Key Telehealth Provisions in the Calendar Year 2023 Physician Fee Schedule Final Rule
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On November 1, 2022, the Centers for Medicare and Medicaid Services (CMS) issued the Calendar Year (CY) 2023 Physician Fee Schedule (PFS) final rule. The rule updates payment rates and finalize policy changes effective January 1, 2023. See the Press Release, Fact Sheet, Fact Sheet (MSSP), and the Final Rule.
General
CMS finalized its proposal to add some services to the Medicare Telehealth Services List on a Category 3 basis through the end of 2023, some of which had not been previously added to the Medicare Telehealth List during the PHE, but will be added on a sub regulatory basis.
In addition, CMS finalized its proposal that Medicare telehealth services furnished on or before the 151st day after the end of the PHE, in alignment with the extensions of telehealth-related flexibilities in the CAA, 2022, will continue to be processed for payment as Medicare telehealth claims when accompanied with the modifier “95”. CMS also finalized its proposal that physicians and practitioners can continue to report the place of service code that would have been reported had the service been furnished in-person during the 151-day period after the end of the PHE, as finalized on an interim basis in the March 31 IFC.
Payment for Medicare Telehealth Services Under Section 1834(m) of the Act
Requests to Add Services to the Medicare Telehealth Services List for CY 2023
CMS found that none of the requests received by the February 10 submission deadline met Category 1 or Category 2 criteria for permanent addition to the Medicare telehealth services list. As a reminder, Category 1 are services that are similar to professional consultations, office visits, and office psychiatry services that are currently on the Medicare Telehealth Services list, and the criterion for adding services under Category 2 is that there is evidence of clinical benefit if provided as telehealth.
CMS also assessed the appropriateness of adding the proposed services to the Medicare Telehealth Services List on a Category 3 basis instead. CMS did not propose changes to the length of time the services included on the temporary Category 3 basis. Category 3 will continue to be included through the end of CY 2023. In the event the public health emergency (PHE) extends into CY 2023, CMS may consider revising this policy.
After consideration of public comments, CMS is finalizing the proposed addition of CPT codes 90901, 97150, 97530, 97537, 97542, 97763, and 98960-98962 to the Medicare Telehealth Services List on a Category 3 basis through the end of CY 2023. CMS believes their proposal, consistent with the amendments made by provisions of the CAA, 2022, to extend the period that these services will be available on the Medicare Telehealth Services List temporarily for the PHE by 151 days following the end of the PHE will further enhance the opportunity for the collection of information on the experiences of clinicians who are furnishing telehealth services during the PHE for COVID–19. This will also help CMS to determine which services may ultimately be eligible for permanent addition under Category 1 or Category 2 criteria. CMS encourages interested parties to use this extended time period to gather data on use of services, that is more than statements of support and more than subjective attestations of clinical benefit, to support their potential addition in future rulemaking.
CMS did not finalize its proposal to keep telephone E/M services on the Medicare Telehealth Services List after the end of the PHE and the 151-day post-PHE extension period. CMS believes the statute requires that telehealth services be so analogous to in-person care such that the telehealth service is essentially a substitute for a face-to-face encounter. CMS does not believe that, outside of the circumstances of the PHE, the telephone E/M services would be analogous to in-person care; nor would they be a substitute for a face-to-face encounter. While CMS acknowledges that audio-only technology can be used to furnish mental health telehealth services to patients in their homes under certain circumstances after the PHE ends, two-way, audio-video communications technology continues to be the appropriate standard that will apply for Medicare telehealth services after the PHE and the 151-day extension period. At the conclusion of the PHE and the 151-day extension period provided by the CAA, 2022, the only Medicare telehealth services that will be permitted to be furnished using audio-only technology will be the mental health telehealth services. When a practitioner furnishes such an E/M service using audio-only technology, they would bill for the same service they would bill if the service had been furnished in person. As such, there is not a need to add the telephone-only E/M codes to the Medicare Telehealth Services List for this purpose.
CMS did not finalize its proposal to add GI Tract Imaging, CPT code 91110 and Ambulatory Continuous Glucose Monitoring, CPT code 95251 services to the Medicare Telehealth Services List on a Category 3 basis. CMS does not believe these CPT codes describe services that are a substitute for an in-person visit, and the services that are not inherently face-to-face services are not services that can be furnished as Medicare telehealth services.
CMS finalized its proposal to add CPT codes 95970, 95983, and 95984 to the Medicare Telehealth Services List on a Category 3 basis. Medicare claims data suggest that these services are being provided via telehealth and CMS believes there is some possible clinical benefit for these services when furnished via telehealth; however, there is not yet sufficient evidence available to consider the services for permanent addition to the Medicare Telehealth Services List under the Category 1 or Category 2 criteria.
CMS finalized its proposal to retain emotional/behavior assessment, psychological, or neuropsychological testing and evaluation services on the Medicare Telehealth Services List on a Category 3 basis. CMS believes more time may be necessary to develop evidence that could support the decision to add these services to the Medicare Telehealth Services List permanently on a Category 1 or Category 2 basis.
Other Services Proposed for Addition to the Medicare Telehealth Services List
CMS finalized its proposal to add a number of services to the list on a Category 3 basis that are currently included on the Medicare Telehealth Services List temporarily during the PHE. These services would be included on the Medicare Telehealth Services List through 2023 to allow us to evaluate data that may support their permanent addition to the list on a Category 1 or Category 2 basis.
