SummaryApproximately ⅓ of physician services payments are eligible for telehealth reimbursement under Medicare (fee-for-service) FFS through existing Center for Medicare and Medicaid Services (CMS) guidance as of January 2020, in addition to temporary coding guidance specific to COVID-19 effective as of March 1, 2020. Avalere’s analysis highlights the immediate potential for specific physician specialties to utilize telehealth based on temporary flexibilities regarding which procedures are eligible for telehealth reimbursement.
Including existing and temporary guidance, 191 physician procedure codes are currently eligible for reimbursement via telehealth. These procedures comprise an estimated 33% of total Medicare FFS physician payments for the latest full year of data assessed, CY2018. For certain specialties, 90% or more of Medicare payments are eligible for reimbursement via telehealth, based on Avalere’s assessment of commonly performed services per specialty.
Additionally, major commercial payers are initiating coverage policy changes similar to Medicare, including adding codes to telehealth lists, expanding of telehealth partners, waiving originating site requirements, and waiving member cost sharing. Payers interviewed by Avalere generally expect a number of these flexibilities to continue into the future.
|CMS Category||# of Codes||% of Medicare Payments|
|Existing 2020 Telehealth Codes||106||24%|
|Temporary COVID Guidance||85||9%|
Source: CMS Covered Telehealth Services for PHE, Avalere Analysis of Medicare Provider/Supplier Procedure Summary File
Existing and Temporary COVID Guidance for Medicare Telehealth Codes
Annually, CMS updates the list of telehealth services allowed to be furnished as well as policies that govern telehealth.
As of March 30, CMS will now allow for more than 80 additional services to be furnished via telehealth. During public health emergencies, individuals can use interactive apps with audio and video capabilities to visit with their clinician for an even broader range of services. Providers can also evaluate beneficiaries who have audio phones only.
|Telehealth Requirements||Existing Telehealth||Telehealth Flexibilities Under COVID-19|
|Originating Site Requirements||Within a rural health professional shortage area or in a county outside a metropolitan statistical area||No limitations|
|Originating Place of Service||Physician office, hospital, CAH, rural health clinic, FQHC, SNF, community mental health centers, renal dialysis facilities, mobile stroke units, patient’s home only for ESRD for home dialysis||Adds patient’s home, nursing facilities, IRF, hospice, ER|
|Equipment Requirements||HIPAA-complaint audio-visual equipment||Any audio-visual equipment or application|
|Provider Type||Physicians, NP, PA, Nurse-midwives, Clinical nurse specialists, CRNA, Clinical Psychologists, and Clinical Social Workers, Registered dietitians, Nutrition professionals||Adds physical therapists, occupational therapists, speech-language pathologists|
|Patient Type||Established patients||New and established patients|
|Payment Methodology||Facility payment rate||Non-facility payment rate when appropriate|
Providers can bill for telehealth visits at the same rate as in-person visits. Telehealth visits include emergency department visits, initial nursing facility and discharge visits, home visits, and therapy services, which must be provided by a clinician that is allowed to provide telehealth. New as well as established patients may now stay at home and have a telehealth visit with their provider
CMS is allowing telehealth to fulfill many face-to-face visit requirements for clinicians to see their patients in inpatient rehabilitation facilities, hospice, and home health. CMS is making it clear that clinicians can provide remote patient monitoring services to patients with acute or chronic conditions, as well as patients with only 1 disease. For example, remote patient monitoring can be used to monitor a patient’s oxygen saturation levels using pulse oximetry.
Medicare Advantage plans have also been granted increased flexibility regarding telehealth benefits through CMS finalized policies regarding the use of telehealth diagnoses for purposes of risk adjustment calculations. CMS explained that COVID-19 related expanded use of virtual care made inclusion necessary.
In addition, CMS is allowing physicians to supervise their clinical staff using virtual technologies when appropriate, instead of requiring in-person presence.
|Speech, physical, occupational therapy||0||20||20|
|Home visit, new and established patients||0||15||15|
|Observation and hospital care||0||12||12|
|Pediatric and neonatal care||0||11||11|
|Psychiatry and psychotherapy||14||9||23|
|Emergency department visit, critical care||0||7||7|
|Nursing facility care||4||5||9|
|Health and behavior assessment, intervention||12||2||14|
|Patient risk assessments||2||0||2|
|Subsequent observation care||3||0||3|
|Subsequent hospital care||3||0||3|
|Prolonged service codes||6||0||6|
|Smoking, alcohol, opioid treatment||11||0||11|
|Care planning and management||8||0||8|
|Telehealth consultation (various)||9||0||9|
|Observation or hospital care||2||0||2|
Impact by Specialty Varies in Terms of Procedures Utilized
Avalere analysis of Medicare data illustrates that, for certain specialties, 90% or more of historic Medicare FFS payment would be eligible for telehealth payment based on new COVID telehealth flexibilities.
- Avalere assessed the top 50 Medicare FFS Current Procedural Terminology (CPT) codes utilized by physicians billing under relevant specialty types to assess the existing and recently granted telehealth coverage by each specialty type.
- The top 50 CPT codes generally represent 85%–95% of total Medicare payments to each specialty and serve as a rough proxy for average Medicare FFS practice revenue.
The figures below highlight the number of CPT codes out of the top 50 CPT codes which are billable via telehealth under existing or recently added telehealth codes, as well as the corresponding Medicare FFS payments (as a percentage of total payments) represented by each.
% of Payments
% of Payments
Source: Avalere Analysis of 5% Standard Analytical File, CY2018 Claims
Commercial Payer Policies Have Generally Followed CMS Guidance to Date
Historically, payers have been more likely to cover telehealth benefits where opportunity for cost savings or quality of care improvements exist. Many people with chronic conditions are susceptible to 1 or more comorbidities, and patients with comorbidities are often costly. Multiple studies have illustrated that telehealth consultations may produce improved or equal outcomes compared to traditional settings. Payers have generally covered procedures in line with CMS guidance, though policies may vary in terms of OOP costs, provider partnerships, preventive services, and benefit design. The commercial payer response continues to develop on a daily basis. Payers interviewed by Avalere have illustrated new coverage policies, with an expectation that flexibilities may further expand during the period of COVID-19 concern.
For example, several commercial payers, including UnitedHealthcare, Aetna, Anthem, and Excellus, have recently made public announcements of changes to their telehealth policies. Policy changes include:
- Addition of codes to the covered telehealth list
- Designated telehealth partners
- Expansion of provider telehealth access
- Waiving of CMS originating site restrictions
- Waiving of member cost-sharing
Key Questions for Physician Practices and Investors
In assessing the applicability of new and evolving telehealth guidance for provider practices, several key questions will provide further granularity on the impact and applicability of telehealth guidance to individual practices and specialties:
- To what extent can a given provider practice or specialty shift patient and procedure volume to telehealth? How may this vary in the short and long term?
- What are the reimbursement implications of shifting volume to telehealth, including potential rate differences for telehealth delivery vs. in-person procedures?
- Are there novel procedure opportunities via telehealth that a provider practice or specialty is not offering today that they should be?
- What are the potential barriers to telehealth implementation, both from a provider and supervisory standpoint and a patient access and technology standpoint?
- For in-person or elective procedures that are being delayed due to COVID-19, to what extent are different practices and specialties impacted, and on what timeline and intensity is the expected return in volume?
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