On July 7, the Centers for Medicare & Medicaid Services (CMS) released its annual proposed rule updating the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2023, which included various proposed changes related to the provision of telehealth, including implementing telehealth provisions included within the Consolidated Appropriations Act, 2022, and extending coverage through the end of CY 2023 for some telehealth services that have been enabled during the PHE, among others. CMS also proposed changes to address concerns about access to remote therapeutic monitoring services. This newsletter summarizes select telehealth and remote therapeutic monitoring provisions.
Telehealth Provisions
Implementation of Congressional Telehealth Improvements. In March 2022, President Biden signed the Consolidated Appropriations Act, 2022, an omnibus funding bill that included several telehealth provisions aimed at ensuring a smooth transition after the end of the COVID-19 PHE.1 The bill extended Medicare coverage for a broad range of telehealth services for 151 days after the end of the PHE that would have otherwise expired at the end of the PHE.
CMS proposes to implement several telehealth provisions in the Consolidated Appropriations Act, 2022, by:
- Proposing to extend coverage of services temporarily added to the Medicare Telehealth Services list during the PHE for 151 days after the end of the PHE
- Proposing to extend the following telehealth policy flexibilities, via program instruction or other sub-regulatory guidance, for 151 days after the end of the PHE:
- Any site in the United States, including a patient’s home, will be considered an eligible originating site for the delivery of telehealth services.
- Facility fees will not be paid to newly covered originating sites (e.g., a patient’s home).
- Eligible telehealth practitioners will continue to include qualified occupational therapists, physical therapists, speech-language therapists and audiologists.
- Federally qualified health centers (FQHCs) and rural health clinics (RHCs) may serve as originating or distant sites for the delivery of telehealth services.
- Providers will not be required to meet in-person visit requirements in order to deliver mental health services via video or audio-only visits. This applies to all sites of care, including FQHCs and RHCs (except in the case of hospice patients).
- Coverage of telehealth services delivered via audio-only format will continue for specific service codes identified by Medicare as being eligible for delivery via audio only.
- Practitioners will be able to use telehealth to conduct face-to-face encounters prior to recertification of eligibility for hospice care.
Proposed Changes to the Medicare Telehealth Services List. CMS proposes several changes to the list of telehealth services eligible for Medicare coverage.
- Temporarily Extending Coverage for Some “Category 3” Telehealth Services Through CY 2023. CMS is proposing to make several services that are temporarily available via telehealth during PHE available through the end of CY 2023 under the “Category 3” designation. Category 3 services are services with respect to which CMS has determined there is likely clinical benefit when furnished via telehealth but there is not sufficient evidence available to justify permanent coverage. Acknowledging the need to gather more information regarding the utilization, clinical appropriateness and value of these services, CMS is proposing to cover the following services, among others, through CY 2023: emotional/behavioral assessment, psychological, and neuropsychological testing and evaluation services; eye exams with established patients; select neurostimulator pulse generator/transmitter services; wheelchair management training; and psychophysiological therapy.
- Permanently Adding Coverage for Prolonged Services in Various Settings as a “Category 1” Service. CMS is proposing to permanently cover prolonged services delivered via telehealth by a physician or other qualified health practitioner in inpatient or observation, nursing facility or home/residence settings as “Category 1” telehealth services.
- Removing Some Services From the Medicare Telehealth Services List After the End of the 151-Day Period Following the End of the PHE. CMS is proposing to end coverage for some telehealth services that have been temporarily covered via telehealth during the PHE after the end of the 151-day period following the end of the PHE, including neonatal and pediatric critical care initial services, radiation services, eye exams with new patients, some auditory tests and assessments, some hospital and nursing-facility-level care, and telephone evaluation and management visits.
Proposed Changes to Modifiers. During the COVID-19 PHE, CMS temporarily instructed providers delivering services via telehealth to report those services with a place of service that would have been reported had the service been furnished in person, along with modifier “95.” This policy allowed CMS to pay for services furnished via Medicare telehealth that would have been furnished in person at the same rate they would have been paid if the services were furnished in person.
CMS now proposes policies for the winding down of this procedure. As proposed, after the end of the 151-day period following the end of the PHE, providers would indicate the appropriate place of service on telehealth claims. CMS also proposes requiring modifier “93” for telehealth services delivered via audio-only technology.
Discontinuation of Virtual Direct Supervision. Prior to the PHE, some Medicare Part B services (e.g., diagnostic tests, incident to services) were required to be furnished under the direct supervision of a physician or practitioner. In response to the PHE, Medicare temporarily allowed the use of audio/visual telehealth technology to conduct virtual direct supervision. Due to a gap in available evidence and concerns related to patient safety, CMS is proposing to expire this flexibility at the end of the calendar year in which the PHE ends; however, CMS will continue to seek information regarding virtual direct supervision to inform future permanent policy decisions.
Remote Therapeutic Monitoring Services
CMS finalized Medicare payment for five Remote Therapeutic Monitoring (RTM) codes in the CY 2022 Physician Fee Schedule (PFS) final rule. In the CY 2023 PFS, CMS proposes four new codes to address concerns about access to RTM services and supervisory requirements. One pair of codes (GTRM3-4) enables nonphysician qualified health care professionals (QHPs) to bill directly for RTM services. A second pair of codes (GTRM1-2) will enable general supervision by physicians or nonphysician practitioners (NPPs) of auxiliary personnel performing “incident to” services. CMS also clarified that the RTM device supply codes (98975-7) must be billed in order to bill the RTM professional codes (GTRM1-4).
CMS notes that there was a request from stakeholders to develop a generic device code for RTM (the current codes are limited to monitoring respiratory or musculoskeletal systems), but CMS ultimately decided to wait on developing a general code and is seeking comments to better understand the costs, data and utilization of expanding to additional systems and conditions.
Lastly, CMS proposes that for 2023, the CPT code covering cognitive behavioral therapy monitoring device supply (989X6) be contractor priced (i.e., reimbursement rates established by each local Medicare Administrative Contractor).
1 For more on the telehealth provisions included in the omnibus legislation, see the Manatt Health newsletter.