CMS Issues Proposed Rule to Implement New Medicare Billing and Payment Schedule for Telehealth Reimbursements

10-10-17 Legal Intelligencer Article by Vasilios (“Bill”) J. Kalogredis & Katherine E. LaDow

On July 13, 2017, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2018.  The Proposed Rule (CMS-1676-P) proposes to add Telehealth reimbursements and bolster payment for office behavioral healthcare by factoring in overhead costs and ease reporting requirements for Telehealth medical providers.

In order for Medicare to make payments for Telehealth services under the PFS, the services must meet the following requirements:

1) the service shall be furnished through an interactive telecommunications system;
2) the service shall be furnished by a physician or other authorized practitioner;
3) the service shall be furnished to an eligible Telehealth patient; and
4) the patient receiving the Telehealth service must be located in a Telehealth originating site. Practitioners furnishing  Medicare  Telehealth  services  submit  claims  for  Telehealth  services to the  Medicare  Administrative  Contractors  (MACs)  that  process claims  for  the  service  area where  their  distant  site  is  located.   Section  1834(m)(2)(A)  of  the Social Security Act requires  that  a practitioner who  furnishes  a Telehealth  service  to an eligible  Telehealth  individual  be paid an amount  equal  to the  amount  that  the practitioner  would  have  been paid  if  the service  had been furnished  without the  use of a telecommunications  system.

Once all four of these conditions are met, Medicare would pay a facility fee to the originating site and makes a separate fee to the Telehealth practitioner furnishing the service.

The Proposed Rule establishes a process for adding services or deleting services from the official list of Medicare Telehealth Services. Requests to add services to the list of Medicare Telehealth Services must be submitted and received by CMS no later than December 31 of each calendar year to be considered for the next rulemaking cycle. CMS will sort and analyze these requests into two categories in order to qualify the specific request. The two categories are:

Category  1:   Services  that  are similar  to professional  consultations,  office  visits,  and office psychiatry  services  that  are currently  on the list  of Telehealth  services.   In reviewing  these requests,  CMS looks  for similarities  between  the requested  and existing  Telehealth  services  for  the roles  of, and  interactions  among,  the beneficiary,  the  physician  (or other  practitioner)  at the distant  site  and, if  necessary ,  the  telepresenter,  a practitioner  who  is  present  with  the  beneficiary in  the  originating  site.   CMS also looks  for  similarities  in  the  telecommunications  system  used  to deliver  the  service;  for example,  the use  of interactive  audio  and video  equipment.

Category  2:   Services  that  are not similar  to the  current  list  of  Telehealth  services.   CMS’s review  of these  requests  includes  an assessment  of whether  the service  is accurately  described  by the  corresponding  code when  furnished  via  Telehealth  and whether  the  use of a telecommunications  system  to furnish  the  service  produces  demonstrated  clinical  benefit  to the patient.   Submitted  evidence  should  include  both  a description  of relevant  clinical  studies  that demonstrate  the  service  furnished  by Telehealth  to a Medicare  beneficiary  improves  the  diagnosis or treatment  of an illness  or injury  or improves  the functioning  of a malformed  body part, including  dates and findings,  and a list  and copies  of published  peer reviewed  articles  relevant  to the  service  when  furnished  via  Telehealth.

For calendar year 2018, CMS proposes to add several codes, on a Category 1 basis, to the list of Telehealth services including:

  • HCPCS code G0296 Counseling visit  to discuss  need for  lung  cancer  screening  using low  dose CT scan (ldct)  (service  is for  eligibility  determination  and shared  decision  making));
  • CPT code 90785 (Interactive Complexity (listed separately  in  addition  to the  code for primary  procedure));
  • CPT codes 96160 and 96161 (Health Risk Assessment);
  • HCPCS code G0506 (Comprehensive assessment  of and  care planning  for  patients requiring  chronic  care management  services  (listed  separately  in  addition  to primary  monthly  care management  service));
  • CPT codes 90839 and 90840 (Psychotherapy for Crisis; first 60 minutes)  and (Psychotherapy  for crisis;  each  additional  30 minutes  (listed  separately  in  addition  to code for primary  procedure)); and
  • CPT codes 96160 and 96161 (Administration of patient-focused  health  risk  assessment instrument  (e.g.,  health  hazard  appraisal)  with  scoring  and  documentation,  per standardized instrument)  and (Administration  of  caregiver-focused health  risk  assessment  instrument  (e.g., depression  inventory)  for  the benefit  of the  patient,  with  scoring  and documentation,  per standardized  instrument).

Additionally, the Proposed Rule eliminates the required reporting of the Telehealth modifier for professional claims in an effort to reduce administrative burden for practitioners. Medicare has  required distant  site  practitioners  to report  one of two longstanding  HCPCS modifiers  when  reporting  Telehealth  services.   Current guidance instructs practitioners to submit claims for Telehealth services using  the appropriate  CPT or HCPCS code for  the professional service along with the Telehealth modifier GT (via interactive audio and video telecommunications  systems).  In the  CY 2017 PFS final  rule  (81 FR 80201), CMS finalized  payment  policies  regarding Medicare’s  use of a new Place of Service  (POS) Code describing  services  furnished  via Telehealth. Because a valid  POS code is  required  on professional  claims  for  all  services,  and the appropriate  reporting  of the Telehealth  POS code serves  to indicate  both  the provision  of the service  via  Telehealth  and certification  that  the requirements  have  been met,  CMS believes  that  it  is unnecessary  to also require  the distant  site  practitioner  report the  GT modifier  on the  claim. Therefore, CMS proposes to eliminate the GT modifier on professional claims.

To read the Proposed Rule, CMS-1676-P, visit:

Vasilios (“Bill”) J. Kalogredis, Esquire is Chairman of Lamb McErlane’s Health Law Department. Bill has been practicing health law for over 40 years, representing exclusively physicians, dentists, group practices, other health care professionals and health care-related entities.

*Katherine (“Katie”) E. LaDow, Esquire, an associate with Lamb McErlane PC., contributed to this article. Katie is an associate in the litigation department. She concentrates her practice in the areas of state civil litigation, family law and health law.