- The services added to the Medicare Telehealth Services List on a Category 3 basis includes CPT codes 90875, 92012, 92014, 92014, 92507, 94005, 96105, 96110, 96112, 96113, 96127, 96170, 96171, 97129, 97130, and 99473. (See table above)
CMS finalized its proposal to add the remote audiology testing services to the Medicare Telehealth Services List on a Category 3 basis, which would allow these services to be available via telehealth through the end of CY 2023.
CMS finalized its proposal to create HCPCS codes G0316, G0317, G0318 to the Medicare Telehealth Services List on a Category 1 basis. These codes will be replacing existing codes that describe prolonged services, specifically inpatient prolonged services CPT codes 99356 and 99357.
Services Proposed for Removal from the Medicare Telehealth Services List After 151 Days Following the End of the PHE
As noted in the CY 2022 PFS final rule (86 FR 65054), at the conclusion of the PHE for COVID-19, the associated waivers and interim policies will expire, payment for Medicare telehealth services will once again be limited by the requirements of section 1834(m) of the Act, and CMS will return to the policies established through the regular notice-and-comment rulemaking process, through which CMS established Medicare Telehealth Services List.
CMS finalized its proposal to continue to include on the Medicare Telehealth Services List the services that are currently set to be removed from the list when the PHE ends (that is, those not currently added to the list on a Category 1, 2, or 3 basis) for an additional 151 days after the PHE ends.
Implementation of Telehealth Provisions of the Consolidation Appropriations Acts, 2021 and 2022
CMS finalized policies to implement provisions of section 1834(m) of the Act (including the amendments made by the CAA, 2021) and provisions of the CAA, 2022 that extend certain Medicare telehealth flexibilities adopted during the PHE for 151 days after the end of the PHE, including originating site, practitioner type, in-person visit requirements on mental health, and other congressionally extended authorities.
Use of Modifiers for Medicare Telehealth Services Following the End of the PHE for COVID-19
CMS finalized its proposal that Medicare telehealth services furnished on or before the 151st day after the end of the PHE, in alignment with the extensions of telehealth-related flexibilities in the CAA, 2022, will continue to be processed for payment as Medicare telehealth claims when accompanied with the modifier “95”. Practitioners will continue to bill with modifier 95 along with the POS code corresponding to where the service would have been furnished in-person through the later of the end of the year in which the PHE ends or CY 2023.
CMS finalized its proposal that, beginning January 1, 2023, a physician or other qualified health care practitioner billing for telehealth services furnished using audio-only communications technology shall append CPT modifier “93” to Medicare telehealth claims (for those services for which the use of audio-only technology is permitted under § 410.78(a)(3)), to identify them as having been furnished using audio-only technology. CMS believes that using modifier “93”, which is a CPT modifier, will simplify billing, as this modifier is used by payers outside of Medicare.
CMS is also finalizing its proposal to require all providers including RHCs, FQHCs, and OTPs to use modifier “93” when billing for eligible mental health services furnished via audio-only telecommunications technology. Providers have the option to use the “FQ” or the 93” modifiers or both where appropriate and true, since they are identical in meaning. Supervising practitioners continue to be required to append the “FR” modifier on any applicable telehealth claim when they provide direct supervision for a service using virtual presence through real-time, audio and video telecommunications technology.
Other Non-Face-to-Face Services Involving Communications Technology Under the PFS
Expiration of PHE Flexibilities for Direct Supervision Requirements
CMS changed the definition of “direct supervision” during the PHE for COVID-19 as it pertains to supervision of diagnostic tests, physicians’ services, and some hospital outpatient services, to allow the supervising professional to be immediately available through virtual presence using real-time audio/video technology, instead of requiring their physical presence.
CMS sought comment on whether the flexibility to meet the immediate availability requirement for direct supervision through the use of real-time, audio/video technology should potentially be made permanent, and on the possibility of permanently allowing immediate availability for direct supervision through virtual presence using real-time, audio/video technology for only a subset of services.
In the final rule, CMS notes that it plans to continue to gather information on this topic. CMS believes allowing additional time to collect information and evidence for direct supervision through virtual presence will help CMS to better understand the potential circumstances in which this flexibility could be appropriate permanently, outside of the PHE for COVID-19. CMS expects to continue to permit direct supervision through virtual presence through at least the end of CY 2023.
Telehealth Facility Payment Rate
CMS has abandoned its proposal to pay telehealth at the facility rate following the 151-day period. It is instead finalizing a proposal to continue to allow for payment be made for Medicare telehealth services at the rate that ordinarily would have been paid under the PFS if the services were furnished in-person, through the latter of the end of the of CY 2023 or the end of the calendar year in which the PHE ends. For those services furnished in a facility as an originating site, POS 02 may be used, and the corresponding facility fee can be billed, per pre-PHE policy, beginning the 152nd day after the end of the PHE. CMS is concerned about issues raised by commenters related to payment stability in the post-PHE period as care delivery will potentially be transitioning between virtual, hybrid, and in-person models.
Telehealth Originating Site Facility Fee Update
For CY 2023, the final payment amount for HCPCS code Q3014 (Telehealth originating site facility fee) is $28.64. The CY2022 rate was $27.59
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
CMS finalized the proposal to implement sections 303 and 304 of the Consolidated Appropriations Act, 2022 to:
- Temporarily continue payment for telehealth services furnished by FQHCs and RHCs for the 151-day period beginning on the first day after the end of the COVID-19 PHE using the methodology established for telehealth services furnished by FQHCs and RHCs during the PHE, which is based on payment rates that are similar to the national average payment rates for comparable telehealth services under the PFS.
