Major changes to payment for outpatient office visits; relaxed documentation requirements; new reimbursement for virtual check-ins, remote evaluations of pre-recorded patient information, and interprofessional internet consultations; additions to list of Medicare telehealth services.

The final 2019 Medicare Physician Fee Schedule regulation released by the U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services (“CMS”) on Nov. 1 includes major changes effective in 2021 to Medicare payments for outpatient office visits. As formerly proposed by CMS, the fee schedule would have paid professional billing providers the same for CPT code levels two through five. Instead, the final rule clarifies there will be three payment levels for new and established patients, with a blended payment for levels two through four and separate payments for levels one and five.

The two-year delay in implementation provides the opportunity for CMS to respond to work done by the American Medical Association and the CPT Editorial Panel, as well as other stakeholders, particularly regarding changes to CPT coding for evaluation and management (“E/M”) services, and recommendations regarding appropriate valuation of new or revised codes.

Changes taking effect Jan. 1, 2019, include relaxed documentation requirements:

1. For established patients at E/M office outpatient visits to simplify documentation of history and exam.
2. For teaching physicians, detailed in 42 C.F.R. §§ 415.172(b) and 415.174. 

The 2019 Medicare Physician Fee Schedule has also established brand new payments outside of the restrictions of the traditional Medicare telehealth reimbursement statute, which pursuant to Social Security Act (the “Act”) § 1834(m), requires patients to be located at an originating site location and only in non-MSA or rural health professional shortage areas. New payments include:

1. Virtual check-ins (HCPCS code G2012).
2. Remote evaluations of pre-recorded patient information (HCPCS code G2010).
3. Interprofessional internet consultations (CPT codes 99451, 99452, 99446, 99447, 99448, and 99449).

CMS also added to the list of Medicare-reimbursed telehealth services (which can be updated by CMS each year within the parameters of § 1834(m) of the Act), and telehealth services for stroke and kidney disease. The stroke and renal dialysis services can even be provided when patients are located in their own homes given specific statutory authority from recent federal legislation.

While the final CMS fee schedule rule expands Medicare reimbursement for telehealth services, each new payment comes with particular compliance requirements. In certain cases, the rule requires memorialization of patient consent in the medical record. 

Taft’s Health & Life Sciences attorneys can provide guidance on how to interpret and implement these new reimbursement opportunities, changing payment methodologies and related documentation requirements.