On November 1, 2022, The Centers for Medicare and Medicaid Services (CMS) announced their last 2023 Medicare Physician Fee Schedule (PFS) rule. When it is finalized, some of the most significant telehealth-related policy changes are:
- The discontinuance of reimbursement of phone (audio-only) Evaluation and Management (E/M) service;
- Stopping the use of direct supervision via virtual devices;
- Five new codes for telehealth that are permanent to provide extended E/M and chronic pain management
- Removing the effective date for the six-month rule on telemental health until 151 days after the period of a public health crisis (PHE) is over;
- The coverage extends for those temporary code telehealth for 151 days after PHE is over;
- With the addition of 54 numbers on the telehealth category 3 lists, they are changing their expiration date to 2023 or 151 days after PHE expires.
In September 2021, Medicare Telemedicine Snapshot Telehealth services had been growing more than 30 times since the beginning of the PHE and were employed by over 50% of the Medicare population. Telehealth and other digital health options continue gaining importance for Medicare patients and healthcare providers. Therefore, as the PHE is slated to end as the waivers for telehealth approach their expiration, CMS continues to grapple with the issue of how to ensure adequate access to telehealth care without crashing into the “Telehealth Cliff.” Most changes to the PFS reflect this battle and the post-PHE re-imposition of the Social Security Act’s Section 1834(m) conditions for health care telemedicine.
The Discontinuing Reimbursement of the Telephone (Audio-Only) E/M Services
As part of the PHE exemptions, CMS provided separate funding for the phone (audio-only) E/M-related services (CPT code 99441-99443). It was embraced by many doctors and patients, especially those living in rural areas or who do not have adequate broadband connectivity and patients who lack access to technology and digital literacy.
However, audio-only services were not generally accepted as a service that covered for a long time with a separate reimbursement. As a final decision, CMS elected to discontinue the coverage after PHE and did not add these services to Medicare’s Telehealth Services List. Besides certain telemental health services, CMS said that two-way audio-video telecommunications would remain the Medicare requirement for telehealth services after PHE. This is due to Section 1834(m)(2)(A) (A) of the Social Security Act requires telehealth services to be similar to in-person healthcare in that they can serve as a substitute for face-to-face interaction. CMS declared, “We believe that the statute requires that telehealth care be similar to care in person that they are an alternative to face-to-face interaction.” Because telehealth that uses audio is inherently not face-to-face, CMS determined the modality does not meet the statutory standards.
CMS also denied a request by a commenter to develop an additional virtual check-in code that includes a crosswalk with CPT code 99443 to allow an extended virtual check-in time than the current G2012 (5-10 minutes) as G2252 (11-20 minute) codes. CMS explained that the codes used for virtual check-in are intended to assess the need for medical attention; therefore, there is no reason to have an extended virtual check-in time.
Thus, 151 days following the PHE expiration and with the exception of certain mental health services that are telehealth-based, audio-only telephone E/M will return to their prior PHE “bundled” condition within Medicare (i.e., they are covered, but not separately payable, also referred to by the term “provider-liable”). Practitioners will not be reimbursed separately for these services.
Eliminating the Use of Virtual Direct Supervision
In Medicare Part B, specific types covered (e.g., diagnostic tests or services related to practitioners’ or physician’s professional services) must be provided with oversight by a doctor or practitioner. For Medicare purposes for direct supervision, it is required for the supervisory professional to be present physically within the same office as the supervisor and readily available to provide assistance and guidance during the execution of the course of the procedure. The professional in charge of supervision needs to reside in a different space during the procedure. Still, it is essential to note that the “immediate availability” condition requires that they be in-person and have physical, not virtual, availability.
In the case of PHE exemptions, CMS has temporarily altered the rules for direct supervision to permit the professional who supervises to be remotely located and utilize the latest technology in real-time audio video. This change didn’t require the professional’s presence in real-time during or live viewing of the procedure using interactive audio-video technology for the entire execution of the process. Temporarily the change was made because CMS was concerned that overall direct supervision via virtual presence might not be secure in certain instances of clinical practice.
In the final ruling, CMS rejected requests to create virtual direct supervision as an indefinite feature of Medicare. So, virtual direct supervision is scheduled to expire at the close of the calendar year when the PHE expires. By extending the PHE until November 11, 2023, the virtual Direct supervision would be in place until at least 2023’s end.
Three New Telehealth Codes for Extended E/M Services as well as Chronic Pain Management
CMS has rejected all stakeholder demands for adding codes to Medicare’s Telehealth Services List. In the standard process of evaluating requests for these requests, CMS assessed whether the requests fell into the appropriate criteria.
Category 1 services must be “similar to professional office consultations or office psychiatry which are currently listed on the Medicare Telehealth List.” Services in Category 2 must have “evidence of clinical value when provided via the telehealth service, ” and all the service’s essential elements must be delivered via a remote connection. CMS rejected this year’s requests because none of the proposed services (e.g., therapy, electronic analysis of implanted neurostimulator pulse generator/transmitter, adaptive behavior treatment, and behavior identification assessment codes) met the requirements of Category 1 or 2 services. The interested parties should collect and submit more convincing evidence to convince CMS to include these codes on either a basis of Category 1 or 2. next year (submissions are due on February 10, 2023).
CMS’s proposal for five new codes that should add to the Medicare Telehealth Services list on an ongoing basis:
- G0316 Prolonged hospital evaluation of observation or inpatient care and treatment service over the time allotted for your primary care when you have selected the service that is chosen based on the date of the leading service) and each additional 15 minutes must be arranged by the doctor or qualified healthcare professional, including or not having direct contact with the patient (list the additional CPT codes 99223,99233, and 99236 to refer to hospital inpatient or observation health evaluation and management).
