One of the biggest hurdles to clinicians and clinical systems adopting new digital health tools has been how to be reimbursed for this type of care.
In 2016, federal Medicare reimbursement for telehealth services totaled just $28.75 million out of their $990 billion overall CMS budget, which is felt to be tiny. This amount was low because of how CMS narrowly defined what is permissible as a telehealth service. Specifically, there were significant limitations in using the previously established Current Procedural Terminology (CPT) codes that were supposed to be used to document telehealth encounters.
We must remember that the Center for Medicare and Medicaid considers telehealth service to be significantly different than remote patient monitoring services because of the interpretation of medication information without a direct interaction between a practitioner and beneficiary. For remote patient monitoring of physiological information in the previous Medicare model, the feeling was that reimbursement was essentially non-existent.
In 2014, the AMA created a Telehealth Services Workgroup (TSW) to recommend solutions for the reporting of non-telehealth services when provided remotely utilizing telehealth technology. That work lead to the convening of the Digital Medicine Payment Advisory Group (DMPAG), a volunteer body of clinical subject matter experts with decades worth of experience utilizing digital medicine services and tools in clinical practice.
On Thursday, November 2, the Centers for Medicare and Medicaid Services (CMS) released Final Rules for the 2018 Quality Payment Program (QPP) and 2018 Physician Fee Schedule (PFS) that both expand telehealth services and restructure remote patient monitoring payments, changes that were in line with what a broad range of provider and health IT groups, including the AMA, were recommending.
For those participating in the Quality Payment Programs, CMS is now offering a “high” rating for Patient Generated Data. CMS has upgraded the Clinical Practice Improvement Activity (CPIA) of “Engage Patients and Families to Guide Improvement in the System of Care” to a “high” weighting, meaning that physician groups will achieve more points in the CPIA category for using technology to engage their patients within the scope of this improvement activity.
Additionally, CMS has placed emphasis on the importance of “clinical endorsement” of patient generated health data (PGHD) technologies, including the feedback the software generates for patients. CMS also appears to be incentivizing the use of more “active devices” that can inform the patient or their care team about critical changes to the patient’s health, such as their adherence to a medication or treatment, so that the care team can react and intervene in a timely way.
This improvement activity maps to the 2015 Edition Certification Criteria for patient generated data, providing patient access to their health information, and allowing patients the ability to view, download, or transmit their health data. Clinicians conducting this activity using Certified EHR Technology will now be eligible for a 10 percent bonus in the separate MIPS category of “Advancing Care Information” (ACI) when they incorporate patient generated health data and provide patients access to their health information and educational resources.
Clinicians can also take advantage of another PGHD-related improvement activity, “Use of CEHRT to Capture Patient Reported Outcomes” using digital health tools that capture data (such as meal logs, blood pressure or blood glucose logs taken at home) to achieve the ACI bonus—this activity remains from year one of the program.
For those using the fee for service model, the Physician Fee Schedule Rule includes reimbursement for remote patient monitoring and new telemedicine codes to cover more telemedicine services.
CMS has added the following codes to the list of covered telehealth services:
- HCPCS code G0506 for chronic disease management care planning
- HCPCS code G0296 for a visit to determine low dose computed tomography eligibility
- CPT code 90785 for interactive complexity
- CPT codes 96160 and 96161 for health risk assessments
- CPT codes 90839 and 90840 for crisis psychotherapy
In terms of remote patient monitoring, CMS has un-bundled CPT code 99091 for 2018, meaning that providers will soon be able to get reimbursed separately for time spent on collection and interpretation of health data that is generated by a patient remotely, digitally stored and transmitted to the provider, at a minimum of 30 minutes of time. CMS stated that this is a first step toward recognizing remote patient monitoring services for separate payment, and it will continue to closely track the AMA’s CPT Editorial Panel activities as they further refine and value the code sets for remote monitoring.
These policy updates signal that CMS is moving quickly to incentivize the integration of innovative technologies as it pushes for the transition to value-based care.
This panel will discuss the new CMS rules and concrete ways of how clinicians can make sure they’re reimbursed for using remote patient monitoring and telemedicine tools, thoughts on if the new rules went far enough for 2018, and what can be improved in the future.
Pending
As the the technology advances rapidly, it is extremely hard for scientific validation to catch up with that pace. What I believe should happen is that technological advances when being designed or developed should incorporate clinical utility data and integrated study designs. This can help accelerate scientific evidence review process and give us insights into appropriate applications and adoptions of these technologies.