- Delay the in-person requirements under Medicare for mental health services furnished through telehealth under the PFS and for mental health visits furnished by RHCs and FQHCs via telecommunications technology for a 151-day period beginning on the first day after the end of the public health emergency (PHE) for COVID-19. These proposals are necessary to fulfill these statutory requirements.
Remote Therapeutic Monitoring Services
CMS is not finalizing the proposal to create 4 new G-codes, (GRTM-1-4) which were proposed to address various issues relating to incident-to services, inclusions of clinical staff time, and supervision levels. CMS agreed that confusion remains about how the new G-codes, if finalized, would or would not possibly create a chilling effect on the availability of RTM services. CMS will continue to gather information and consider the need for further rulemaking regarding these services.
Instead, the rule, includes a clarification and new policy regarding the billing requirements for the current RTM codes: CPT codes 98975, 98976, 98977, 98980, and 98981. Beginning January 1, 2023, below modifications to our existing RTM policies take effect:
- General supervision for all RTM services- Any RTM service may be furnished under general supervision requirements.
- Cognitive behavioral therapy monitoring device – CMS is finalizing the proposal to accept the RUC recommendation to contractor price CPT code 989X6, a PE-only device code.
Behavioral Health
Tele-behavioral health
In-Person Requirement
Section 304(a) of the CAA, 2022 amended section 1834(m)(7)(B)(i) of the Act to delay the requirement for an in-person visit with a physician or practitioner within 6 months prior to an initial mental health telehealth service, and again at subsequent intervals as the Secretary determines appropriate. In light of this amendment, the in-person requirements for telehealth services furnished for purposes of diagnosis, evaluation, or treatment of a mental health disorder will again be effective on the 152nd day after the PHE ends. In addition, section 304(b) and (c) of the CAA, 2022 modified sections 1834(y) and 1834(o)(4) of the Act, respectively, to similarly delay in-person visit requirements for mental health visits furnished by Rural Health Clinics and Federally Qualified Health Centers via telecommunications technology.
CMS clarifies in the final rule that CMS does not believe the in-person requirement applies to beneficiaries who began receiving mental health telehealth services in their homes during the PHE. In other words, if a beneficiary began receiving mental health telehealth services during the PHE or during the 151-day period after the end of the PHE, then they would not be required to have an in-person visit within 6 months; rather, they will be considered established and will instead be required to have at least one in-person visit every 12 months (so long as any such subsequent telehealth service is furnished by the same individual physician or practitioner (or a practitioner of the same sub-specialty in the same practice) to the same beneficiary). This means that these services would be subject to the requirement that an in-person visit is furnished within 12 months of each mental health telehealth service for those services that are subject to in-person visit requirements (unless an exception is documented by their treating practitioner).
Chronic Pain Management and Treatment (CPM) Bundles (HCPCS GYYY1, and GYYY2)
In the CY 2022 PFS proposed rule (86 FR 39104, 39179 – 39181), CMS explored refinements to the PFS that would appropriately value chronic pain management and treatment (CPM) by soliciting comment on CPM for the purpose of future rulemaking. In CMS’s solicitation, they described Federal efforts for more than a decade to effectively address pain management as a response to the nation’s overdose crisis, such as the National Pain Strategy and the HHS Pain Management Best Practices Inter-Agency Task Force Report.
Through solicitation of comments, the CCM/CCCM/PCM code family now includes five sets of codes, each set with a base code and an add-on code. The sets vary by the degree of complexity of care, who directly performs the services, and the time spent furnishing the services. The RUC-recommended values for work RVUs and direct PE inputs for these codes in CY 2022 were derived from a recent RUC specialty society survey.
CMS has finalized its proposal to create separate coding and payment for CPM services beginning January 1, 2023.
- HCPCS Code G3002: Chronic pain management and treatment, monthly bundle including, diagnosis; assessment and monitoring; administration of a validated pain rating scale or tool; the development, implementation, revision, and/or maintenance of a person-centered care plan that includes strengths, goals, clinical needs, and desired outcomes; overall treatment management; facilitation and coordination of any necessary behavioral health treatment; medication management; pain and health literacy counseling; any necessary chronic pain related crisis care; and ongoing communication and care coordination between relevant practitioners furnishing care, e.g. physical therapy and occupational therapy, and community-based care, as appropriate. Required initial face-to-face visit at least 30 minutes provided by a physician or other qualified health professional; first 30 minutes personally provided by physician or other qualified health care professional, per calendar month. (When using G3002, 30 minutes must be met or exceeded.)
- HCPCS code G3003: Each additional 15 minutes of chronic pain management and treatment by a physician or other qualified health care professional, per calendar month. (List separately in addition to code for G3002. When using G3003, 15 minutes must be met or exceeded.)
Revisions to “Incident To” Physicians’ Services Regulation for Behavioral Health Services
In the CY 2014 PFS final rule, CMS created an exception to its “incident to” regulation under which “incident to” services generally must be furnished under direct supervision, to allow general, rather than direct, supervision when chronic care management services are furnished incident to the billing physician’s or NPP’s services outside of the practice’s normal business hours by clinical staff. In the CY2017 PFS final rule, CMS also revised regulations to allow general, rather than direct, level of supervision for designated care management services, and established that it would designate care management services through notice and comment rulemaking.
CMS noted in the proposed rule that currently there is no separate benefit category under the statute that recognizes the professional services of licensed professional counselors (LPCs) and Licensed Marriage and Family Therapists (LMFTs). Therefore, payment for the services of LPCs and LMFTs can only be made under the PFS indirectly when an LPC or LMFT performs services as auxiliary personnel incident to, the services, and under the direct supervision, of the billing physician or other practitioner.
