CMS Proposes Medicare Telehealth Coverage in 2021

Physician Fee Schedule proposed rule lays the groundwork for payment and policy changes.

The Centers for Medicare & Medicaid Services (CMS) released a proposed rule on Aug. 3 to address changes to the Medicare Physician Fee Schedule (MPFS) and other Medicare Part B payment policies for 2021, and beyond. We’ve got good news and bad news.

Summary of the 2021 MPFS Proposed Rule

In this major proposed rule, CMS is proposing to establish relative value units (RVUs) for calendar year (CY) 2021 for the MPFS to ensure that payment systems are updated to reflect changes in medical practice and the relative value of services, as well as changes in the statute. This proposed rule also includes discussions and provisions regarding several other Medicare Part B payment policies.

The bad news is: The proposed CY 2021 MPFS conversion factor is $32.26 – a decrease of $3.83, or 10.6 percent, from last year.

The proposed FQHC market basket update for CY 2021 is 2.5 percent, and the proposed multifactor productivity adjustment for 2021 is 0.6 percent, making the CY 2021 FQHC payment update 1.9 percent.

To find proposed code changes that might affect your practice, search the PDF version of the proposed rule for codes or keywords applicable to your practice.

Making Temporary Telehealth Coverage Permanent

In response to the public health emergency (PHE) for the COVID-19 pandemic, CMS undertook emergency rulemaking to add a number of services to the Medicare telehealth services list on an interim final basis, including communication technology-based services (CTBS). CMS is now considering which of those services should remain on the Medicare telehealth services list permanently after the end of the PHE.

The good news is: CMS is proposing to add the services in Table 8 on page 82 of the proposed rule to the Medicare telehealth services list on a Category 1 basis (services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the Medicare telehealth services list) for CY 2021. See page 94 for the proposed list for temporary additions to the list.

Type of Service	Specific Services and CPT® Codes
Services CMS is proposing for permanent addition to the Medicare telehealth services list.	Group Psychotherapy (CPT® code 90853)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 E/Ms (HCPCS Level II code GPC1X)Prolonged Services (CPT® code 99XXX)Psychological and Neuropsychological Testing (CPT® code 96121)
Services CMS is proposing as temporary additions to the Medicare telehealth services list.	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 1-3 (CPT® codes 99281-99283)Nursing facilities discharge day management (CPT® codes 99315-99316)Psychological and Neuropsychological Testing (CPT® codes 96130- 96133)

CMS is also proposing to allow billing of other CTBS by certain nonphysician practitioners (NPPs), consistent with the scope of the practitioners’ benefit categories through the creation of two additional HCPCS Level II G codes that can be billed by practitioners who cannot independently bill for E/M services:

HCPCS Level II Code	Descriptor
G20X0	Remote assessment of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment
G20X2	Brief communication technology-based service, e.g. virtual check-in, by a qualified health care professional who cannot report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to a service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

CMS is proposing to value these services identically to HCPCS Level II codes G2010 and G2012, respectively.

To facilitate billing of the CTBS by therapists, CMS proposes to designate HCPCS Level II codes G20X0, G20X2, G2061, G2062, and G2063 as “sometimes therapy” services. When billed by a private practice physical therapist (PT), occupational therapist (OT), or speech-language pathologist (SLP), the codes would need to include the corresponding GO, GP, or GN therapy modifier to signify that the CTBS are furnished as therapy services furnished under an OT, PT, or SLP plan of care. In section II.K. of this proposed rule CMS is proposing for CY 2021 to replace the eVisit G codes with corresponding CPT® codes, and this policy would also apply to those codes.

