Find out what you need to know about proposed Medicare reimbursement for 2023 and how you can advocate for your patients, business, and industry.
Telehealth is one of the biggest and brightest changes healthcare has seen in a long time. Sure, it’s not the most exciting advancement in science or technology, but neither was sliced bread.
But it’s here to stay.
And because of that, we have moved into a time where legislatures are working to keep up. Specifically, we are referring to the Centers for Medicare & Medicaid Services (referred to in this post as the CMS). On July 7th, 2022, they released their proposed rule for 2023.
This means these are just their ideas, but if history is any indication, many of these changes will be in the final ruling, which will be released later this year.
These changes cover everything from expanding remote therapeutic monitoring codes to allowing ACOs to jump on the patient monitoring train. And while all of the proposed ideas are important, a few stick out.
So, in this post, we will quickly review how we got here, explain the top medicare fee schedule changes proposed, examine what the CMS missed, and how ALL of this could impact you and your practice.
A Quick History of the Fee Schedule
Everyone has to get paid, right? And in an industry as vast as healthcare, there needs to be an equally vast standard for how to do it, specifically for fees paid to doctors and other providers via Medicare.
Institute and impose clinical and quality programs
Reimburse care facilities for services they provide Medicare patients
Govern care costs
Punish providers that underperform based on set standards, which looks like fines or lower reimbursement rates
Provide bonuses to facilities that are high-performing
The CMS also releases “Proposed Changes” for each coming year. As the world, technology, and scientific understanding progress, so does healthcare, and there needs to be some way to keep up—this is how they do it.
The New Fee Schedule Changes: An Overview
Sometimes, the industry moves too fast for legislative bodies, and they can’t keep up. While 2022 saw a lot of positive changes to the fee schedule, it also had some snags. This year is looking to be the same—good, progressive changes right along with things that will eventually need fixing.
The changes include
Expanded Remote Therapeutic Monitoring Codes
Extended telehealth waivers and other forms of flexibility
Adopted E/M changes
Changes to the Shared Savings Program
Updates to payment rates for physicians and other providers
In the following sections, we will break down these changes and how they’ll impact your practice.
Expanding Remote Therapeutic Monitoring Codes
In the final rule of the 2022 Physician Fee Schedule, the CMS introduced a family of codes that broadened the use of Medicare reimbursement beyond the existing standards of remote patient monitoring.
What even is Remote Therapeutic Monitoring?
It is defined by the CMS as both the management and remote monitoring of data that is non-physiological in nature. What does that mean? Things like the general state of a patient’s health, the respiratory and musculoskeletal system condition, and the patients’ responses to things like therapy and medication.
Also, remote patient monitoring was reimbursed strictly for analyzing and supervising a patient’s health data. This limited the ability of billing to only physicians, even if these kinds of services can be performed by all sorts of clinical staff.
But these new codes give way to reimbursement on the grounds of “general medicine”, expanding outside of usual clinical settings. And it allows billing from all kinds of practitioners, including
Clinical social workers
They have proposed four new HCPCS G-Codes that make two things happen, relax the burden on physicians and NPs and improve access to remote therapeutic monitoring. These new codes will open up “incident to” billing for staff and other kinds of providers.
The CMS is also asking for input on the coding relating to the supply of RTM devices, which is good.
Extended Telehealth Waivers & Other Flexibilities
One issue a lot of providers have run into is the limitation on remote patient monitoring services caused by the need for a Public Health Emergency (PHE) to be happening. So, another change we see in this proposed rule takes allowances in a PHE and extends that for 151 days past its end.
This will look like the implementation of the Consolidated Appropriations Act of 2022, which allows telehealth services to be furnished in any area, even a patient's home. It allows the use of audio-only technology, which studies have shown to be very good for underserved areas. Physical therapists, OTs, speech-language pathologists, and audiologists will be allowed to bill.
Changes to the Shared Savings Program
We have good news for any ACOs out there!
The CMS also offered up a variety of changes for the Medicare Shared Savings Program to further incentivize participation. This is exciting because it will allow advanced payments to ACOs or Accountable Care Organizations with lower amounts of revenue and generally serve underserved populations.