Given CMS’ goal in the 2022 CMS Behavioral Health Strategy to improve access to and quality of mental health care services, CMS finalizes several regulatory changes to make greater use of the services of LPCs and LMFTs. CMS notes that it does not have authority to create a statutory benefit category for practitioner types, but it finalizes its proposal to amend the direct supervision requirement under the “incident to” regulation to allow behavioral health services to be furnished under the general supervision of a physician or NPP when these services or supplies are provided by auxiliary personnel incident to the services of a physician or NPP.
CMS further clarifies that any service furnished primarily for the diagnosis and treatment of a mental health or SUD can be furnished by auxiliary personnel under the general supervision of a physician or NPP who is authorized to furnish and bill for the services provided incident to their own professional services.
CMS further plans to address payment for new codes that describe caregiver behavioral management training in the CY 2024 PFS.
New Coding and Payment for General Behavioral Health Integration (BHI) billed by Clinical Psychologists (CPs) and Clinical Social Workers (CSWs)
In the CY2017 and CY2018 PFS final rules, CMS established codes and payment for monthly services furnished using the Psychiatric Collaborative Care Model (CoCM), an evidence-based approach to behavioral health integration that enhances “usual” primary care by adding care management support and regular psychiatric inter-specialty consultation, and for services furnished using other models of BHI in the primary care setting.
In those rules, CMS additionally sought comment on the circumstances under which this model of care is happening and whether additional coding would be needed to accurately describe and value other models of care. CMS received feedback that initiating visit services for BHI should include in-depth psychological evaluations delivered by a CP, and that CMS should consider allowing professionals who were not eligible to report the approved initiating visit codes to Medicare to serve as a primary hub for BHI services.
CMS is now finalizing a proposal to create a new G code describing General BHI performed by CPs or CSWs to account for monthly care integration where the mental health services furnished by a CP or CSW are serving as the focal point of care integration. The finalized new code is :
- G0323 (Care management services for behavioral health conditions, at least 20 minutes of clinical psychologist or clinical social worker time, per calendar month, with the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, coordination with and/or referral to physicians and practitioners who are authorized by Medicare law to prescribe medications and furnish E/M services, counseling and/or psychiatric consultation; and continuity of care with a designated member of the care team.)
CMS has finalized its proposal to value this service under the proposed HCPCS code G0323 based on a direct crosswalk to the work values and direct PE inputs for CPT code 99484 (Care management services for behavioral health conditions, at least 20 minutes of clinical staff time, directed by a physician or other qualified health care professional, per calendar month, with the following required elements: initial assessment or follow-up monitoring, including the use of applicable validated rating scales; behavioral health care planning in relation to behavioral/psychiatric health problems, including revision for patients who are not progressing or whose status changes; facilitating and coordinating treatment such as psychotherapy, pharmacotherapy, counseling and/or psychiatric consultation; and continuity of care with a designated member of the care team), because the services described by GBHI1 closely mirror those described by CPT code 99484.
Modifications Related to Medicare Coverage for Opioid Use Disorder (OUD) Treatment Services Furnished by Opioid Treatment Programs (OTPs)
Section 2005 of 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 OUD treatment services furnished by OTPs during an episode of care beginning on or after January 1, 2020. CMS implemented Medicare coverage and provider enrollment requirements and established a methodology for determining the bundled payments for episodes of care for the treatment of OUD furnished by OTPs, among other related policies, in the CY2020 PFS final rule. CMS subsequently adopted new add-on codes and payment, and made certain policy changes, in the CY2021 and CY2022 final rules.
CMS has now finalized several additional updates to payment and policies regarding OUD treatment services furnished by OTPs.
- Methadone Pricing – CMS has finalized its revised methodology for pricing the drug component of the methadone weekly bundle and the add-on code for take-home supplies of methadone. CMS will base the payment amount for the drug component of HCPCS codes G2067 and G2078 for CY 2023 and subsequent years on the payment amount for methadone in CY 2021 and update this amount annually to account for inflation using the PPI for Pharmaceuticals for Human Use (Prescription).
- Proposed Changes to the Rate for Individual Therapy in the Bundled Rate – CMS has finalized its proposal to modify the payment rate for the non-drug component of the bundled payments for episodes of care to base the rate for individual therapy on a crosswalk code describing a 45-minute session, rather than the current crosswalk to a code describing a 30-minute session.
- Mobile Components Operated by OTPs – CMS clarifies that OTPs can bill Medicare for medically reasonable and necessary services furnished via mobile units in accordance with SAMHSA and DEA guidance. CMS finalizes its proposal that locality adjustments for services furnished via mobile units would be applied as if the service were furnished at the physical location of the OTP registered with DEA and certified by SAMHSA.
- Flexibilities for OTPs to Use Telecommunications for Initiation of Treatment with Buprenorphine – CMS has finalized its proposal to allow the OTP intake add-on code to be furnished via two-way audio-video communications technology when billed for the initiation of treatment with buprenorphine, to the extent that the use of audio-video telecommunications technology to initiate treatment with buprenorphine is authorized by DEA and SAMHSA at the time the service is furnished. CMS also finalizes its proposal to permit the use of audio-only communication technology to initiate treatment with buprenorphine in cases where audio-video technology is not available to the beneficiary.
