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Reimbursement Update: It’s raining new codes!

August 21, 2018

Reader alert: reimbursement codes are not exciting but are critical in advancing connected health… and, after all, we all want to advance connected health. Read on!

It is just shy of two years since the American Medical Association (AMA) asked me to co-chair their Digital Medicine Payment Advisory Group (DMPAG).  At the time, I was waking up to the idea that, for us to speed adoption of connected health in the provider community, we need more billing codes. This may sound obvious to all of you, but I was a late-comer to this party. My reasoning was that value-based reimbursement is growing and value-based contracts are very telehealth friendly, so why should I waste my time on bolstering the fee-for-service reimbursement system?

The insight I gained from this collaboration was beautifully articulated by the AMA’s CEO, Dr. James Madara, during an interview I did with him on my new podcast, Well/Connected (click here to listen to Jim talk about this directly). Jim said that no matter what reimbursement system you choose, providers need to have a way to quantify their work product and codes allow them to do that. Indeed this has helped me understand why adoption of remote monitoring for care of chronically ill patients has lagged. Until very recently, we had no mechanism for providers to document the level of work required to take care of patients in the context of remote monitoring.

2017 was the first year of DMPAG activity and, early on, we decided to move two new types of codes through the process, one for physician-to-physician online consultation and another set for remote monitoring.  I detailed this journey in a post in November 2017.

In that post, I had referenced the Lemony Snicket movie, “A Series of Unfortunate Events,” noting that Medicare reimbursement for remote monitoring was just the opposite: it was the culmination of aseries of fortunate events. Back in November, these new reimbursement codes had been moved forward to the point where they were sitting with The Centers for Medicare & Medicaid Services (CMS) committee that proposes a value for them (known as the RUC process). It’s old news now, but as of January 1, 2018, CMS also unbundled an old code – CPT 99091 – that allows a practitioner to bill for the evaluation of remote monitoring data.

I don’t have specific data on utilization of that code, but anecdotally, it has not been a big hit. It requires a doctor (or nurse practitioner) to review data for 30 minutes/month in order to submit the code.  In our experience, unless a patient is very sick and complex, no one provider devotes 30 minutes of time/month reviewing remote monitoring data.  This code was as step in the right direction but predictably not a big winner.

About a month ago, CMS came out with their guidance on what new codes they propose to include in the code structure starting in 2019.  Some of what they published was predictable, moving forward with the codes we submitted last fall, and some was unpredictable, with the addition of new codes. But as far as I can tell, all of it is positive!  CMS is now collecting comments on these proposed new codes and, once again in November, will release what is to be included in the 2019 code set.

So, I warned you.  I tried to think of a way to make this topic interesting, but there’s just no way around it, CPT codes are necessarily dry and technical. The exciting part, however, is the receptivity of CMS, under current leadership, to move connected health forward.

New and Exciting Proposed Reimbursement Codes!

Two of the new codes are different from CPT medical billing codes. So, without getting too deep into the weeds, following is a very brief explanation of these two new codes, known as HCPCS codes (Healthcare Common Procedure Coding System). If you want to learn more about the difference between CPT and HCPCS codes, follow this link.

New Proposed Code #1: Brief Communication Technology-based Service, e.g. Virtual Check-in (HCPCS code GVCI1)

This is to replace a code (99441) which covered a brief telephone check-in with the patient between office visits to determine if the patient needed to come in sooner or make another adjustment.  This is a new area for reimbursement and CMS is looking for lots of early stage guidance. It’s not clear what the fate of this code will be, but the fact that they proposed it is encouraging.

New Proposed Code #2: Remote Evaluation of Pre-Recorded Patient Information (HCPCS code GRAS1)

This is to cover remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with verbal follow-up with the patient within 24 business hours.  This would seem to be a dream come true for my dermatologic colleagues (and others who evaluate images as part of their clinical decision making).  This is also early stage, but CMS suggested a value(0.8 RVU) for this code, leading me to believe they are serious about it.

Also of note is that the interprofessional Internet Consultation codes (CPT codes 994X6, 994X0, 99446, 99447, 99448 and 99449) were recently valued by the RUC, and CMS is seeking comment on some of the details.

Finally, there is good news for the home health industry, as CMS is proposing reimbursement of remote monitoring services in that sector as well.

Admittedly, all of this is a very superficial review, and for those of you interested in the details, start with the CMS announcement and work your way through it.

And even if you’re not interested in the fine print details of reimbursement, for telehealth adoption, the future looks quite bright, considering that, when CMS pays for services, it is common for other carriers to follow suit. It’s a reality I have come to appreciate – even in a value-based care delivery system, providers need to quantify their work and billing codes for connected health are a necessity.

And what does all this mean for connected health? In the next few years, as these reimbursement trends continue, we could finally begin to see the needed acceleration of telehealth adoption. And that is a very exciting proposition!

 

 

 

One Comment leave one →
  1. Jeffrey Phillips permalink
    August 23, 2018 10:31 am

    Hi Joe- Agree that this is boring, but is probably the biggest single barrier to large scale adoption of remote monitoring. Ears will perk up when people realize that we can be paid for this. Obviously, will require some workflow changes.

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