CMS Continues to Modernize by Expanding Reimbursement for Digital Health Services

The COVID-19 Public Health Emergency (“PHE”) fundamentally changed the healthcare industry, forcing healthcare providers and patients onto their computers and phones to enable continuation of care when patients were mandated to stay home across the country. Prior to the COVID-19 PHE, approximately 12,5000 Medicare beneficiaries received telehealth services and only 106 telehealth services were reimbursable. By October 2020, over 24.5 million (of 63 million) Medicare beneficiaries received telehealth services.^[1] 

CMS first began reimbursing remote patient monitoring (“RPM”) services in 2019 and expanded coverage for RPM services each year. As of January, 1 2022, CMS further expanded remote care by recognizing therapeutic monitoring (“RTM”) services as Medicare-reimbursable services under the Centers for Medicare and Medicaid Services’ (“CMS”) CY 2022 Medicare Physician Fee Schedule (“PFS”) Final Rule (“CY 2022 Final Rule”).^[2] Under the CY 2022 Final Rule, CMS also expanded coverage of telehealth services by removing access barriers — increasing access to mental healthcare nationwide.

Medicare Coverage of RTM

While similar to RPM, RTM has a few notable differences. First, RTM involves the collection of non-physiological data, including medication adherence, therapy and medication responses, and pain levels. This data may be patient reported or digitally uploaded, whereas RPM data is physiological and may only be digitally uploaded. Further, RTM codes may only be used to monitor health conditions (e.g., musculoskeletal system status, respiratory system status, and therapy adherence and response). Finally, primary billers of RTM services are projected to be physiatrists, nurse practitioners, and physical therapists while RPM services are primary billed by physicians and ancillary providers.

The CY 2022 PFS Final Rule^[3] adds coverage for the following RTM Codes:

• CPT code 98980: Remote therapeutic monitoring treatment management services, physician/other qualified healthcare professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes.
  
  
• CPT code 98981: Remote therapeutic monitoring treatment management services, physician/other qualified healthcare professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes.
  
  
• Practice Expense-only RTM codes:
  
  
  
  • CPT code 98975: Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment.
    
    
  • CPT code 9897: Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days.
    
    
  • CPT code 98977: Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor.

Permanent Telemental Health Medicare Reimbursement Changes

CMS first established reimbursement for certain audio-only telemental health services in its Medicare and Medicaid Programs’ Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency Final Rule.^[4] CMS was primarily focused on continuation of care for opioid use disorders (“OUD”). CMS further expanded coverage for telehealth audio-only services (e.g., E/M services) on an interim basis in its CY 2021 PFS Final Rule.^[5]

While still trailing far behind commercial third-party payor policies, CMS has further softened its historic requirement for real-time two-way audio-video technology for telehealth services and has recognized that audio-only telehealth may be appropriate in certain circumstances for the provision of mental health services (i.e., the evaluation, diagnosis, and treatment of mental health conditions) provided by rural health clinics (“RHCs”), federally qualified health centers (“FQHCs”), and opioid treatment programs.

Notably, CMS also provided some insight into post-pandemic telehealth reimbursement and technology requirements, stating, “[f]or telehealth services other than mental health care, we continue to believe that two-way, audio/video communications technology is the appropriate, general standard that will apply for telehealth services after the PHE, so we do not believe it would be appropriate for these codes to remain on the telehealth list after the end of the PHE.”^[6]

RHCs and FQHCs

To address the concerns that, following the PHE, without changes to the definition of “mental health visits,” RHCs and FQHCs would no longer be paid for telemental health services, CMS finalized its proposal “to revise the current regulatory language for RHC or FQHC mental health visits to include visits furnished using interactive, real-time telecommunications technology and for RHCs and FQHCs to report and be paid for mental health visits furnished via real-time, telecommunication technology in the same way they currently do when these services are furnished in-person…” during the PHE.^[7] Further, CMS noted that RHCs and FQHCs would be paid for telemental health visits at the same rate as in-person visits.

Opioid Treatment Program Counseling and Therapy

CMS approved the use of audio-only telephone calls following the COVID-19 PHE for substance use counseling and therapy, including group therapy, furnished by opioid treatment programs where two-way audio-video technology is not available to the beneficiary (i.e., the beneficiary is not capable of using two-way audio-video technology or has not consented to the use of such technology) and other applicable requirements are met. CMS deferred to the treating clinicians to determine when and if in-person sessions were necessary for SUD and co-occurring mental health disorders.^[8]

CMS also clarified that practitioners may continue to use the therapy/counseling add-on HCPCs code G2080 for audio-only telephone sessions following the conclusion of the COVID-19 PHE.

The Future: Medicare Telemental Health Services Coverage for Patients Located in Their Homes

Following recently enacted legislation that added individual’s homes as a permissible originating site location^[9], CMS proposed to offer coverage for telemental health services provided to Medicare beneficiaries in their homes via audio-only technology with a caveat that the provider must have the capacity to furnish two-way, audio-video telehealth services. CMS is currently in the process of finalizing a service-level modifier for such services. However, a physician or practitioner must have furnished a Medicare reimbursable item or service in-person without the use of telehealth within six months prior to the initial telemental health service and once within twelve months of each subsequent telehmental health visit.^[10] There are some exceptions to the periodic subsequent in-person visit requirements, including when the risk of an in-person visit outweighs the benefits; however, there are no exceptions to the initial in-person visit requirement.^[11]

Staying up-to-date on regulatory and reimbursement changes remains incredibly important for digital healthcare providers to ensure that they are receiving appropriate payments for the services they provide and making informed business decisions when it comes to service area expansions and market entries.

^[1]86 Fed. Reg. 64996.
^[2]Id.
^[3]Id. at 65114-65117.
^[4]85 Fed. Reg. 19230, 19238 (Apr. 6, 2020).
^[5]85 Fed. Reg. 84536. (Dec. 2, 2020).
^[6]Supra fn 1. For more information on telehealth in Medicare post-PHE, check out MedPac’s Report to Congress – Medicare Payment Policy, Chpt. 14 (Telehealth In Medicare after the Coronavirus Public Health Emergency), available here.
^[7]Supra fn 1 at 65209-10.
^[8]95056
^[9]Consolidated Appropriations Act of 2021, Div. CC, Sec. 2 (Pub. L. 116–260, December 27, 2020).
^[10]45 C.F.R § 410.78(b)(3)(xiv)(B)
^[11]Supra fn 1 at 65058.