CMS tweaks telehealth coverage again, but its power to change is limited

By Brian Dolan
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iHealth Blood Pressure iPhoneOver the Thanksgiving holiday weekend the Centers for Medicare and Medicaid Services announced a number of incremental changes to how they will cover telehealth services in 2014. The American Telemedicine Association spends a lot of effort each year pushing CMS toward incremental change and wider coverage of telehealth. For 2014, the ATA sees a few important changes coming for Medicare patients who benefit from remote care:

1. CMS has slightly expanded the "geographic areas where telehealth service can be provided into the fringes of metropolitan areas", according to the ATA.

2. CMS has added coverage for "transitional care management services (CPT codes 99495 and 99496) and [made] explicit that coverage includes the Evaluation and Management portion of these services", the ATA wrote.

3. CMS also added coverage for "chronic care services (CPT codes 99487-99489) for patients with multiple chronic conditions that are expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk", according to the ATA's summary of the change.

When CMS announces these changes it publishes a lengthy document that outlines them along with a discussion of those proposed changes from commenters that it ultimately decided not to adopt. One particular exchange regarding a service a commenter wanted CMS to add sheds some light on the limitations that legislation puts on CMS' ability to make changes even if it desired to:

"A commenter urged CMS to reconsider its decision to not include CPT codes 98969 (Online assessment and management service provided by a qualified nonphysician health care professional to an established patient, guardian, or health care provider not originating from a related assessment and management service provided within the previous 7 days, using the Internet or similar electronic communications network) ... on the list of Medicare telehealth services. The commenter noted that such services can serve as a valuable preventive benefit in the treatment and care of Medicare beneficiaries; that such services are often are unavailable to beneficiaries who reside in very rural areas; and that telehealth services should be expanded in view of the increasing number of beneficiaries and the projected physician shortage," CMS wrote.

CMS said it would not extend coverage to these types of services because, as they explained in their 2008 rulemaking document, "(1) these services are non- face-to-face; and (2) the code descriptor includes language that recognizes the provision of services to parties other than the beneficiary and for whom Medicare does not provide coverage (for example, a guardian). Under section 1834(m)(2)(A) of the Act, Medicare pays the physician or practitioner furnishing a telehealth service an amount equal to the amount that would have been paid if the service was furnished without the use of a telecommunications system."

Another commenter asked whether some telehealth services would be covered if they were provided in the private homes or assisted living facilities of the Medicare patient. CMS responded that they would not and again cited the law:

"Response: No, in furnishing TCM services as telehealth services, all other conditions for telehealth services still apply. In addition to geographic criteria, the statutory criteria for eligible originating sites include only certain types of locations specified in section 1834(m)(4)(C)(ii) of the Act, and those do not include private homes and assisted living facilities."

CMS announces these kinds of tweaks toward the end of every year, but suggestions for new changes are due a full year in advance -- the deadline for 2015 proposed changes is the end of 2013. While the glacial pace of change via the CMS' rulemaking on telehealth each year clearly shows some progress, it is clear that Congress must pass legislation if digital health technologies are ever going to help Medicare patients in the era of reimbursement.

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