CMS reimbursement changes include telehealth platform expansion and eConsult

July 29, 2019

With healthcare spending in the United States projected to continue to rise through 2027, innovations designed to improve access to healthcare while reducing costs are more crucial now than ever. By making access to care more convenient and reducing costs, virtual care is empowering the modern patient population to be more proactive in managing their health; thus, improving population health metrics. Yet telehealth adoption has lagged disproportionately despite the positive impact it has across the healthcare sphere.

63 percent of health systems surveyed said improved federal support would speed implementation of virtual care services or increase use. Meanwhile, financial decision-makers insist on supporting these technologies only once they produce improved outcomes and reduced waste.

2019 CMS fee structure change objectives brought positive support for connected health to modernize the healthcare system and help “restore the doctor-patient relationship” by reducing administrative burden. These changes have made several telehealth services reimbursable for physicians, including virtual check-ins, remote patient monitoring and eConsults.

Virtual Check-ins: Virtual check-ins refer to brief non-face-to-face interactions with patients via communication technology, often telephone. Previously, they were not reimbursed by CMS, meaning check-ins not resulting in office visits would result in no payment. Virtual check-ins are an effective way of mitigating unnecessary office visits and improving efficiency. Adding reimbursement conditions makes adopting this procedure more viable for physicians.

Remote Patient Monitoring (RPM): Patients with chronic conditions often face many challenges in receiving quality care–the largest obstacles being the high cost of repeated office visits for monitoring of physiological data and the ability to receive care in a timely fashion. CMS added additional codes for reimbursement of RPM of certain parameters. Added reimbursement codes will facilitate adoption and result in improved quality, timeliness, and affordability of care for patients.

Interprofessional  Internet Consultations (eConsults): Treating practitioners often require input from specialists to provide adequate care to their patients. Because time spent consulting with specialists has not historically been reimbursed, the general practice has been referring patients to schedule a separate appointment. However, patients often experience difficulty accessing specialty care. Telehealth technologies, such as eConsults, increase access by providing primary care with a means of treating lower-acutity patients with the guidance of a specialist, freeing up face-to-face specialist appointments for higher-acuity patients.

CMS proposed new reimbursement codes covering eConsult time for all Original Medicare and select Medicare Advantage and Medicaid plans.

For Medicare Advantage beneficiaries, reimbursement rates may differ from those offered to Original Medicare. Further, the availability of reimbursement may depend on the state of residence for the patient’s plan and the provider’s contract status. The patient’s Medicare Advantage eConsult eligibility can be confirmed with the Medicare Advantage administrator. For Medicaid programs, eConsults are covered under CPT codes 99451 and 99452 in Connecticut, Kentucky, Michigan, Minnesota, Montana, Nebraska, and Utah. States where eConsults are not covered include Indiana, Maryland, Mississippi, Missouri, Texas, West Virginia, and the District of Columbia. All other states either have yet to release their 2019 fee schedule or do not list information about eConsult coverage.

For Medicare Advantage beneficiaries, reimbursement rates may differ from those offered to Original Medicare. Further, the availability of reimbursement may depend on the state of residence for the patient’s plan and the provider’s contract status. The patient’s Medicare Advantage eConsult eligibility can be confirmed with the Medicare Advantage administrator. For Medicaid programs, eConsults are covered under CPT codes 99451 and 99452 in Connecticut, Kentucky, Michigan, Minnesota, Montana, Nebraska, and Utah. States where eConsults are not covered include Indiana, Maryland, Mississippi, Missouri, Texas, West Virginia, and the District of Columbia. All other states either have yet to release their 2019 fee schedule or do not list information about eConsult coverage.

 Important considerations for eConsult reimbursement

· Code 99451 should only be billed by the consultative physician and 99452 by the treating and requesting physician. 

· A written report from the consultative physician is required to fulfill CPT code 99451; code 99452 should be billed when the referring physician spends at least 16 minutes preparing the information for the referral.

· Codes cover peer-to-peer (non-patient) communication only.  

· While usually required for telehealth reimbursements, modifiers and specific place of service codes do not apply for CPT Code 99452.

The rising cost of healthcare in the United States is a burden not only on patients, but on healthcare professionals as well. It’s imperative that stakeholders pursue innovative technologies for improving efficiency and quality of care. Virtual health and eConsult technologies are critical for improving healthcare providers’ ability to provide quality care, and their rate of adoption depends on financial viability for patients and physicians alike.

By adding new opportunities for reimbursement of telehealth tools, CMS is making it more feasible than ever before for healthcare professionals to leverage these technologies, improving efficiency and broadening access to healthcare for patients.

Dereck Tatman is President & COO at AristaMD. Click on his name above for more information.

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