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2018 Final MPFS Rule: Update on Telehealth Services

On November 15, 2017, the Centers for Medicare and Medicaid Services ("CMS") published the 2018 Final Medicare Physician Fee Schedule Rule (the "MPFS Final Rule") in the Federal Register. The MPFS Final Rule addresses changes to the Medicare physician fee schedule and other Medicare Part B payment policies, as well as changes in the federal statutes affecting the Medicare Program. Among the changes addressed is telehealth services, specifically the addition of those services eligible for Medicare reimbursement as telehealth services, the elimination of a modifier, the announcement of the originating site payment for 2018, and a reminder regarding the application of civil rights laws to telehealth services.

Telehealth services are services furnished via an interactive telecommunications system (i.e., audio and video equipment permitting two-way, real-time interactive communication) by a physician or other authorized practitioner who is at one location (i.e., distant site) to a Medicare patient who is located in a rural health professional shortage areas or in a county that is not included in a metropolitan statistical area (i.e., originating site). If all the requirements are met, Medicare pays a facility fee to the originating site where the Medicare patient is located and makes a separate payment to the distant site practitioner providing the service.

The service must be on the list of Medicare telehealth services in order to be reimbursed by Medicare, and CMS through its rulemaking process (e.g., the MPFS Final Rule) annually updates the telehealth services which will be eligible for Medicare reimbursement. For 2018, CMS added the following to the list of telehealth services eligible for reimbursement: HCPCS code G0296 (counseling visit to discuss need for lung cancer screening using low dose CT scan); HCPCS code G0506 (comprehensive assessment of and care planning for patients requiring chronic care management services); CPT code 90785 (interactive complexity); CPT codes 90839 and 90840 (psychotherapy for crisis, first 60 minutes, and psychotherapy for crisis, each additional 30 minutes); and CPT codes 96160 and 96161 (administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument, and administration of caregiver-focused
health risk assessment instrument (e.g., depression inventory) for the benefit of the patient, with scoring and documentation, per standardized instrument). CMS rejected the following for inclusion in the list of Medicare-reimbursable telehealth services: physical and occupational therapy and speech-language pathology services; initial hospital care services; and online evaluation and management services. CMS retained the requirement that for end-stage renal disease services related to home dialysis, the practitioner must furnish at least one face-to-face encounter with the home dialysis patient per month for clinical examination of the catheter access site. Click here to view the list of services payable under the Medicare Physician Fee Schedule when furnished via telehealth.

In addition, CMS decided to make separate payment for remote patient monitoring, specifically CPT Code 99091 (collection and interpretation of physiologic data (e.g.,ECG, blood pressure, glucose monitoring)). For separate payment for CPT Code 99091, the practitioner must obtain advance beneficiary consent for the service and document this in the patient's medical record and, for new patients or patients not seen by the billing practitioner within one year prior to billing CPT Code 99091, there must have been a face-to-face visit with the billing practitioner. Although this was included in the discussion of telehealth services in the MPFS Final Rule, CMS acknowledges that remote patient monitoring services would generally not be considered Medicare telehealth services, as these services involve the interpretation of medical information without a direct interaction between the practitioner and beneficiary.

CMS had required distant site practitioners to submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT (via interactive audio and video telecommunications systems). Because a valid place-of-service or POS code is required on professional claims for all services and the appropriate reporting of the telehealth POS code serves to indicate both the provision of the service via telehealth and certification that the requirements have been met, CMS eliminated the requirement that the distant site practitioner report the GT modifier on the claim. Because a POS code is not used on an institutional claim, CMS still requires that distant site practitioners billing under Critical Access Hospital ("CAH") Method II continue to use the GT modifier on institutional claims (under the Standard Payment Method, payments for CAH outpatient services are made at 101 percent of reasonable costs; however a CAH may elect the Optional Payment Method or Method II, under which the CAH bills for both facility services and professional services furnished to its outpatients by a physician or practitioner who has reassigned his or her billing rights to the CAH).

The facility fee for the telehealth originating site, which is the site where the patient is located, was raised to $25.76 for calendar year 2018. It had been $25.40 for calendar year 2017.

In the commentary to the MPFS Final Rule, CMS also reminds that telehealth services are subject to the same non-discrimination laws as other services, including the effective communication requirements for persons with disabilities of section 504 of the Rehabilitation Act of 1973 and section 1557 of the Affordable Care Act, as well as language access for persons with limited English proficiency, as required under Title VI of the Civil Rights Act of 1964 and section 1557 of the Affordable Care Act. Although beyond the scope of this article, the civil rights laws require that for persons with disabilities, the covered entity must take appropriate steps to ensure that communications with individuals with disabilities are as effective as communication with others and this may include the providing of appropriate auxiliary aids and services, such as alternative formats and sign language interpreters, where necessary for effective communication. As for persons with limited English proficiency, the civil rights laws may require the provision of language assistance services, such as oral language assistance or written translation. The posting of notices providing information about communication assistance is also mandated under the laws. For a more in depth discussion, an article was published in the Baird Holm Health Law Advisory in July 2016, click here to view the article.


Joseph P. "Joe" Loudon

1700 Farnam Street | Suite 1500 | Omaha, NE 68102 | 402.344.0500