Comment Solicitation on Intensive Outpatient Mental Health Treatment, including Substance Use Disorder (SUD) Treatment, Furnished by Intensive Outpatient Programs (IOPs)
CMS noted in the proposed rule that there are a range of services described by existing coding under the PFS that can be billed for treatment of mental health conditions, including SUDs, such as individual, group, and family psychotherapy. Over the past several years, CMS has increased the coding and payment mechanisms for substance use treatment services paid under the PFS.
CMS requested feedback on whether the current coding and payment mechanisms under the PFS adequately account for intensive outpatient services that are part of a continuum of care in the treatment, among other information.
CMS thanks commenters for their feedback and may consider the comments in future rulemaking.
Comment Solicitation on Payment for Behavioral Health Services under the PFS
CMS solicited comment on how it can best ensure beneficiary access to behavioral health services, including any potential adjustments to the PFS rate-setting methodology, for example, any adjustments to systematically address the impact on behavioral health services paid under the PFS.
CMS noted that it appreciates the feedback received and may consider the comments in future rulemaking.
Medicare Telehealth Analysis
Share This Study!
Fall 2022
The Alliance for Connected Care commissioned an independent Medicare claims data analysis to better understand telehealth utilization and the potential financial impact of long-term telehealth expansion on the Medicare program. As expected, the findings of this analysis align with the individual experiences and data collected by Alliance for Connected Care members.
“It’s hard to break conventional wisdom in Washington. We finally have comprehensive telehealth utilization data in Medicare that should rectify the misconception that telehealth is somehow uniquely subject to over-use.” – Krista Drobac, Alliance for Connected Care
The research project, executed by Teus Health, fully analyzed Medicare fee-for-service claims data[1] across three full years – 2019, 2020, and 2021 – to answer and further explore the following crucial questions:
- Is telehealth adding to the total volume of Medicare services or replacing in-person services?
- Compared to patients who had an initial in-person visit, did patients who had a telehealth visit have more follow-up visits?
We expect this research to be useful to the Congressional Budget Office, MedPAC, and other entities which have expressed concerns that telehealth legislation may lead to additional costs for the Medicare program.
Finding 1: There is no evidence that telehealth is adding to the total volume of Medicare services.
The analysis examined the utilization of services to determine better understand if telehealth is adding to the total volume of Medicare services or replacing in-person services. Additionally, the researchers classified the primary diagnosis based on whether the diagnosis appeared Covid-related (including symptoms associated with Covid) or not in order to understand the effect of COVID on the utilization.
- Total evaluation and management (E&M) visits in 2021 remain below 2019 levels, even with telehealth services included. In 2021, telehealth services leveled off at around 5 percent of all E&M services.
[1] Source: Medicare 5% sample, outpatient and carrier files, 2019-2021, accessed under CMS DUA 58059.
- Telehealth did not add to the total volume of Medicare services in any subset of the telehealth-eligible services examined with the exception of home-based E&M visits. Telehealth continues to represent a larger percentage of home visits than overall E&M visits.
- Of significant note with respect to Medicare spending – the average per service cost of an E&M telehealth visit to the Medicare program is less than in-person services by approximately 20%. The reason for this difference was that telehealth clinicians generally billed shorter visit codes than in-person providers.
- Provider types most heavily relying on telehealth included all mental health and substance use disorder providers, primary care clinicians, as well as endocrinologists, pain management, anesthesiology, and sleep medicine specialties.
- This finding demonstrates that telehealth is being used as another modality physicians can utilize to bring care to the Medicare population. Medicare services followed previous quarters’ trends, even with expanded telehealth flexibilities.
Finding 2: There is no evidence that patients initiating care who used telehealth had more E&M revisits for the same medical issue than patients with in-person visits.
The analysis examined revisit rates to answer whether patients who had a telehealth E&M visit had more follow-up visits than patients who had an initial in-person visit. Additionally, the researchers included criteria to identify if the primary diagnosis appeared COVID-related (including symptoms associated with COVID) in order to understand the COVID-related revisit rates.
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- Overall revisit rates for telehealth and in-person visits were consistent across emergent and chronic conditions, with a 20.1 percent revisit rate for in-person visits and a 20.2 percent revisit rate for telehealth.
- Telehealth patients with COVID-related diagnoses were somewhat more likely to have higher revisit rates – but this was to be expected, as during the pandemic telehealth was used to screen patients with COVID-related symptoms who might otherwise have directly sought in-person care.
- While our overall finding is that telehealth does not lead to more revisits, there is potentially significant variation between diagnoses categories within this data. We recommend additional research and direct clinician interviews to understand this variation.
- For example, E&M visits for mental health and digestive diagnoses offered through telehealth were less likely to result in a revisit, while diseases of the eye often resulted in more revisits. There are many clinical situations that could explain these variations, and we draw no immediate conclusions from them.
See the analysis below or here.
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Telemedicine management of type 2 diabetes mellitus in obese and overweight young and middle-aged patients during COVID-19 outbreak: A single-center, prospective, randomized control study
PLoS One: Telemedicine management of type 2 diabetes mellitus in obese and overweight young and middle-aged patients during COVID-19 outbreak: A single-center, prospective, randomized control study
Objective: The coronavirus disease-2019 (COVID-19) pandemic severely affected the disease management of patients with chronic illnesses such as type 2 diabetes mellitus (T2DM). This study aimed to assess the effect of telemedicine management of diabetes in obese and overweight young and middle-aged patients with T2DM during the COVID-19 pandemic.
