CMS Finalizes Telehealth, RPM Coverage in 2021 Physician Fee Schedule

Expanding Coverage to New Services and Providers

The final rule begins with roughly 60 new telehealth services that can be reimbursed under Medicare, as follows:

• Group Psychotherapy (CPT code 90853);
• Psychological and Neuropsychological Testing (CPT code 96121);
• Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes 99334-99335);
• Home Visits, Established Patient (CPT codes 99347-99348);
• Cognitive Assessment and Care Planning Services (CPT code 99483);
• Visit Complexity Inherent to Certain Office/Outpatient Evaluation and Management (E/M) (HCPCS code G2211); and
• Prolonged Services (HCPCS code G2212).

Those services are included under Category 1, making coverage permanent. A separate group, called Category 3, reflects services that were included in emergency waivers issued during the past year to improve connected health coverage and adoption during the public health emergency created by the coronavirus pandemic. CMS has decided these services will continue to be reimbursed through the calendar year that the public health emergency concludes:

• Domiciliary, Rest Home, or Custodial Care services, Established patients (CPT codes 99336-99337);
• Home Visits, Established Patient (CPT codes 99349-99350);
• Emergency Department Visits, Levels 1-5 (CPT codes 99281-99285);
• Nursing facilities discharge day management (CPT codes 99315-99316);
• Psychological and Neuropsychological Testing (CPT codes 96130-96133; CPT codes 96136-96139);
• Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161-97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507);
• Hospital discharge day management (CPT codes 99238-99239);
• Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT codes 99469, 99472, 99476);
• Continuing Neonatal Intensive Care Services (CPT codes 99478-99480);
• Critical Care Services (CPT codes 99291-99292);
• End-Stage Renal Disease Monthly Capitation Payment codes (CPT codes 90952, 90953, 90956, 90959, 90962); and
• Subsequent Observation and Observation Discharge Day Management (CPT codes 99217; CPT codes 99224-99226).

In addition, CMS will now cover one nursing facility visit via telehealth every 14 days, down from once every 30 days. Telehealth advocates had argued that the frequency limit should be reduced to once every three days or even eliminated altogether, but the agency noted that these patients require longer care than hospital patients, and that a lax policy on virtual visits could have a detrimental effect on in-person care.

In its final rule, CMS has expanded the list of care providers able to be reimbursed for using telehealth to include clinical social workers, clinical psychologists, physical and occupational therapists and speech language pathologists. The agency is adding two new billing codes so that these providers can bill for virtual check-ins and remote evaluation of patient-submitted video or images.

The agency is also noting that telehealth rules don’t apply if the provider and patient are in the same location, even if the provider is using telecommunications equipment to monitor a patient to, for example, avoid risk of exposure to COVID-19.

With regard to coverage for audio-only phone check-ins, CMS is creating a new code for 11-20 minutes spent on the phone to determine the necessity of in-person care. This reimbursement would be about half as much as equivalent in-person care.

Remote Patient Monitoring Coverage

With more healthcare providers looking to extend care into the home, CMS has been gradually expanding coverage for what it calls remote physiologic monitoring services, and the agency proposed significant changes in the initial PFS released in August. That coverage is now set in place with the 2021 PFS.

The following RPM rules are included in the final document:

• Once the public health emergency ends, a care provider must have an established patient-physician relationship for RPM services to be furnished.
• Consent to receive RPM services may be obtained at the time that RPM services are furnished.
• Auxiliary personnel (including contracted employees) may provide services described by CPT codes 99453 and 99454 incident to the billing practitioner’s services and under their supervision.
• The mHealth technology supplied to a patient in an RPM program must be defined as a medical device under Section 201(h) of the Federal Food, Drug, and Cosmetic Act and must be reliable and valid. In addition, the data coming from these platforms must be electronically (i.e., automatically) collected and transmitted rather than self-reported.
• After the PHE ends, 16 days of data must be collected and transmitted every 30 days to meet the requirements to bill CPT codes 99453 and 99454.
• Only physicians and NPPs who are eligible to furnish E/M services may bill RPM services.
• RPM services may be medically necessary for patients with acute conditions as well as patients with chronic conditions.
• Via CPT codes 99457 and 99458, an “interactive communication” takes place in real-time and includes synchronous, two-way interactions that can be enhanced with video or other kinds of data as described by HCPCS code G2012.  In addition, the 20-minutes of time required to bill for the services of CPT codes 99457 and 99458 can include time for furnishing care management services as well as for the required interactive communication.

Expanded Telehealth Coverage

In addition, CMS is expanding coverage for direct supervision through interactive communications technology, under the idea that providers can use telemedicine platforms to supervise others and monitor patients without being in the same room. To that end, the agency will allow coverage for direct supervision through real-time interactive audio-visual technology until the end of the PHE or 2021, whichever comes first.

Finally, in a press release accompanying the 2021 PFS, CMS announced that it will commission a study on telehealth use during the pandemic to “explore new opportunities for services where telehealth and virtual care supervision, and remote monitoring can be used to more efficiently bring care to patients and to enhance program integrity, whether they are being treated in the hospital or at home.”