Care Management Services Code Refinements

To improve payment for care management services, CMS is proposing code refinements related to remote physiologic monitoring (RPM), transitional care management (TCM), and psychiatric collaborative care model (CoCM) services. For CY 2021, they are clarifying how we read CPT® code descriptors and instructions associated with CPT® codes 99453, 99454, 99091, and 99457 (and the add-on code 99458) and their use to describe remote monitoring of physiologic parameters of a patient’s health. Clarifications include:

• The medical device should digitally (automatically) upload patient physiologic data (data are not patient self-recorded and/or self-reported). The device must:
  • Be reasonable and necessary for the diagnosis or treatment of the patient’s illness or injury or to improve the functioning of a malformed body member.
  • Be used to collect and transmit reliable and valid physiologic data that allow understanding of a patient’s health status to develop and manage a treatment plan.
• As E/M codes, CPT® codes 99453, 99454, 99091, 99457, and 99458 can be ordered and billed only by physicians or NPPs who are eligible to bill Medicare for E/M services.
• RPM services are services furnished to patients with chronic conditions. Practitioners may furnish these services to remotely collect and analyze physiologic data from patients with acute conditions, as well as from patients with chronic conditions.
• “Interactive communication” for purposes of CPT® codes 99457 and 99458 involves, at a minimum, a real-time synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission.

New Payment Rates for Immunization Administration Services

During the current PHE related to the COVID-19 pandemic, CMS says it is evident that consistent beneficiary access to vaccinations is vital to public health. In the CY 2020 PFS final rule, CMS acknowledged that it is in the public interest to ensure appropriate resource costs are reflected in the valuation of the immunization administration services that are used to deliver vaccines.

Therefore, CMS is proposing to crosswalk the valuation of CPT® codes 90460, 90471, and 90473 and HCPCS Level II codes G0008, G0009, and G0010 to CPT® code 36000 Introduction of needle or intracatheter, vein.

This valuation would apply to all of these existing vaccine administration codes, using the valuation of CPT® code 90471 for base codes and CPT® code 90472 for add-on codes, and include a vaccine for COVID-19 or other infectious disease if one became available.

Increasing the Value of Services

CMS is proposing to increase many services that are comparable to or include office outpatient E/M visits, such as maternity care bundles, ED visits, and PT and OT evaluation services. CMS has finalized new values for CPT® codes 99202 through 99215 and assigned RVUs to the new office/outpatient E/M prolonged visit code 99XXX, as well as the new HCPCS Level II code GPC1X. These valuations were finalized with an effective date of Jan. 1, 2021. Check out AAPC’s E/M Workshop Series to help you prepare for the changes in 2021.

See Section H “Valuation of Specific Codes” in the proposed rule for proposed valuations of newly created and revised CPT® codes.

Scope of Practice and Related Issues

CMS is proposing several policies to modify supervision and other requirements of the Medicare program that limit healthcare professionals from practicing at the top of their license.

1. Teaching Physician and Resident Moonlighting Policies

CMS implemented several policies in the March 31 COVID-19 interim final rule with comment period (IFC) and the May 1 COVID-19 IFC related to MPFS payment for the services of teaching physicians involving residents and resident moonlighting regulations. CMS is considering whether these policies should be extended on a temporary basis — that is, if the PHE ends in 2021, these policies could be extended to Dec. 31, 2021, to allow for a transition period before reverting to status quo policy — or be made permanent.

The policies adopted on an interim basis during the COVID-19 PHE that are under consideration for extension include:

• Requirement for the presence of a teaching physician during the key portion of the service furnished with the involvement of a resident can be met using audio/video real-time communications technology.
  • For the primary care exception, CMS adopted a policy on an interim final basis for the duration of the COVID-19 PHE to allow the teaching physician to direct the care furnished by the resident, and to review the services furnished by the resident during or immediately after the visit, remotely using audio/video real-time communications technology.
• To allow MPFS payment to be made for the interpretation of diagnostic radiology and other diagnostic tests if the interpretation is performed by a resident when the teaching physician is present through audio/video real-time communications technology.
  • A physician other than the resident must still review the resident’s interpretation.
• Requirement for the presence of the teaching physician during the psychiatric service in which a resident is involved may be met by the teaching physician’s direct supervision using audio/video real-time communications technology.

CMS is soliciting public comments on whether these policies should continue once the PHE ends to assist them in identifying appropriate policy continuation decisions that may be finalized in the CY 2021 MPFS final rule.