- G0317 (Prolonged nursing facility evaluation and management service(s) over the time allotted for this service (when your primary provider was determined by the time of the day of the leading service) and each additional 15 minutes are determined by the doctor or a qualified healthcare professional including or not having direct contact with the patient (list separately, in addition to CPT codes 99306,99310 for evaluation of nursing facilities as well as management and evaluation services).
- G0318 (Prolonged evaluation of the home or residence and management service(s) for your primary services (when you have selected the service that is determined by the time of the day of the primary service). Each additional 15 minutes are supervised by the doctor or qualified healthcare professional and with direct contact with the patient (list separately, in addition to CPT codes 99345 and 99350 for evaluation of residence, home, or management).
- G3002 (Chronic pain management and treatment) monthly bundle that includes diagnosis, assessment, and monitoring; the use of a validated pain ratings instrument or scale; the creation of, implementation, modification, or maintenance of a patient-centered treatment plan that outlines strengths goals, objectives, requirements for clinical care and desired outcomes general treatment management as well as coordination and facilitation of any needed behavioral health care medications; health literacy and pain counseling; any required urgent crisis treatment for chronic pain in continuous interaction and coordination of care between the relevant professionals providing, e.g., occupational therapy and physical therapy, as well as integrative and complementary methods, and community-based health treatment, if needed. The initial visit must be a minimum of 30 minutes of therapy provided by a physician or another qualified health professional and; initial 30 minutes of personal care provided by a doctor or other certified health professional each calendar month. (When you are using G3002, 30 minutes must be achieved or not exceeded.))
- G3003 (Each further 15 minutes in chronic pain and care provided by a medical doctor or other qualified healthcare professional per calendar month. (List separately, in addition to the code for G3002). (When you are using G3003, the 15-minute limit must be achieved or not exceeded. )).
The E/M extended services and Chronic Pain Management codes have been added to Category 1 since they’re sufficiently similar to similar Medicare Telehealth Services currently listed on a category 1 basis. The main difference is that the initial instance of G3002 will be delivered in person with no recourse to technology for telecommunications.
The Delay of the Effective Date of the Telemental Health Six-Month Rule until at Least 151 Days after the PHE Deadline.
In 2020 Congress imposed new restrictions for telemental health coverage in Medicare and created an in-person examination requirement along with coverage for telemental health care for patients at home. The rule states that Medicare will pay for telehealth services in the presence of the patient at home when all the conditions listed below are fulfilled:
- The doctor will conduct an in-person examination of the patient in the six months preceding the first Telehealth service being initiated.
- The telehealth services are provided to aid in the diagnosis or evaluation of a mental health condition (other than treatment for a substance use disorder that is diagnosed (SUD) as well as co-occurring mental health disorders); and
- The doctor conducts at minimum one in-person appointment every 12 months—subsequent telehealth treatment.
For a complete understanding of the rules, please look at frequently asked questions and what it means to practitioners on Medicare Telehealth mental health FAQs.
The rule was initially scheduled to go into effect one day after PHE expires. It is now scheduled to be in effect within 151 days of the day it expires. PHE expires.
The Temporary Telehealth Codes until 151 days After the PHE Terminates
Temporary telehealth codes refer to services added to Medicare’s Telehealth Services List in this PHE only intermittently but not categorized into Category 1, 2, or 3. The coverage of these temporary telehealth codes was set to expire at the time that they expired. PHE expires.
With the final PFS regulation, CMS finalizes the extension of the coverage of these temporary telehealth codes to 15 days after PHE expires. CMS has done this to ensure coherence with Consolidated Appropriations Act, 2022 (CAA). CMS said that this extension could simplify the transition post-PHE by applying the same coverage ending date to all codes related to waivers to reduce the number of billing errors.
Add 54 Codes to the Category 3 Telehealth List.
CMS added new features to the Medicare Telehealth Service List on a category 3 basis. They could also extend the expiration dates of the codes by changing their expiration date to 2023 or 151 days after the PHE closes. CMS has ruled out a few other codes from being included on a Cat 3 basis since they pertain to inherently non-face-to-face services. These are offered by practitioners and are no longer permitted to provide telehealth-related services on the 152 second day after the conclusion of the PHE, or all of the services cannot be currently offered via two-way audio-video communications technology.
CMS’ Category 3 list includes services that could benefit patients in the event of telehealth services. However, there needs to be more evidence to justify coverage for a long time. CMS suggested the addition of 54 codes to the category 3 list. The services fall into nine categories: (1) therapy; (2) electronic analysis of implanted neuro-stimulator pulse generator/transmitter; (3) adaptive behavior treatment and behavior identification assessment; (4) behavioral health; (5) ophthalmologic; (6) cognition; (7) ventilator management; (8) speech therapy; and (9) audiology.
CMS reiterated in the PFS that it is hoping that those interested will take advantage of the extended timeframe of Category 3 to collect data that will allow for the permanent incorporation of codes like these into future rules, which go beyond affirmations of support and subjective claims of benefits from clinical research. In addition, CMS is looking for concrete evidence of benefits from clinical research, like clinical studies or peer-reviewed studies. Therefore, interested parties must submit evidence before the deadline of February 2023 if they would like to see services in Category 3 included regularly.
The final ruling CMS has clarified the overlap that we noted in our report on the new PFS, which could have resulted in Category 3 codes being expired before temporary telehealth codes if the PHE expires after August 2023. It means that CMS may have extended the expiration time of Category 3 codes by altering their expiration date from 2023’s expiration date until earlier in 2023, or 151 calendar days after the PHE is over to ensure the Category 3 codes are accessible through the extension provisions of the CAA.
