CMS announced important changes to Medicare reimbursement for remote patient monitoring and telemedicine that can help accelerate adoption and use of these digital health tools. These changes are implemented through two rules released this week that will take effect January 1, 2018. Understanding these rules can help you incorporate these tools into clinical practice and can positively affect the business model for technology developers and innovators.

What are these new rules and do they affect me?

The 2018 Quality Payment Program Final Rule provides policy updates to the Quality Payment Program (QPP), which was established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and will be entering its second year. MACRA offers two “tracks” for eligible clinicians to take as they move toward value-based care:

  • Participation in QPP and its scoring, or
  • Participation in an Advanced Alternative Payment Model (APM).

The majority of Medicare payments are still tied to fee-for-service, but HHS has set a goal of moving to 50 percent of Medicare payments for alternative payment models by 2018. For previous coverage of QPP proposals, visit our summary here.

The 2018 Physician Fee Schedule Final Rule addresses revised payment policies for the Medicare physician fee schedule. Any provisions in the PFS rule typically apply to fee-for-service type providers.

Both rules contain important policy changes that impact health care providers and the health technology developers creating the digital innovations that are being incentivized in 2018.

Quality Payment Program Offers “High” Rating for Patient Generated Data

CMS has upgraded the Clinical Practice Improvement Activity (CPIA) of “Engage Patients and Families to Guide Improvement in the System of Care” to a “high” weighting, meaning that physician groups will achieve more points in the CPIA category for using technology to engage their patients within the scope of this improvement activity.

CMS has placed emphasis on the importance of “clinical endorsement” of patient generated health data (PGHD) technologies, including the feedback the software generates for patients. Additionally, CMS appears to be incentivizing the use of more “active devices” that can inform the patient or their care team about critical changes to the patient’s health, such as their adherence to a medication or treatment, so that the care team can react and intervene in a timely way.

Key takeaways from CMS guidance on how to get credit for this activity includes:

  • Clinicians should use digital tools in such a way that allows them to provide ongoing guidance and assessments for patients outside of the in-office visit. This includes the collection and use of patient generated health data.
  • Clinicians must use health technology platforms and devices that collect patient data as part of an “active feedback loop” which CMS defines as “providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or real-time automated feedback to the patient.”
  • Platforms and devices used for this improvement activity must be, at a minimum, “endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way).”
  • CMS makes a distinction between technologies covered by this activity, versus “passive platforms or devices” that collect but do not transmit PGHD in real-time. The latter is not eligible technology under this activity.

Additionally, this improvement activity maps to the 2015 Edition Certification Criteria for patient generated data, providing patient access to their health information, and allowing patients the ability to view, download, or transmit their health data. Clinicians conducting this activity using Certified EHR Technology will now be eligible for a 10 percent bonus in the separate MIPS category of “Advancing Care Information” (ACI) when they incorporate patient generated health data and provide patients access to their health information and educational resources.

Clinicians can also take advantage of another PGHD-related improvement activity, “Use of CEHRT to Capture Patient Reported Outcomes” using digital health tools that capture data (such as meal logs, blood pressure or blood glucose logs taken at home) to achieve the ACI bonus—this activity remains from year one of the program.

Physician Fee Schedule Rule Includes Reimbursement for Remote Patient Monitoring and New Telemedicine Codes

CMS has un-bundled CPT code 99091 in 2018, meaning that providers will soon be able to get reimbursed separately for time spent on collection and interpretation of health data that is generated by a patient remotely, digitally stored and transmitted to the provider, at a minimum of 30 minutes of time. CMS stated that this is a first step toward recognizing remote patient monitoring services for separate payment, and it will continue to closely track the AMA’s CPT Editorial Panel activities as they further refine and value the code sets for remote monitoring.

Key guidelines on the use of this code include:

  • Providers must obtain advance beneficiary consent for the service and document this consent in the patient’s medical record.
  • For new patients or those not seen within one year before the provision of remote monitoring services, providers must initiate these services in a face-to-face visit, such as an annual wellness visit or physical.
  • Providers can use 99091 no more than once in a 30-day period per patient.
  • The code includes time spent accessing the data, reviewing or interpreting the data, and any necessary modifications to the care plan that result, include communication with the patient and/or her caregiver and any associated documentation.
  • This code will not be subject to any of the restrictions on originating sites or technology that telehealth services are subject to by statute, allowing users of this technology more flexibility.

Last year, CMS created a process for adding new telehealth services, based on proposals received by stakeholders. Under this new process, CMS has included several new services for 2018 that will be reimbursed when performed using telehealth technology. These new services are:

  • Counseling visit for lung cancer screening (HCPCS code G0296)
  • Psychotherapy for crisis (CPT codes 90839 and 90840)
  • Interactive complexity (CPT code 90785)
  • Patient-focused and caregiver-focused health risk assessment (CPT codes 96160 and 96161)
  • Chronic care management services including assessment and care planning (HCPCS code G0506)

Each of these new services is subject to existing statutory conditions for telehealth, including requirements for use of interactive telecommunications systems and originating site restrictions.

These policy updates signal that CMS is moving quickly to incentivize the integration of innovative technologies as it pushes for the transition to value-based care. Health technologists can seize the opportunity to help hospital and clinician customers to meet their regulatory incentives by ensuring that digital health products conform to the requirements set out in these rules.

For more detailed guidance on how to leverage these federal policy changes within your practice or as you develop your technology product, please contact:

Jodi Daniel

Maya Uppaluru