMS’ earlier proposal, which would have collapsed Level 2 through 5 codes into a single payment by 2019. For 2019 and 2020, practices will continue using the current coding and payment structure for E&M office and outpatient visits

Don Crane, president and CEO, America’s Physician Groups, praised CMS’s decision to delay the payment changes for two years.We are pleased that CMS will continue in dialogue with stakeholders to further refine the regulations as they become effective in 2021,” Crane said in a statement. “CMS also takes aim at reducing clinician burden by removing several duplicative notation and documentation requirements,” he said.

In a statement, Anders Gilberg, senior vice president, government affairs at the Colorado-based Medical Group Management Association (MGMA), also applauded CMS’s efforts to reduce documentation burden for E&M office visits and the agency’s deferral and revision of the collapsed E&M codes to 2021. However, similar to concerns he raised about the proposed rule back in July, Gilberg again questioned the benefit to physicians of a single blended payment rate.

“Blending payments rates in 2021 won't necessarily reduce burden, especially with CMS’s newly required add-on codes. MGMA will continue to examine the rule, leverage feedback from members, and work with CMS to create meaningful burden reduction for physician practices across the country,” Gilberg said.

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