Vasilios J. Kalogredis
Vasilios J. Kalogredis ()

On July 13, 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 Jan. 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: the service shall be furnished through an interactive telecommunications system; the service shall be furnished by a physician or other authorized practitioner; the service shall be furnished to an eligible telehealth patient; and 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 Dec. 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.

Cateogory 2: Services that are not similar to the current list of telehealth services. CMS’ review of these requests includes an assessment of whether the service is accurately described y 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,

Katherine E. LaDow, an associate with Lamb McErlane, contributed to this ­