The Centers for Medicare & Medicaid Services (CMS) began reimbursing providers for virtual and digital communication services on January 1, 2019, a step that should further facilitate the adoption of digital medicine. While CMS previously stated that these interactions should be considered part of standard Evaluation and Monitoring (E/M) services, CMS revised their position as part of the CY2019 final rule revising the Medicare Physician Fee Schedule (MPFS). In this rule, CMS specified 2 Healthcare Common Procedure Coding System (HCPCS) codes and 3 Current Procedural Terminology (CPT) codes eligible for reimbursement of remote monitoring and digital communication services (see Table 1 and 2 further below).

This change comes as part of a larger movement by CMS to reimburse for technology-enabled healthcare delivery, a key feature of Administrator Seema Verma’s remarks at HIMSS 2019.

One of the first steps toward reimbursing physicians for virtual care delivery came in 2001 when Congress carved out a specific set of “telehealth” services eligible for payment under MPFS. Defined by statute, telehealth services may only be reimbursed if the patient being treated “originates” from a rural county or an area with health professional shortages. However, despite these limitations, reimbursement for telehealth services was an important first step toward establishing reimbursement for technology-based services.

Then, in 2015, CMS implemented Chronic Care Management (CCM) under MPFS. While limited to patients with 2 or more chronic conditions, CCM allows providers to be reimbursed for time they spend coordinating care per patient per month—even without face-to-face interaction with the patient. These services may include phone calls to patients or their specialty providers, as well as time spent reviewing healthcare data reported through remote monitoring technology. When CCM was initially announced, it was met with broad stakeholder enthusiasm. However, strict requirements around documentation, personnel, and electronic health records, as well as the limitation that only 1 provider may bill for CCM per patient per month, have limited uptake below what CMS expected. Due to the low utilization, CMS has decreased some of the requirements of CCM as well as expanded the number of eligible codes to describe the service.

In 2019, CMS is further expanding reimbursement for virtual communications and remote monitoring while applying lessons learned from past efforts. Now, any provider may hold a telephone call with 1 of his or her standard patients who might be worried about a minor ailment, such as a persistent cough, and receive reimbursement for time spent on the call. Similarly, providers can receive reimbursement for evaluating recorded videos or images that patients send to them—activities that many providers have already been offering their patients, but without compensation for their time.

Administrator Verma’s stated priority to expand technology-enabled healthcare makes it likely that Medicare reimbursement of virtual health services will expand further in the future. Additionally, the American Medical Association (AMA) has identified CPT codes that could be performed remotely, which CMS may leverage for further expansion of reimbursement of remote services.

To learn more about Avalere’s work on virtual care delivery and remote monitoring, connect with us.