It also gives ACOs more time to come into the fold, moves performance historical benchmarks, and increases the available options for ACOs helping high-risk groups. Overall, the ruling will aim to reduce the risk posed to them.
New CBT Codes
Something remote patient monitoring services and coding has barely touched on is mental health services, but this year, the CMS is combating that standard by including a new code for both the initial setup and the supply of a Cognitive Behavioral Therapy device. This code could work in tandem with the new remote therapeutic monitoring and care management codes.
The CMS is even letting each regional Medicare Administrative Contractor or MAC price the code as they see fit while they “learn more about the devices being used to furnish this service.”
We will definitely be watching this to see where it goes!
“Incident-to” Behavioral Health Codes
Speaking of mental health, the CMS will allow licensed professional counselors and related providers to bill Medicare under “general supervision, " as we mentioned earlier.
This is a big deal because it will also allow the initial visit for behavioral health integration to include psychiatric diagnostic testing. This will open the possibilities for assistance in the current mental health crisis.
Furthermore, it will allow payment to go to clinical psychologists and licensed clinical social workers that are providing this kind of care as a part of the patient's primary care team. Specifically, this looks like a new HCPCS G-code.
Codes in the Fee Schedule for Chronic Pain Management
Another expansion this proposed ruling saw was for patients battling chronic pain or continuous pain that lasts longer than three months. There will be two new G-codes. These chronic pain management or treatment services will be allowed under “general supervision” and not under “incident-to” the billing physician.
We’ve uncovered quite a bit of good news, so now it’s time to get into some of the bad news. Physicians will be seeing a deliberate decrease in the conversion factor on January 1st, 2023.
In this case, the rate will be moving from $34.6062 to $33.0775.
It looks like through updates to practice expense, work, and malpractice RVUs, payments to cardiologists will decrease by 1% from 2022 to 2023. Of course, the estimate provided by the CMS is based on the whole cardiology profession, so take it with a grain of salt.
How People Feel About The CMS Changes
Some feel this whole topic indicates trouble ahead. For example, the update fails to take the whole inflation problem into consideration. They feel that this whole 2023 Fee Schedule proposal should motivate concentrated effort to protect access to Medicare-participating physicians.
What About Remote Physiological Monitoring?
Sadly, there is nothing. If you’ve had your ear on the industry, you’ll know that there have been continuous cries for medicare changes regarding requirements for billing the RPM (remote patient monitoring) codes.
What are we talking about? Good question.
There is this thing called the 16-Day Rule, where the CMS clarified that codes 99453 and 99454 should only be billed once in a 30-day period. It doesn’t matter if you’ve given the patient more than one device; that’s just how this goes.
The reason it’s got “16-Day” in the name is because there needs to ALSO be 16 individual days of readings for the situation to qualify for the 99453 and 99454 codes.
Interested parties have pointed out some issues with this ruling, including how it can be more of a barrier than an incentive to new organizations implementing this service.
Where Do We Go From Here? Medicare Fee Schedule Changes
The problem now is that there is a deadline coming, marking 151 days after the end of a PHE or a public health emergency. Thankfully, the CMS has given us that, but the whole remote patient monitoring industry is not just a pandemic-era-blip moment—it’s here to stay.
The only way we can stay is if the CMS picks the ball right where they dropped it at the end of 151 days. We would see this happen in the form of more PHE-related waivers/exceptions that did us a few favors.
Some of these favors look like
An expansion of the scope of telehealth sites to include any site in the United States where the beneficiary is located at the time. Specifically including the person’s home.
The interim expansion of eligible telehealth practitioners to include audiologists and other practitioners.
Relaxing the in-person requirements for audio-only telemental health services.
Coverage of particular telehealth services provided using audio-only technology during the PHE.
If you couldn’t tell, the theme of these exceptions is focused on getting us all ready for the final bow of the PHE. We are all going to be impacted by that change. Ultimately, we need Congress to adopt legislation that removes billing and reimbursement completely from the PHE.
But, we’ll just have to see about that, won’t we?
Accuhealth Stands With YOUR PRACTICE
Your remote patient monitoring company needs to be watching this, so you don’t have to. And we understand that this whole post has been a bit of a roller coaster, and if you feel particularly overwhelmed, here are some resources that might clear things up for you.