CMS Fees and the Future of Connected Health

One of the biggest trends to emerge from what was arguably the most hectic year in recent history from a healthcare perspective is significant growth in the use of connected health technologies. Most of the growth was driven by the need for healthcare continuity during the pandemic, but it served to advance connected health services as a part of normal healthcare delivery.

At the end of 2020, CMS issued its final rule updating its Medicare Physician Fee Schedule (PFS), effective January 1, 2021. The changes reflect a continued commitment to creating new healthcare models that promote access, affordability, empowerment, and innovation to improve care quality. The updated PFS brings new opportunities for Remote Patient monitoring, expands access to certain remote healthcare services while adding new connected health services CPT codes.

By mid-October of 2020, almost 40% of Medicare beneficiaries have received connected health-based services during the pandemic.  The changes for 2021 are intended to expand access to connected health services for Medicare beneficiaries not only during the remainder of the public health emergency but beyond. They may also provide increased evidence that connected health can deliver value for providers and patients in several ways:

  • Provide better access to care
  • Promote Remote Patient Monitoring services for better management of conditions
  • Increase provider efficiency, reduce time and cost of care, limit burnout
  • Drive data-driven medical decision-making and value-based care, models

While the new rule is in effect for the calendar year 2021 and some of the new guidelines expire at the end of 2021, many enhancements can provide a cushion for continued discussion on advancing connected health services from temporary emergency provisions permanent fixtures across the healthcare system.

Expanded Connected Health Practitioners

In clarification of previous guidance, the new rule includes provisions for licensed clinical social workers, psychologists, physical therapists, occupational therapists, and speech pathologists to deliver assessments and management virtually. CMS has also added two new CPT codes for billing of telehealth services by providers.

Testing Supervision

Individual non-physician practitioners, such as nurse practitioners, clinical nurse specialists, physician assistants, and others, will continue to supervise diagnostic testing. Likewise, physical and occupational therapists may extend maintenance therapy performance to PT or OT assistants to enable their practices to treat patients efficiently.

Phone-based Check-ins

CMS has created a new HCPCS code for phone (voice-only) check-ins, which supports short (11-20 minutes) phone consultations to determine whether an in-person visit is necessary.

Remote Patient Monitoring

CMS updated several of its RPM policies to provide greater clarity. For instance, following the PHE end, there must be an existing patient-physician relationship to use RPM services; and RPM services must use FDA-approved devices and transmit data digitally. The new rule also adds greater flexibility for RPM’s use, allowing for its use with patients with acute or chronic conditions and allowing auxiliary personnel to provide RPM services on behalf of prescribing physicians.

Direct Supervision with Telehealth

Supervising physicians have previously needed to be in-building to support telehealth interactions. Under the new rule, they may supervise through telehealth applications that support real-time, two-way, audio, and video communications.

Additional Services List

CMS has added more than 60 services to its covered telehealth services list, including several Category 1 services and many more temporary Category 3 services.

Category 1

    • 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)
    • Prolonged Services (HCPCS code G2212)

Category 3

    • 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)
    • Subsequent Observation and Observation Discharge Day Management (CPT codes 99217; CPT codes 99224-99226)

The long-term impact of these changes remains to be seen, especially since permanently changing some of the restrictions that were loosened during the pandemic will require legislative action. But, what is clear is connected health has been an asset during the past year, and the policy changes that were enacted help create a much more positive perception of connected health services.

With the latest changes, CMS is providing not only greater clarity for providers to enable them to more effectively deliver connected health services, but it is also creates additional time for Congress to enact permanent changes based on additional data showing the value and benefits of connected health. Several organizations have already expressed support for additional legislative action to broaden the availability of connected health services, and the President signed an Executive Order to improve telehealth access in rural areas, setting the stage for even greater action.

To learn more about how to effectively leverage the new connected health tools that are revolutionizing healthcare, visit us here.