CMS’ 2019 PFS Payment Policies for Telehealth Services

CMS’ 2019 PFS Payment Policies for Telehealth Services

By Mark S. Armstrong, J.D.

The Centers for Medicare and Medicaid Services (“CMS”) recently published its final rule regarding payment policies under the Physician Fee Schedule (“PFS”). CMS’ final rule approves and pays under the PFS for a discrete set of new patient services that are provided via remote communication technology and increases access for Medicare beneficiaries to physicians by recognizing the following services that involve the use of communication technology.

  1. Brief Communication Technology- Based Service, e.g. Virtual Check-In .

Beginning January 1, 2019, CMS will pay physicians for a newly defined type of service furnished using communication technology. This service is billable when a physician or other qualified health care professional has a brief non-face-to-face check-in with a patient via communication technology, to assess whether the patient’s condition necessitates an office visit. CMS’ final rule approves payment for virtual check-ins under the following circumstances:

  • Utilizes real-time audio-only telephone interactions in addition to synchronous, two-way audio interactions that are enhanced with video or other kinds of data transmission. (Telephone calls that involve only clinical staff cannot be billed under code be billed using HCPCS code G2012 since the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.)
  • If the service originates from a related E/M services provided within the previous 7 days by the same physician or other qualified health care professional the service is considered bundled into the previous service.
  • Verbal consent is noted in the patient’s medical record for each billed service.
  • The service is limited to established patients. (CPT defines an established patient as one who has received professional services from the physician or qualified health care professional or another physician or qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past 3 years.)
  • There are no frequency limits on the use of the code.
  • There are no specific documentation requirements for this service; however, the services must be medically reasonable and necessary.
  1. Remote Evaluation of Pre-Recorded Patient Information.

Beginning January 1, 2019, CMS will also pay physicians for the remote professional evaluation of patient transmitted information conducted via pre-recorded “store and forward” video or image technology, provided, however, that the service is not separately billable if there is no resulting E/M office visit and there is no related E/M office visit within the previous 7 days of the remote service being furnished.

CMS’ final rule approves separate payment for remote evaluation of recorded video and/or images submitted by the patient under code G2010 under the following conditions:

  • The service is limited to established patients.
  • Beneficiary consent that could be verbal or written, including electronic confirmation that is note in the patient’s medical record for each billed service.
  • Practitioner follow-up may take place by phone call, audio/video communication, secure texting messaging, email or patient portal communication, but must be compliant with HIPAA.
  1. Interprofessional Internet Consultation.

CMS’ final rule approved six new CPT codes (99451, 99452, 99446, 99447, 99448 and 99449) that describe assessment and management services conducted through telephone, internet, or electronic health record consultations furnished when a patient’s treating physician or other qualified healthcare professional requests the opinion and/or treatment advice of a consulting physician or qualified healthcare professional with specific specialty expertise to assist with the diagnosis and/or management of the patient’s problem without the need for the patient’s face-to-face contact with the consulting physician or qualified healthcare professional.

CMS is requiring the treating practitioner to obtain verbal beneficiary consent in advance of these services, which consent must be documented in the patient’s medical record.

In adopting these six codes, CMS is adapting to new trends involving comprehensive patient-centered care management, which particularly impacts patients with chronic conditions including heart disease, diabetes, respiratory disease, breast cancer, allergies, Alzheimer’s Disease, and factors associated with obesity.

CMS’ final rule recognizes that virtual care may improve beneficiary access to high-quality services while lowering the cost of healthcare. By adopting these rules, CMS hopes to support innovation and provide a telehealth benefit without regard to certain geographic limitations.