Methods: A single-center randomized control study was conducted in 120 obese or overweight (body mass index [BMI] ≥ 24 kg/m2) young and middle-aged patients (aged 18-55 years) with T2DM. Patients were randomly assigned to the intervention (telemedicine) or control (conventional outpatient clinic appointment) group. After baseline assessment, they were home isolated for 21 days, received diet and exercise guidance, underwent glucose monitoring, and followed up for 6 months. Glucose monitoring and Self-Rating Depression Scale (SDS) scores were evaluated at 22 days and at the end of 3 and 6 months.
Results: Ninety-nine patients completed the 6-month follow-up (intervention group: n = 52; control group: n = 47). On day 22, the fasting blood glucose (FBG) level of the intervention group was lower than that of the control group (p < 0.05), and the control group’s SDS increased significantly compared with the baseline value (p < 0.05). At the end of 3 months, glycated hemoglobin (HbA1c) and FBG levels in the intervention group decreased significantly compared with those in the control group (p < 0.01). At the end of 6 months, the intervention group showed a significant decrease in postprandial blood glucose, triglyceride, and low-density lipoprotein cholesterol levels as well as waist-to-hip ratio compared with the control group (p < 0.05); moreover, the intervention group showed lower SDS scores than the baseline value (p < 0.05). Further, the intervention group showed a significant reduction in BMI compared with the control group at the end of 3 and 6 months (p < 0.01).
Conclusion: Telemedicine is a beneficial strategy for achieving remotely supervised blood glucose regulation, weight loss, and depression relief in patients with T2DM.
Efficacy of telemedicine for the management of cardiovascular disease: a systematic review and meta-analysis
Efficacy of telemedicine for the management of cardiovascular disease: a systematic review and meta-analysis
Background: Telemedicine has been increasingly integrated into chronic disease management through remote patient monitoring and consultation, particularly during the COVID-19 pandemic. We did a systematic review and meta-analysis of studies reporting effectiveness of telemedicine interventions for the management of patients with cardiovascular conditions.
Methods: In this systematic review and meta-analysis, we searched PubMed, Scopus, and Cochrane Library from database inception to Jan 18, 2021. We included randomised controlled trials and observational or cohort studies that evaluated the effects of a telemedicine intervention on cardiovascular outcomes for people either at risk (primary prevention) of cardiovascular disease or with established (secondary prevention) cardiovascular disease, and, for the meta-analysis, we included studies that evaluated the effects of a telemedicine intervention on cardiovascular outcomes and risk factors. We excluded studies if there was no clear telemedicine intervention described or if cardiovascular or risk factor outcomes were not clearly reported in relation to the intervention. Two reviewers independently assessed and extracted data from trials and observational and cohort studies using a standardised template. Our primary outcome was cardiovascular-related mortality. We evaluated study quality using Cochrane risk-of-bias and Newcastle-Ottawa scales. The systematic review and the meta-analysis protocol was registered with PROSPERO (CRD42021221010) and the Malaysian National Medical Research Register (NMRR-20-2471-57236).
Findings: 72 studies, including 127 869 participants, met eligibility criteria, with 34 studies included in meta-analysis (n=13 269 with 6620 [50%] receiving telemedicine). Combined remote monitoring and consultation for patients with heart failure was associated with a reduced risk of cardiovascular-related mortality (risk ratio [RR] 0·83 [95% CI 0·70 to 0·99]; p=0·036) and hospitalisation for a cardiovascular cause (0·71 [0·58 to 0·87]; p=0·0002), mostly in studies with short-term follow-up. There was no effect of telemedicine on all-cause hospitalisation (1·02 [0·94 to 1·10]; p=0·71) or mortality (0·90 [0·77 to 1·06]; p=0·23) in these groups, and no benefits were observed with remote consultation in isolation. Small reductions were observed for systolic blood pressure (mean difference -3·59 [95% CI -5·35 to -1·83] mm Hg; p<0·0001) by remote monitoring and consultation in secondary prevention populations. Small reductions were also observed in body-mass index (mean difference -0·38 [-0·66 to -0·11] kg/m2; p=0·0064) by remote consultation in primary prevention settings.
Interpretation: Telemedicine including both remote disease monitoring and consultation might reduce short-term cardiovascular-related hospitalisation and mortality risk among patients with heart failure. Future research should evaluate the sustained effects of telemedicine interventions.
Alliance Submits Comments to the Proposed CY 2023 Medicare Hospital Outpatient Prospective Payment System (OPPS)
The Alliance for Connected Care submitted comments in response to the CMS Calendar Year (CY) 2023 Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System Proposed Rule.
The Alliance applauded the proposal to ensure the continuation of patient access to mental health services from hospital-based providers after the conclusion of the COVID-19 public health emergency (PHE). The Alliance is committed to leveraging telehealth and remote patient monitoring to improve the quality of care while also lowering costs and improving efficiency, and we believe this extension will help to serve all three of those aims.
To read the full letter, click here or see below:
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Hundreds of Stakeholders Call on Senate Leaders to Make Telehealth a Priority This Fall
Washington, DC, September 13, 2022 – Today, an astounding 375 organizations sent a joint letter to bipartisan leadership of the U.S. Senate urging action on telehealth legislation this fall. Policy certainty beyond the COVID-19 public health emergency (PHE) is essential to continuing access to telehealth for both Medicare and commercial market patients.
The letter urges the Senate to pass a two-year extension of important telehealth policies enacted at the start of the COVID-19 pandemic, which are currently set to expire 151 days after the end of the PHE. The letter represents the diversity of groups across the health care spectrum whose constituencies are impacted by telehealth policy – from consumer groups representing mental health, chronic disease, primary care; and providers including physicians, nurses, physical therapists; to employers representing millions of Americans who receive their coverage through their jobs.
