CMS has issued its 2019 Physician Fee Schedule Proposed Rule, containing highly anticipated new reimbursement policies for telehealth, remote monitoring, and other uses of digital tools, as well as updates to health IT requirements in the Quality Payment Program, with a stronger focus on patient access to health information. Comments are due September 10 at 5pm.

Three New Codes for Remote Monitoring

The latest step in a long, public-private collaboration to modernize federal reimbursement for remote monitoring tools, the 2019 Proposed Rule offers three codes that providers can use to get reimbursed for integrating remote monitoring data into their practice (p. 237).

The first two are practice expense codes, a category encompassing the resources providers spend such as office rent, supplies, and medical equipment. The third code tracks the amount of time a care provider spends managing patient care using the remote monitoring data, including direct communication with the patient.

• 990X0: Remote monitoring of physiologic parameter(s) (Includes examples such as weight, blood pressure, pulse oximetry, and respiratory flow rate). Covers the time providers spend on setting up the technology and explaining to patients how it works.
• 990X1: Remote monitoring of physiologic parameter(s). Covers device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
• 994X9: Remote physiologic monitoring treatment management services. Covers 20 minutes or more of clinical staff, physician, or other qualified healthcare professional time in a calendar month. The code requires interactive communication with the patient and/or the patient’s caregiver during the month.

Challenges remain with the proposed codes. The codes only cover the exchange and interpretation of “physiologic” data; yet many providers today would agree that there is a wealth of patient data that is helpful at the point of care, including patient-reported outcomes or behavioral data, that would fall outside the definition of physiologic. (However, CMS has proposed an alternative approach that may work for some use cases, described in the next section.)

Further guidance may be helpful to determine exactly which providers on a care team can spend time working with remote monitoring data. While the code definition states “clinical staff, physician, or other qualified healthcare professional,” elsewhere in the PFS proposed rule refers to the term “practitioner,” which “is used to describe both physicians and nonphysician practitioners (NPPs) who are permitted to bill Medicare under the PFS for the services they furnish to Medicare beneficiaries.” (p. 9)

In many healthcare settings, a case manager or care coordinator would be the person to review data and flag patients who need follow up phone calls or outreach. That role is not typically a type of provider that directly bills Medicare. For other codes, such as Chronic Care Management, CMS has made it clear that these staff can bill for time “incident to” physician services. Similar guidance would be helpful for these remote monitoring codes.

New Reimbursement for “Communication Technology-Based Services”

CMS acknowledges the evolution of physician services furnished through communication technology since the Medicare telehealth services statutory provision was enacted and the innovations being use in the active management and ongoing care of patients with chronic conditions. Recognizing the many statutory restrictions on telehealth in Section 1834(m) of the Social Security Act, CMS has taken the interpretation that there are physician services that involve interaction with a patient via remote communication technology that are not considered telehealth services and therefore are not covered by these restrictions (however, they note that compliance with HIPAA is required) (p. 63-65).

CMS proposed several new HCPCS codes that are not considered “telehealth” services and as such, not subject to the conditions of Section 1834(m):

• HCPCS code GVCI1: Brief Communication Technology-Based Service, e.g. Virtual Check-in. This would include the kinds of brief non-face-to-face check-in services furnished by a physician or other qualified health care professional, using communication technology, to evaluate whether or not an office visit or other service is warranted.
• HCPCS code GRAS1: Remote Evaluation of Pre-Recorded Patient Information. This covers physician time spent reviewing patient-submitted video or images to determine if a follow up visit is needed.

In keeping with national priorities for shifting toward value-based care and care coordination, CMS acknowledges that modern communication technology allows for “the kinds of brief check-in services furnished using communication technology that are used to evaluate whether or not an office visit or other service is warranted.”

Beginning January 1, 2019, CMS is proposing to pay providers for utilizing these types of preventative technology services, even in cases where the activity means that a follow up office visit is not scheduled – thus rewarding physicians for preventative action (p. 67). Where the check-in services precede an office visit or follow a visit within the previous 7 days, they would be bundled into the payment for the visit, but where the service does not lead to an office visit, there could be a separate payment.

These types of services could incentivize the use of communications technology to facilitate opioid or substance abuse treatment regimens, and could be broad enough to encompass activities such as virtual medication management or mental health monitoring.

CMS is seeking comments on the implications of this approach, as well as more information from industry about the types of technologies in use today to achieve these goals. Additionally, CMS seeks insight from industry as to whether such services are appropriate for new patients or should be restricted to existing patients and whether patient consent should be required.

Streamlining Health IT Requirements, with a Focus on Patient Access and Opioid Treatment

In the proposed QPP rule, CMS continues to push for increased patient access and carries over the new branding of “Promoting Interoperability” for health IT requirements. All QPP participating providers will need to be using 2015 Edition Certified EHRs by 2019, each enabled with a certified application programming interface (API) to allow for patient access to health information.

In an overall effort to simplify a complex points system, CMS proposes removing the existing categories of base scores and performance scores, and instead allowing providers to get credit based on how well they perform (i.e., more credit for a higher percentage of performance). Table 38 is a helpful illustration of how it works (p. 623).

For patient access, a provider will now be able to get more points (up to 40, the highest weight of any measure) for delivering access to more patients. To obtain all 40 points, providers will need to provide 100% access. If they provide access to 50% of their patients, they will get 20 points. Previously, an all-or-nothing “base score” was the reward for giving just a single patient access to their health data, with a 10 percent “performance score” for doing more than that. The new program is considerably simpler, rewarding providers based on performance.

By allocating 40 points for patient access, CMS is also increasing providers’ incentive to enable information access for more patients. In the agency’s words, “We believe that it is important for patients to have control over their own health information, and through this highly weighted objective we are aiming to show our dedication to this effort.”

CMS is also proposing to add a few new measures. The first two measures are aimed to support efforts related to the treatment of opioid and substance use disorders, are optional in 2019 and provide opportunities for obtaining 5 bonus points for each measure:

• Query of Prescription Drug Monitoring Program (PDMP) – The provider uses data from CEHRT to query a PDMP for prescription drug history for at least one Schedule II opioid electronically prescribed prior to the prescription. (p. 639-643)
• Verify Opioid Treatment Agreement: The provider seeks to identify the existence of a signed opioid treatment agreement and incorporates it in CEHRT, for at least one unique patient for whom a Schedule II opioid was electronically prescribed where the total duration of the patient’s Schedule II opioid prescriptions is at least 30 cumulative days within a 6-month look-back period. (p. 643-649)
• Support Electronic Referral Loops by Receiving and Incorporating Health Information: A revamped measure for clinical information reconciliation for medication, medication allergy, and current problem list, with the goal of enabling smoother transitions of care and referral management; required in 2019 with exclusion criteria.

Similar to CMS’s policy proposal in the Inpatient Prospective Payment System (IPPS) proposed rule, the Coordination of Care Through Patient Engagement objective will be eliminated, including measures relating to patient-generated health data (PGHD), view/download/transmit, and secure messaging.