In November 2018, CMS finalized and released the 2019 Physician Fees Schedule, which contains significant changes aimed at modernizing the healthcare system by using technology, reducing administrative burden and improving the doctor-patient relationship.^1,2 While CMS’s interpretation and implementation of telehealth is amongst the most restrictive, this latest release expands and clarifies things, at least a little. 

Telehealth-delivered services under Medicare are regulated in statute by 1834(m) of the Social Security Act, which limits the use of telehealth to certain services, providers, technology (mainly live video) and patient locations (certain types of healthcare facilities in rural areas). The CMS rule expresses concern that these requirements may be limiting the coding for new kinds of services that use communication technology.

Out-of-office Care

Luckily, these restrictions only apply to professional services specified in the statutory provisions, such as office visits, professional consultations and other in-office services. Other services that can be provided remotely using communications technology are not subject to these restrictions because they are not considered “Medicare telehealth services.” Because of this, optometrists need to be aware of three scenarios and the associated new codes:

• Brief communication technology-based service, e.g. virtual check-in (HCPCS code G2012): This applies to check-in services used to evaluate whether or not an office visit or other service is necessary. The modalities include audio-only real-time phone interaction, in addition to synchronous, two-way audio interactions enhanced with video or other forms of data transmission. CMS pays approximately $14 for this service (unless it is the result of a previous appointment or leads to a face-to-face appointment). CMS believes the check-ins will mitigate the need for potentially unnecessary office visits.

• Remote evaluation of pre-recorded patient information (HCPCS code G2010): CMS finalized the creation of a specific new code to describe remote professional evaluation of patient-transmitted information conducted via pre-recorded “store-and-forward” video or image technology. These services are not subject to the Medicare telehealth restrictions because they could not substitute for an in-person service currently separately payable under the PFS.

• Interprofessional internet consultation (CPT codes 99452, 99451, 99446, 99447, 99448 and 99449): These codes cover interprofessional consultations performed via communications technology such as telephone or internet. This supports a team-based approach to care that is often facilitated by electronic medical record technology.

Clinicians must understand that CMS restricts the use of the virtual check-in and the pre-recorded patient information codes, which can only be used by practitioners who furnish E/M codes.

Carrier Considerations

As technology continues to expand and drives changes in the patient journey and the quality of clinical outcomes, optometrists must stay abreast of the rule sets and changes that come at a furious pace. Pay attention to the rules of each of your contracted medical carriers, as they can differ based on whether the carrier is commercial, Medicaid, Medicare Part C (Medicare Advantage), or traditional Medicare Part B. And as always, make sure you are aware of these rules prior to providing the care—never assume that meeting the requirements of telehealth for one carrier means you meet the rules for other carriers. 

Hopefully we will eventually have a universal rule set that streamlines the delivery of care by telehealth; but until then, you must maintain a separate rule set for each carrier.

Send questions and comments to rocodingconnection@gmail.com.