The letter calls on the Senate to pass legislation that would extend critical telehealth flexibilities, including provisions to waive provider and patient location limitations, remove in-person requirements for telemental health, ensure continued access to clinically appropriate controlled substances without in-person requirements, and increase access to telehealth services in the commercial market, including for those with a high-deductible health plans coupled with a health savings account (HDHP-HSA).
“More than 400 members of the House voted to extend telehealth flexibilities in July, and it’s time for the Senate to follow. Without more policy certainty around telehealth, beneficiary access could be compromised,” said Krista Drobac, Executive Director, Alliance for Connected Care. “The House created the momentum, we hope the Senate will seize it and enact comprehensive telehealth legislation this fall.”
Patient satisfaction surveys and claims data from CMS and private health plans demonstrate that many Americans have come to see telehealth as one of the most positive improvements to our nation’s health care system in recent memory. Telehealth has also helped to bridge gaps in care, especially in communities facing significant workforce shortages. Importantly, almost three in four Americans “strongly agree” or “somewhat agree” that patients should have the option to receive telehealth, even after the pandemic, which increases to 84 percent among recent telehealth patients. Most recently, reports from the HHS Office of Inspector General showed that that dually-eligible beneficiaries were more likely than others to use telehealth to ensure access to care and that telehealth expanded access for minority populations.
The joint letter was co-led by the Alliance for Connected Care, American Telemedicine Association (ATA), College of Healthcare Information Management Executives (CHIME), Connected Health Initiative, Consumer Technology Association, Executives for Health Innovation, Health Innovation Alliance, HIMSS, and Partnership to Advance Virtual Care.
To read the full letter, click here or see below:
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FOR IMMEDIATE RELEASE
CONTACT:
Chris Adamec
(571) 225-6792
cadamec@connectwithcare.org
Initial Experience with Telemedicine for Interstage Monitoring in Infants with Palliated Congenital Heart Disease
Pediatric Cardiology: Initial Experience with Telemedicine for Interstage Monitoring in Infants with Palliated Congenital Heart Disease
Infants with staged surgical palliation for congenital heart disease are at high-risk for interstage morbidity and mortality. Home monitoring programs have mitigated these risks. This study examines caregivers and clinicians of the Infant Single Ventricle Monitoring Program (ISVMP). All consecutive patients discharged following neonatal operation/intervention were monitored until subsequent stage 2 surgical palliation.
In six visits (10 percent), significant clinical findings were identified which avoided an emergency department (ED) visit. Caregivers and clinicians expressed high levels of satisfaction with telemedicine. Researchers concluded that telemedicine for this high-risk population is feasible and effective in identifying clinical concerns and preventing unnecessary ED visits. Telemedicine was particularly effective during the COVID-19 pandemic, allowing for easy adaptation of care to ensure patient safety in this fragile cohort.
Alliance Statement on HHS OIG Telehealth Reports
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September 7, 2022, Washington, D.C. – The only way to truly understand the impact of covering telehealth in Medicare on fraud is the analysis of real data. The HHS Office of the Inspector General (OIG) continues to do just that, and we applaud their efforts. These reports add to the growing body of evidence showing that telehealth meaningfully expands access to care, and that long-term telehealth expansion is feasible with some limited steps to ensure continued oversight and evaluation.
We agree with most of the findings and recommendations of HHS Office of the Inspector General (OIG) thus far, and look forward to a more conclusive finding that covering treatment of seniors virtually does not uniquely expose Medicare to fraud.
The reports released today build on the OIG report “Telehealth Was Critical for Providing Services to Medicare Beneficiaries During the First Year of the COVID-19 Pandemic” from earlier this year. The new reports include:
- HHS OIG: Certain Medicare Beneficiaries, Such as Urban and Hispanic Beneficiaries, Were More Likely Than Others To Use Telehealth During the First Year of the COVID-19 Pandemic
- OIG Report: Medicare Telehealth Services During the First Year of the Pandemic: Program Integrity Risks
The Alliance was pleased to see the continued evaluation of beneficiary access through telehealth show that that dually-eligible beneficiaries, and some minority populations were more likely than others to use telehealth to ensure access to care. The finding that audio-only services benefitted older beneficiaries, the dually eligible, and Hispanic populations emphasize the importance of maintaining access to audio-only telehealth services. While OIG found greater utilization of telehealth in urban areas, we believe this number is likely skewed by the effect of COVID-19 on urban populations, rather than to indicate any long-term utilization trend. OIG made the following subsequent recommendations:
- Take appropriate steps to enable a successful transition from current pandemic-related flexibilities to well-considered long-term policies for the use of telehealth for beneficiaries in urban areas and from the beneficiary’s home,
- The Alliance agrees with this recommendation
- Temporarily extend the use of audio-only telehealth services and evaluate their impact,
- The Alliance agrees with this recommendation
- Require a modifier to identify all audio-only telehealth services provided in Medicare, and
- The Alliance supported a modifier in our 2023 Physician Fee Schedule comments
- Use telehealth to advance health care equity.
- The Alliance strongly agrees that telehealth can help reach underserved populations
The Alliance also appreciated OIG’s evaluation of program integrity risks related to telehealth during the COVID-19 pandemic. OIG examined a selected group of providers that they believe pose a higher risk to the Medicare program, but did not draw any conclusions around the use of telehealth and if there is any relation to fraud. OIG recommends the following actions:
- Strengthen monitoring and targeted oversight of telehealth services,
- The Alliance has supported additional oversight to ensure bad actors do not undermine access to telehealth in Medicare.
