CMS Proposes Expanding Medicare Telehealth Benefits and Scope of Practice Changes Beyond Pandemic

The Centers for Medicare & Medicaid Services (CMS) is proposing to maintain—either permanently or temporarily— many of the Medicare telehealth benefits and workforce flexibilities authorized during the Covid-19 pandemic, according to the fiscal year 2021 Medicare physician fee schedule proposed rule the agency released Monday.

In issuing these proposed changes, CMS referred to President Trump’s Aug. 3 Executive Order on “Improving Rural Health and Telehealth Access” that directs the Health and Human Services secretary to propose regulations to extend flexibilities provided during the Covid-19 public health emergency (PHE) as appropriate.

Proposed Extensions of Medicare Coverage of Telehealth

On a permanent basis, CMS proposes to continue Medicare coverage for these telehealth services authorized during the PHE:

Home visits for the evaluation and management of an established patient: less complex and last typically 25 minutes,
Certain types of visits for patients with cognitive impairments,
Group psychotherapy,
Neurobehavioral status exams,
Care planning for patients with cognitive impairment,
Less complex domiciliary, rest home, or custodial care services, and
Prolonged evaluation and management (E/M) services.

CMS has requested public feedback on other services to add to this list of permanent Medicare-covered, telehealth services.

CMS is also proposing to extend Medicare coverage on a temporary basis for telehealth delivery of the following services until the end of the calendar year when the PHE ends:

Psychological and neuropsychological testing,
Emergency department visits,
Home visits to address moderate to severe issues, typically lasting 60 minutes,
More complex domiciliary, rest home, or custodial care services, and
Nursing facilities discharge day management.

CMS has also requested comments on this list of telehealth services that the agency proposes to cover temporarily in Medicare. CMS said it intends these temporary extensions of coverage to allow time for the agency to consider whether these services should be extended permanently.

In the proposed rule, CMS clarified that licensed clinical social workers, clinical psychologists, (as well as physical therapists, occupational therapists, and speech-language pathologists) can furnish the brief online assessment and management services via telehealth as well as virtual check-ins and remote evaluation services.

In addition, CMS has clarified that telehealth rules do not apply when the beneficiary and the practitioner are in the same location even if audio/video technology assists in providing a service.

CMS has not proposed to continue separate payments for audio-only evaluation and management services beyond the end of the PHE. Instead, the agency has requested comment on whether to develop coding and payment for a service similar to virtual check-in but for a longer unit of time with a higher value. CMS is seeking feedback on duration of services and resources required to furnish this service and also whether Medicare coverage of this audio-only service should be extended temporarily or permanently.

Meanwhile, CMS is proposing to allow direct supervision to be provided using real-time, interactive audio and video technology (excluding telephone that does not also include video) through Dec. 31, 2021. The agency is requesting comments on this proposal, including guardrails that should be in place and risks to patient safety and concerns about waste, fraud, and abuse.

CMS also included a number of clarifications about Medicare coverage for remote physiologic monitoring codes and new payment rates for immunization administration.

Updates to Evaluation and Management Codes

In this proposed rule, CMS has proposed revaluing a number of code sets that rely on or are analogous to E/M visits including psychiatric diagnostic evaluations and psychotherapy services.
CMS has also proposed simplified coding and billing requirements for E/M visits to take effect in January 2021.

Proposed Changes to Scope of Practice Rules and Related Issues

CMS has also proposed changes to allow healthcare professionals to practice up to the top of their professional training and to continue some of the workforce flexibilities allowed during the PHE, including:

Allowing nurse practitioners, clinical nurse specialists, physician assistants, and certified nurse-midwives (instead of only physicians) to supervise others performing diagnostic tests consistent with state law and licensure, providing that they maintain the required relationships with supervising/collaborating physicians as required by state law,
Clarifying that physicians and nonphysician practitioners, including therapists, can review and verify documentation entered into the medical record by members of the medical team for their own services that are paid under the Medicare physician fee schedule,
  • Accordingly, in the inpatient psychiatric facility prospective payment system final rule issued July 31, CMS also confirmed as final, changes to the special conditions of participation rules for psychiatric facilities allowing non-physician practitioners, or advanced practice providers (including physicians assistants, nurse practitioners, psychologists, and clinical nurse specialists) to document progress notes in accordance with state laws and scope-of-practice requirements.
Clarifying that therapy students, and students of other disciplines, working under a physician or practitioner who furnishes and bills directly for their professional services to the Medicare program, may document in the record so long as it is reviewed and verified (signed and dated) by the billing physician, practitioner, or therapist, and
Requesting comment on whether to continue temporarily or permanently Medicare coverage for services of residents that are provided outside of the scope of their approved GME programs and furnished to inpatients of a hospital in which they have their training program as separately billable physicians’ services.

Proposed Changes to Opioid Treatment Program Benefit

CMS has proposed making several changes to claiming rules and payment codes for the new Medicare Part B benefit for opioid use disorder services, including medications and services furnished by opioid treatment programs. Of note, add-on codes for nasal naloxone and auto-injector naloxone are proposed along with clarification on periodic assessment add-on code requirements.

SUD Screening in Medicare Initial and Wellness Visits

CMS is implementing a new requirement that the Medicare Initial Preventive Physical Examination and Annual Wellness Visit include screening of beneficiaries for potential substance use disorders, including a review of any current opioid prescriptions, as well as referral for specialty treatment, as appropriate. This new requirement was enacted in the SUPPORT Act.

Electronic Prescribing of Controlled Substances

CMS said it is implementing another SUPPORT Act provision that requires prescriptions of Schedule II, III, IV, or V controlled substances for Medicare Part D beneficiaries to be electronic. CMS issued a request for information on July 30 requesting feedback on whether to include exceptions to this requirement and whether CMS should impose penalties.

Public comments on this proposed rule are due by Monday, Oct. 5.