Medicare Proposed Changes to Remote Care Management: 8 Key Takeaways

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Medicare Proposed Changes to Remote Care Management: 8 Key Takeaways
by Daniel Tashnek

CMS recently released its 2023 Medicare physician fee schedule proposed rule. There are some noteworthy, proposed additions and changes that, if approved, would significantly affect the delivery, coding, and billing of preventive services, remote care management — including remote therapeutic monitoring (RTM) — and telehealth.

Here's a rundown of eight of the key takeaways in these areas from the proposed rule. To learn more about these and other significant potential developments included in the CMS document, watch this on-demand webinar.

1. Virtual direct supervision to end

One of the most significant pieces of news from the proposed rule is that, despite requests from the medical community to make it permanent, CMS indicated it intends to no longer permit the usage of virtual direct supervision once the COVID-19 public health emergency (PHE) ends. More specifically, virtual direct supervision would expire at the end of the year in which the PHE is ended. If the PHE ends this year, the supervision waiver would expire Dec. 31, 2022. If the PHE ends any time next year, the waiver would expire Dec. 31, 2023. Many in the medical community had hoped that CMS would make virtual direct supervision permanent.

Brief background: In connection with the PHE, CMS temporarily changed direct supervision rules to allow clinical staff to be "virtually supervised" by a physician when they were not physically in the same location. As long as the provider was reachable via audio/visual communications, remote employees were considered as being directly supervised. This allowed the likes of annual wellness visits (AWVs) and other preventive services to be performed by clinical staff not physically located in the provider's clinic.

The proposed rule indicates CMS intends to lapse the change at the end of the calendar year of the year that the PHE is ended. If this decision is finalized, as is expected, the ramifications will be significant for reasons we'll get into in a future blog post.

2. Phone E/M services and other audio-only telehealth to be discontinued

Under the COVID-19 PHE, CMS has allowed separate reimbursement of audio-only evaluation and management (E/M) services via CPT 99441-99443. As with virtual direct supervision, CMS indicated it is planning to reject requests to add these services permanently. In addition to the phone E/M services covered under CPT 99441-99443, this would also eliminate the ability to furnish other telemedicine services without real-time, two-way video. If the proposed rule is finalized as written, audio-only telehealth services will no longer be reimbursed 151 days after PHE ends — which is scheduled for Oct. 13, 2022, unless it's extended. Provider phone time will still be reimbursable under care management services when other requirements are met.

What's the significance? Consider that under the current rules, a clinician can provide a Medicare annual wellness visit (AWV) over the phone because the AWV is considered an E/M service. Same with preventive services like alcohol misuse screening and depression screening. CMS is proposing to require the usage of audio-visual telehealth again following the completion of that period after the PHE ends. This is a rather drastic development and one that's likely to spur an increased use of provider-time care management codes after audio-only E/M codes are discontinued.

3. Descriptors for alcohol misuse and depression screening times revised

CMS is proposing to revise the descriptors for the annual alcohol misuse screening and annual screening. Whereas the descriptors previous stated that providers were expected to spend 15 minutes on these services, the time it typically took was lower. The revised descriptors address this discrepancy by specifying screening times of "5 to 15 minutes" as the typical range to furnish these services. The modified descriptors proposed read as follows:

  • HCPCS G0442: "Annual alcohol misuse screening, 5 to 15 minutes"
  • HCPCS G0444: "Annual depression screening, 5 to 15 minutes"

While not a significant change, this would be a welcome one and would be a change that's more reflective of the actual services provided.

4. Creation of the chronic pain management service

One of perhaps the most surprising developments coming out of the proposed rule is CMS's consideration to create a new care management service called "chronic pain management and treatment services (CPM). For the purpose of this service, CMS described chronic pain as "persistent or recurrent pain lasting longer than three months."

Accompanying the proposal to create the CPM service are two new proposed HCPCS codes: GYYY1, for the initial 30 minutes of CPM services, and GYYY2, for additional 15 minutes of CPM services. Of note is that CMS is proposing to allow a physician or "other qualified healthcare professional" to provide CPM and is also proposing to add this service to the general care management HCPCS G0511 used by rural health clinics (RHCs) and federally qualified health centers (FQHCs). Furthermore, CMS is proposing that the new codes do not allow services to be provided incident to the billing provider

Why is CMS interested in covering such a service? Language in the proposed rule highlights CMS's commitment to combatting the opioid epidemic while not stymieing legitimate pain management care. CPM would serve as part of a more overarching opioid and pain management strategy where the goal is to make sure those with pain receive proper and effective treatment.

As the proposed rule describes CPM, the service must be provided entirely by the billing provider, which is likely to limit its reach. But it's clear that CMS isn't attached to this description as it's asking for comments concerning whether the service should be partly furnishable under general supervision. With this uncertainty, it's likely that we won't see CPM approved as a covered service in the 2023 Medicare physician fee schedule final rule, but it's clear that CMS envisions a covered CPM service in the not-so-distant future.

