On November 15, the Centers for Medicare & Medicaid Services (CMS) published its almost 400-page 2018 Medicare Physician Fee Schedule Final Rule. Buried among those hundreds of pages, as has been the case for the last five years, the Final Rule again refines and expands Medicare reimbursement for care management services.
Ambulatory Care Management
Having added reimbursement for transitional care management (TCM) in 2013; for chronic care management (CCM) in 2015; for advance care planning in 2016; and for complex CCM, care planning for CCM, and behavioral health integration in 2017, CMS in 2018 made relatively minor adjustments to the rules regarding these ambulatory care management services.
Most importantly, in the 2018 Final Rule, CMS changed how rural health clinics (RHCs) and federally qualified health centers (FQHC) bill and are paid for CCM. Citing differences between the Medicare Physician Fee Schedule and RHC/FQHC payment methodologies, CMS noted that RHCs and FQHCs cannot bill the full range of CCM services even though they often provide such services to patients.
CMS therefore created HCPCS G0511 (General Care Management Services) for use by RHCs and FQHCs whenever the requirements for CPT® 99490 (20 minutes or more of CCM services), CPT® 99487 (at least 60 minutes of complex CCM services) or HCPCS G0507 (20 minutes or more of behavioral health issues services) are provided. RHC and FQHC claims submitted using CPT® 99490 for dates of service occurring after December 31, 2017, will be denied.
Additionally, CMS changed RHC and FQHC reimbursement for CCM from the national payment amount for CPT® 99490 to the average of CPT® 99490, CPT® 99487, and HCPCS G0507. Using 2017 rates as an example, this would result in an increase from $42.71 to $61.37.
CMS also adds care planning for CCM, G0506, to the list of services which may be furnished via telehealth. On a related note, CMS eliminated the required reporting of the telehealth modifier “GT” for professional claims to reduce administrative burden. (Note: The GT modifier is still required for Critical Access Hospital [CAH] Method II billing.)
In response to a multitude of comments regarding the need for first-dollar coverage for ambulatory care management services (i.e., elimination of the co-payment requirement), CMS continues to assert that only congressional action can effect such change.
Remote Patient Monitoring
The big news in the 2018 Final Rule regarding care management is CMS’ decision to provide reimbursement for remote patient monitoring, or RPM. Starting in 2018, practitioners can receive separate payment (roughly $60) for accessing, reviewing, interpreting, and acting on various physiologic data for at least 30 minutes over a 30-day period. The required 30 minutes may include updating the patient’s care plan, or communicating with the patient, caregivers, or other providers regarding the data. This change is yet another acknowledgement from CMS that services furnished outside the physician office can be just as valuable as those provided within.
Some RPM billing requirements are similar to CCM services. Like CCM, practitioners must obtain and document beneficiary consent in the patient record prior to conducting RPM. An initial face-to-face visit is required prior to initiating RPM for new patients and patients not seen within the last 12 months.
Unlike CCM, the 30 minutes of service must be performed by a practitioner, not clinical staff under general supervision. Also, CMS has not limited the eligible recipients of RPM in any way; all Medicare beneficiaries are eligible as long as all service requirements are met.
Keep in mind that RPM is distinct from telehealth services; telehealth services require the patient to be in a health professional shortage area (HPSA) or rural area, and that the patient be present at a specific site of service. These restrictions do not apply to RPM.
Unlike the introduction of other care management services – which included dozens of pages of explanation – CMS devoted only a single page in the Final Rule to RPM. Not surprisingly, there remain several questions regarding this new billable service:
- How does one distinguish between CCM time and RPM time? Until now, RPM activities could be counted toward the 20 minutes of non-face-to-face services for CCM. Is this still the case? If a practitioner spends 50 minutes furnishing RPM in a given month, may he or she bill both RPM and CCM?
- Is it permissible to bill for reviewing data for multiple patients at the same time? Many RPM products provide an alert when a patient falls outside defined parameters, permitting a provider to monitor several patients at the same time. CMS needs to clarify whether a practitioner may count the same time toward multiple patients.
- Can RPM be furnished “incident to?” The Final Rule does not squarely address whether a physician can include time spent by clinical staff under the physician’s direct supervision reviewing data for established patients.
There are other meaningful questions about RPM to track over the next several months. Industry responses to these questions may shape future policy changes and the overall success of RPM:
- Will $60 be enough to incentivize physicians? Given that the $60 payment for RPM is less than the payment for a standard office visit, will physicians be willing to spend 30 minutes each month reviewing patient-generated data?
- How will the health information technology (HIT) industry respond? Developers have been miffed by the slow uptake of wearables and other monitoring tools, previously underestimating providers’ willingness to perform services for which they are not paid. With some reimbursement now available, will the HIT industry aggressively pursue this opportunity?
As evidenced by the 2018 Final Rule pertaining to care management, CMS continues its commitment to reward high-value healthcare services by revising and implementing policies for services like care management and RPM. Organizations that develop the infrastructure to implement these types of services position themselves well for the steady shift away from a fee-for-service environment.