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CMS proposes telehealth changes under Trump executive order

The agency has yet to say whether parity will remain between an in-person and a telehealth visit.

Susan Morse, Managing Editor

The Centers for Medicare and Medicaid Services has started implementing the proposed rules needed to fulfill President Trump's executive order on Monday to make temporary telehealth services permanent, especially for rural areas.

As directed by Trump's order "Improving Rural and Telehealth Access," CMS said it is taking steps to extend the availability of certain telemedicine services after the public health emergency ends.

Trump on Monday outlined 135 telehealth services to become permanent that CMS added on a temporary basis during the emergency.

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These include initial inpatient and nursing facility visits, physical therapy, home visits, mental health counseling, substance abuse treatment and discharge day management services that can be paid when delivered by telehealth. 

CMS is proposing to permanently allow some of these services to be done by telehealth, including home visits for the evaluation and management of a patient – in the case where the law allows telehealth services in the patient's home – and certain types of visits for patients with cognitive impairments. 

CMS is seeking public input on other services to permanently add to the telehealth list beyond the public health emergency to give clinicians and patients time as they get ready to provide in-person care again.
 
CMS is also proposing to temporarily extend payment for other telehealth services, such as emergency department visits, for a specific time period through the calendar year in which the public health emergency ends. This will also give the community time to consider whether these services should be delivered permanently through telehealth outside of the pandemic.

WHY THIS MATTERS

Before COVID-19, reimbursement for telehealth visits was limited.

CMS has been expanding how and where virtual visits can be used, starting with rural areas and for Medicare Advantage plans.

When the pandemic kept people home, CMS added numerous services to provide temporary telehealth flexibility. Its use skyrocketed.

Of particular importance to providers was the parity given between in-person and telehealth visits.

So far, CMS has not definitively said whether the payment parity will remain in place once the pandemic ends.

MEDICARE PHYSICIAN FEE SCHEDULE

As part of the proposed payment and policy changes to the Medicare Physician Fee Schedule for 2021, CMS is proposing adding a number of services to the telehealth list on a Category 1 basis. Many of these are already allowed.

Additionally, CMS is proposing to create a third temporary category of criteria for adding services to the list of Medicare telehealth services. Category 3 describes services added through the calendar year in which the public health emergency ends.

These include certain home visits and ER visits.

CMS is soliciting comment on services added to the Medicare telehealth list that are temporary during the public health emergency but that the agency is not proposing to add permanently, or is proposing to add temporarily on a Category 3 basis.

NURSING FACILITY VISITS AND OTHER TELEHEALTH FLEXIBILITY

In response to stakeholders who have stated that the once every 30-day frequency limitation for subsequent nursing facility visits furnished via Medicare telehealth provides unnecessary burden and limits access to care for Medicare beneficiaries in this setting, CMS is proposing to revise the frequency limitation from one visit every 30 days to one visit every three days.  

CMS is seeking comment on whether it would enhance patient access to care if it were to remove frequency limitations altogether, and how best to ensure that patients would continue to receive necessary in-person care.

The agency is also clarifying that licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists and speech-language pathologists can furnish the brief online assessment and management services as well as virtual check-ins and remote evaluation services. 

To facilitate billing by these practitioners for the remote evaluation of patient-submitted videos or images and virtual check-ins (HCPCS codes G2010 and G2012), CMS is proposing to use two new HCPCS G codes.

CMS has also received questions as to whether services should be reported as telehealth when the individual physician or practitioner furnishing the service is in the same location as the beneficiary – for example, if the physician or practitioner furnishing the service is in the same institutional setting but is utilizing telecommunications technology to furnish the service due to exposure risks. 

It is therefore reiterating in the proposed rule that telehealth rules do not apply when the beneficiary and the practitioner are in the same location even if audio/video technology assists in furnishing a service.

In the March 31 COVID-19 interim final rule with comment period, CMS established separate payment for audio-only telephone evaluation and management services. While it is not proposing to continue to recognize these codes for payment under the Physician Fee Schedule in the absence of the public health emergency, the need for audio-only interactions could remain as beneficiaries continue to try to avoid sources of potential infection, such as a doctor's office. 

CMS is seeking comment on whether it should develop coding and payment for a service similar to the virtual check-in, but for a longer unit of time and subsequently with a higher value. The agency is seeking comment on whether this should be a provisional policy or if it should become permanent.

CMS has also clarified payment for seven remote physiologic monitoring codes. 

And it is proposing to establish new payment rates for immunization administration services described by certain CPT codes.

In the 2021 Physician Fee Schedule proposed rule, CMS is proposing to allow direct supervision to be provided using real-time, interactive audio and video technology (excluding telephone that does not also include video) through Dec. 31, 2021.  

It is seeking information from commenters as to whether there should be any guardrails in effect as it finalizes this policy though Dec. 31, 2021, or consider it beyond the time specified and what risks this policy might introduce to beneficiaries as they receive care from practitioners that would supervise care virtually in this way.  

Public comments on the proposed rules are due by Oct. 5.
 
THE LARGER TREND

Over the last three years, as part of the Fostering Innovation and Rethinking Rural Health strategic initiatives, CMS has been working to modernize Medicare through private sector innovations and improving beneficiary access to services furnished via telecommunications technology. 

Starting in 2019, Medicare began paying for virtual check-ins, meaning patients across the country could briefly connect with doctors by phone or video chat to see whether they need to come in for a visit. 

In response to the COVID-19 pandemic, CMS expanded payment for telehealth services and implemented other flexibilities. 

Before the public health emergency, about 14,000 beneficiaries received a Medicare telehealth service in a week. That has grown to more than 10.1 million beneficiaries who have received a telehealth service from mid-March through early July. 
 
ON THE RECORD
 
"Telemedicine can never fully replace in-person care, but it can complement and enhance in-person care by furnishing one more powerful clinical tool to increase access and choices for America's seniors," said CMS Administrator Seema Verma. "The Trump administration's unprecedented expansion of telemedicine during the pandemic represents a revolution in healthcare delivery, one to which the healthcare system has adapted quickly and effectively."

Twitter: @SusanJMorse
Email the writer: susan.morse@himssmedia.com