5. Remote therapeutic monitoring (RTM) getting an overhaul

RTM received significant attention in the proposed rule. First, CMS is proposing the addition of four new RTM HCPCS codes that would replace existing CPT codes 98980 and 98981. These new HCPCS codes are as follows:

  • HCPCS GRTM1 and GRTM2 for use by physicians or non-physician practitioners
  • HCPCS GRTM3 and GRTM4 for use by non-physician qualified healthcare professionals

The proposed rule further states that coverage of RTM would allow time spent on "incident to" services by clinical staff under general supervision rather than just direct supervision. This would open the provision of RTM up beyond providers and non-physician providers to include the likes of qualified speech language pathologists and respiratory therapists, for example.

In addition, CMS is proposing to accept contract-priced RTM device CPT code 989X6 for cognitive behavioral therapy (CBT). What this means is that while CMS is not leaning toward approving a general device code yet, as many in the industry have pushed for, the agency is considering adding one more device code for CBT that would join existing RTM device CPT codes for respiratory and musculoskeletal systems.

The proposal also points to CMS's intentions to require providers that want to bill for RTM care time to also bill for the devices as a means of ensuring remote therapeutic management is only being provided to the disease states CMS has defined: respiratory, musculoskeletal, and now cognitive behavior therapy. This would be in contrast with remote patient monitoring (RPM), which does not have such a care/device alignment.

6. New behavioral health integration (BHI) service for social workers and psychologists

The proposed changes to BHI are similar in some ways to those being proposed for RTM. CMS is proposing a new HCPCS code GBHI1 that would be billable by psychologists and social workers. HCPCS GBHI1 would be billable during the same month as chronic care management (CCM) and transitional care management (TCM) services. The addition of the code would also bring with it an additional list of designated care management services for which general supervision is permitted.

What's the significance of these proposals? As with RTM, CMS is moving to open up behavioral health integration services to be provided and billable by non-providers, specifically psychologists and social workers. CMS indicates it is recognizing that considering the amount of medical decision-making inherent in these services, together with the substantial staffing shortage we're experiencing, it behooves the healthcare industry to utilize such qualified professionals to deliver these important services.

As with the new chronic pain management service, CMS is also proposing to add this service to the general care management HCPCS G0511 used by rural health clinics and federally qualified health centers.

Given underlying CMS regulations, psychologists and social workers will have a slightly different experience using the new BHI code. While clinical psychologists can have care staff under their supervision provide time towards the BHI code, clinical social workers will have to provide all 20 minutes themselves.

BHI requires an “initiating visit” to enroll a patient into the program. CMS is proposing to allow psychiatric diagnostic evaluation (CPT 90791) to serve as the initiating visit for HCPCS GBHI1, with CMS stipulating that only one code can be the initiating visit for the new BHI code.

7. CMS still seeking comments for remote patient monitoring

Unlike in years past, RPM was not a focal point of the proposed rule. And that's not good news. Despite asking for and receiving substantial comments concerning RPM during past comment periods, CMS has essentially punted on making concrete decisions around remote physiological monitoring and is asking for even more comments.

Here's what the proposed rule states: "We appreciate the continuing dialogue about the remote monitoring codes and welcome comments including any additional information that the medical community and other members of the public believe may provide further clarity on how remote patient monitoring services are used in clinical practice, and how they would be most appropriately coded, billed and valued under the Medicare physician fee schedule."

For those in the industry looking for clarification around remote patient monitoring, this continued call for comments is frustrating, especially since it's unlikely that RPM comments submitted in response to the 2023 PFS proposed rule will be substantially different from those submitted in the past.

8. CMS seeking comments for a lot of other important areas

It's not just remote patient monitoring where CMS requested comments in the proposed rule. CMS included a large section in the document where it stated it wanted information about underutilized, "high-value" services — those that support beneficiaries and promote health and health education while helping reduce spending and future risks. In CMS's words, "Medicare provides payment for many kinds of services that support beneficiaries in promoting health and well-being and that may also, in some cases, reduce unnecessary spending within the healthcare system by decreasing the need for more expensive kinds of care."

The agency goes on to cite examples such as preventive services, the Medicare annual wellness visit, and diabetes self-management training, and then further outlines the information it's looking for: identifying high-value services, identifying the barriers to underutilization of those services, and suggestions or comments on how to improve access to these valuable services.

CMS also indicated it is seeking comments that can help the agency in its effort to examine conditions of payment or rates for services, determine whether and where to prioritize beneficiary and provider education investments, and gather evidence about benefits of providing emergency department E/M, critical care, and observation services via telehealth to use as a guide for permanently adding codes to list of approved telehealth services.

Comments must be submitted by Sept. 6, 2022. The easiest way to submit a comment is to do so online via the Regulations.gov website, specifically this page for the 2023 Medicare PFS proposed rule.

On-Demand Webinar: Medicare 2023 Physician Fee Schedule Proposed Rule

If you're interested in finding out more about the takeaways highlighted above and several other noteworthy topics included in the proposed rule, access this on-demand webinar, presented by me, Daniel Tashnek, CEO of Prevounce. I hope you find it helpful!

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