- Provide additional education to providers on appropriate billing for telehealth services,
- The Alliance strongly agrees that provider education is useful, as accidental misbilling has in the past been interpreted as fraudulent. Similarly, HHS steps to simplify telehealth billing are welcomed.
- Improve the transparency of “incident to” services when clinical staff primarily delivered the telehealth service,
- The Alliance recognizes the importance of accurate data for analysis. We also stress the importance maintaining “incident to” services for healthcare practitioners unable to bill the Medicare program directly.
- Identify telehealth companies that bill Medicare, and
- If a provider, including a virtual-only provider, wants to bill Medicare directly, they must enroll in Medicare, thereby giving CMS oversight of that provider. We don’t believe there is clear justification for singling out virtual-only providers, particularly when Medicare beneficiaries are overwhelmingly seeing providers that use telehealth services in addition to maintaining brick and mortar. Given that virtual-only is a new modality, limited steps to improve CMS’s understanding and oversight of these providers seems logical, and if it helps prevent limits on beneficiary access to telehealth, then we support it.
- Follow up on the providers identified in this report.
- The Alliance supports OIG investigations into fraudulent behavior in the Medicare program, because these investigations are necessary to differentiate between possible telehealth services issues and much more likely marketing fraud that OIG has continued to identify and report on.
Comment Letter on CY 2023 Physician Fee Schedule Proposed Rule
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The Alliance for Connected Care submitted comments on the Medicare Physician Fee Schedule (PFS) Proposed Rule for calendar year (CY) 2023, which includes several important reforms with respect to telehealth.
The Alliance emphasized the following overarching priorities:
- While we appreciate and support the effort from CMS to create more temporary Category 3 codes (and its proposal to retain these codes through the end of CY 2023), we are disappointed CMS did not find sufficient clinical benefit to add any of the proposed Category 1 or Category 2 codes. We continue to believe these temporary codes do not represent the forward movement on telehealth needed. The Administration should be moving to create the stability and predictability needed for health care providers and patients to plan for future health needs. Additionally, we believe that the lack of forward movement on codes does not align with the significant body of evidence that has developed around the usage of telehealth services and their impact on quality and patient access.
- While we recognize statutory requirements exist, we remain concerned with steps taken by CMS around in-person visit requirements and we encourage CMS to apply these requirements to the minimum extent required by law. The Alliance and its members strongly believe that an in-person requirement constrains telehealth from helping individuals that are homebound, have transportation challenges, live in underserved areas, or have other needs. This reduces access for those who need it the most, while allowing access for those capable of in-person care.
- There continues to be a misconception among many that telehealth is separate and different from in-person care. It is not. It was shown during the pandemic that Medicare telehealth services were used simply as a different modality for a patient’s existing providers to improve access and maintain continuity of care. Given this evidence, we believe limiting non-facility providers to a lower facility payment rate for telehealth would have the effect of disincentivizing telehealth usage by a patient’s existing in-person provider and undermining opportunities to increase patient access.
- We strongly support the continued availability of direct supervision through telehealth. The option for virtual direct supervision has been proven to be a meaningful tool to maintain teams remotely during a public health emergency. However, this expansion of health system capability is needed for more than just public health emergencies – it is also a meaningful tool to meet health care workforce challenges – both in the delivery of care and to grow the workforce through more flexible academic settings.
Please find the full comments below or here.
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A telemedicine-based approach with real-time transmission of blood glucose data improves metabolic control in insulin-treated diabetes: the DIAMONDS randomized clinical trial
J Endocrinol Invest: A telemedicine-based approach with real-time transmission of blood glucose data improves metabolic control in insulin-treated diabetes: the DIAMONDS randomized clinical trial
Purpose: To evaluate if a web-based telemedicine system (the Glucoonline® system) is effective to improve glucose control in insulin-treated patients with type 1 and type 2 diabetes, as compared to standard of care.
Methods: This was a prospective, randomized, controlled trial, carried out at three tertiary referral centers for diabetes in Italy. Adults with insulin-treated type 1 and type 2 diabetes, inadequate glycemic control, and no severe diabetes-related complications and/or comorbidities were eligible for this study. Patients were randomized to either perform telemedicine-assisted (Group A) or standard (Group B) self-monitoring blood glucose (SMBG) for 6 months. In Group A, patients received prompt feedback about their blood glucose levels and therapy suggestions from the study staff via phone/SMS, when appropriate. In Group B, patients had no remote assistance from the study staff between planned visits.
Results: 123 patients were included in the final analysis. After 6 months, patients achieved a significant reduction in HbA1c in Group A (-0.38%, p < 0.05) but not in Group B (+ 0.08%, p = 0.53). A significant difference in the percentage of patients with HbA1c < 7% between Group A and Group B was found after 3 months (28.6% vs 11.1%, p = 0.02). Also, fewer patients (p < 0.05) with HbA1c > 8.5% were found in Group A vs Group B, respectively, after both 3 months (14.3% vs 35.2%) and 6 months (21.8% vs 42.9%).
Conclusions: The use of the Glucoonline™ system resulted in improved metabolic control. Telemedicine services have potential to support diabetes self-management and provide the patients with remote, prompt assistance using affordable technological equipment. Trial registration This study was registered at clinicaltrials.gov (NCT01804803) on March 5, 2013.