administration agreement banking blur 618158

The Center for Medicare and Medicaid Services (CMS) released their final Physician Fee Schedule (PFS) for CY 2022. The PFS are the policies that the agency will be implementing for Medicare beginning on January 1, 2022, unless otherwise noted. This is the typical vehicle utilized by CMS to make administrative changes to telehealth policy in the Medicare program. After receiving and addressing public comments, CMS has decided to finalize the following:

• 93798 – Physician or other qualified health care professional services for outpatient cardiac
rehabilitation; with continuous ECG monitoring (per session)
• G0422 – Intensive cardiac rehabilitation; with or without continuous ECG monitoring with exercise (per session)
• G0423 – Intensive cardiac rehabilitation; with or without continuous ECG monitoring; without exercise (per session)

CONSOLIDATED APPROPRIATIONS ACT – PHYSICIAN FEE SCHEDULE

The Consolidated Appropriations Act (CAA) passed in December 2020. It made certain changes to permanent telehealth policy (permanent telehealth policy is hereafter referred to “Original Telehealth Policy”).
Original Telehealth Policy are the telehealth policies that will revert into effect or remain after the PHE is declared over. 

Among those changes passed in the CAA were removing the geographic limitation when providing mental health services and allowing the home to be an eligible originating site for such services. However, a caveat was included that stated for the exception to the geographic limitation and allowing the home as an eligible originating site for these services to occur, the telehealth provider must have had an in-person interaction with the patient within six months prior to the use of telehealth. This in-person requirement does not apply to cases that would be eligible outside what was required by the CAA. 

For example, if you were receiving services via telehealth in a doctor’s office that would qualify under the rural restriction, the prior in-person visit with the telehealth provider need not have taken place. In addition, it does not apply when a patient is being treated for substance use disorder with co-occurring mental health disorder, since previously existing statute provides an exception in those circumstances from the geographic requirement and allows the home as an eligible site. 

It was left up to CMS to decide if and how often subsequent in-person visits are needed. In the proposed 2022 PFS, CMS had inquired whether the six-month in-person visit requirement needs to occur within six-months before each telehealth service and whether the provider who furnishes the in-person visit needs to be the telehealth provider or if it could be another provider in the same specialty and in the same group.

CMS finalized Physician Fee Schedule includes:
Clarification that the six-month prior in-person visit must be the furnishing of an item or service for which Medicare payment was made in order to meet the six-month in-person requirement.
Therefore, if Medicare payment was not made for that visit, it would not meet the necessary six-month in-person visit.
Subsequent requirements for an in-person visit must take place 12 months prior to the telehealth services and there are some narrow exceptions such as when the patient and provider agree the risks and burdens of an in-person visit are outweighed by continuing via telehealth, such as possible disruptions. However, this must be documented in the medical record as well as documenting that the patient is able to obtain needed point of care testing, including vital sign monitoring and laboratory studies.

A colleague in the same subspecialty and same group may furnish the in-person visit if the telehealth provider is not available to meet the in-person visit requirement.
“Home” may be defined to include temporary lodging (hotels, homeless shelters) and if the patient chooses to travel a short distance from the exact home location.
Also under the CAA, rural emergency hospitals are added as eligible originating sites for telehealth. CMS will make this change beginning in CY 2023.