2. Supervision of Diagnostic Tests by Certain NPPs

In the May 1 COVID-19 IFC, CMS established a policy on an interim basis during the COVID-19 PHE to permit physician assistants (PAs), nurse practitioners (NPs), and certain other NPPs to supervise diagnostic tests. CMS is now proposing to make these changes permanent by modifying the regulations. Proposals being made based on feedback received include the following:

• Amending the basic rule under the regulation at § 410.32(b)(1) to allow NPs, CNSs, PAs, or certified nurse-midwifes (CNMs) to supervise diagnostic tests on a permanent basis as allowed by state law and scope of practice.
• Amending the regulation at § 410.32(b)(2)(iii)(B) on a permanent basis to specify that supervision of diagnostic psychological and neuropsychological testing services can be done by NPs, CNSs, PAs, or CNMs to the extent that they are authorized to perform the tests under applicable state law and scope of practice, in addition to physicians and CPs who are currently authorized to supervise these tests.
• Amending the regulation at § 410.32 on a permanent basis to add paragraph (b)(2)(ix) to specify that diagnostic tests performed by a PA in accordance with their scope of practice and state law do not require the specified level of supervision assigned to individual tests, because the relationship of PAs with physicians under § 410.74 would continue to apply. CMS is also proposing to make permanent the removal of the parenthetical, previously made as part of the May 1, 2020, COVID-19 IFC, at § 410.32(b)(3) that required a general level of physician supervision for diagnostic tests performed by a PA.

3. Pharmacists Providing Services Incident to Physicians’ Services

CMS is reiterating the clarification provided in the May 1 COVID-19 IFC that pharmacists fall within the regulatory definition of auxiliary personnel under our regulations at § 410.26. As such, pharmacists may provide services incident to the services, and under the appropriate level of supervision, of the billing physician or NPP, if payment for the services is not made under the Medicare Part D benefit. This includes providing the services incident to the services of the billing physician or NPP and in accordance with the pharmacist’s state scope of practice and applicable state law.

Coverage Modifications for OUD Treatment Services Furnished by OTPs

The Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities (SUPPORT) Act established a new Medicare Part B benefit category for Opioid Use Disorder (OUD) treatment services furnished by Opioid Treatment Programs (OTPs) during an episode of care beginning on or after Jan. 1, 2020.

CMS is proposing to expand the definition of OUD treatment services to include opioid antagonist medications indicated for the emergency treatment of known or suspected opioid overdose. To best reflect the costs of these medications, CMS proposes to adjust the bundled payment rates through the use of add-on codes to account for instances in which OTPs provide Medicare beneficiaries with naloxone. The table below details the proposed coding and summarizes the proposed payment amounts for nasal naloxone and auto-injector naloxone.

HCPCS Level II Code	Descriptor	Total Payment
GOTP1	Take-home supply of nasal naloxone (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.	$89.63
GOTP2	Take-home supply of auto-injector naloxone (provision of the services by a Medicare-enrolled Opioid Treatment Program); List separately in addition to code for primary procedure.	$178

Comprehensive Screenings for Seniors

CMS is proposing to implement section 2002 of the SUPPORT Act by adding regulatory language to the existing Initial Preventive Physical Examination (IPPE) and Annual Wellness Visit (AWV) regulations to explicitly include elements regarding screening for potential substance use disorders and a review of current opioid prescriptions.

Your Comments Sought

CMS is seeking comments on several provisions, including the following:

• Whether there are additional services that fall outside the scope of telehealth services under section 1834(m) of the Act where it would be helpful for CMS to clarify that the services are inherently non-face-to-face, and so do not need to be on the Medicare telehealth services list in order to be billed and paid when furnished using telecommunications technology rather than in person with the patient present.
• Physicians’ services that use evolving technologies to improve patient care that may not be fully recognized by current MPFS coding and payment, including, for example, additional or more specific coding for care management services.
• Whether CMS should develop coding and payment for a service similar to the virtual check-in but for a longer unit of time and with an accordingly higher value.
• Any impediments that contribute to healthcare provider burden and that may result in practitioners being reluctant to bill for CTBS.
• Any additional information that the medical community and other members of the public believe may provide further clarification on how RPM services are used in clinical practice and how they might be coded, billed, and valued under the MPFS.

Comments regarding proposed changes are due to CMS by Oct. 5, 2020. See the proposed rule for commenting instructions.

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Resources:

CMS Fact Sheet, “Proposed Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021,” Aug. 3

https://www.cms.gov/newsroom/fact-sheets/proposed-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-4