Within hours of one another, the federal government sent two powerful signals that telemedicine is here to stay, but permanency may not be as easy as expected. President Trump issued the "Executive Order on Improving Rural and Telehealth Access," declaring: “the expansion of telehealth services is likely to be a more permanent feature of the healthcare delivery system.” The Centers for Medicare & Medicaid Services (CMS) subsequently released the 2021 Medicare Physician Fee Schedule (PFS) Proposed Rule featuring a section: “Telehealth and Other Services Involving Communications Technology.”
While telemedicine may seem to now be woven into the fabric of the US health care system, the fact is that most of the regulatory relaxations giving way to the current reimbursement environment for telemedicine hinge on the government’s public health emergency (PHE). The PHE—now extended through October 23, 2020—provides shelter from the host of rules that govern telemedicine, from HIPAA to provider licensure.
Prior to the PHE, which was prompted by the COVID-19 pandemic, telemedicine was nearly impossible to perform at any scale. Established in 1997, telemedicine reimbursement was available only in limited circumstances. Among other rules, certain equipment had to be used, and the patient had to be physically in a location that was demarcated as a health care professional shortage area (HPSA). These strict rules meant that less than one percent of Medicare services were performed via telemedicine in 2019—and that was a banner year.
CMS’ Medicare PFS ruling proposes the provision of coverage to nine more services when performed via telemedicine: 99347 and 99348 (Home Visits); 99334 and 99335 (Domiciliary, Rest Home or Custodial Care Services); 99483 (Care Planning for Patients with Cognitive Impairment); 96121 (Neurobehavioral Status Exam); 90853 (Group Psychotherapy), 99XXX (Prolonged Services); and GPC1X (Visit Complexity Associated with Certain Office/Outpatient E/Ms).
In addition to the new CPTs that are covered, the declaration proposes to allow physician supervision via real-time, interactive, audio-visual telemedicine for calendar year 2021. In the absence of a current rule about telemedicine supervision, the definition of direct supervision applies today. As the name implies, direct supervision requires on-site presence of the billing clinician when the service is provided. The government’s proposal would, in essence, allow “incident to” supervision to extend to telemedicine.
Another component of the government’s rule would provide for expansion of the list of providers who are able to bill for telemedicine services through CPT codes G2061-G2063 to include licensed clinical social workers, physical and occupational therapists, and other health care professionals.
In addition to new broadband technology infrastructure funding for rural communities, the Executive Order further directs the Secretary of Health & Human Services (HHS) to “propose a regulation to extend these measures, as appropriate, beyond the duration of the PHE… additional telehealth services offered to Medicare beneficiaries; and the services, reporting, staffing, and supervision flexibilities offered to Medicare providers in rural areas.” HHS Secretary Alex Azar has 60 days to issue these guidelines.
Neither Trump nor CMS, however, can waive a magic wand to release physicians from the strict rules formulated during the origination of telemedicine reimbursement. The barriers are statutory; an executive order can offer instructions about actions and CMS can make minor changes within the confines of the agency’s authority. Both deliver on these promises, but they can’t affect large-scale change.
The federal government could, of course, modify the law, but that would take an act of Congress-- literally and figurately. Recognizing that the law-making process is far from ideal, the government is trying different avenues to achieve the goal of keeping the pandemic-related telemedicine flexibilities intact, even if the PHE concludes. Otherwise, the telemedicine regulations will all resume, ending the reimbursement landscape that unfolded during the pandemic.
For great tips on how to optimize telehealth and related workflows, download this complete guide to seeing patients virtually and getting paid for it.