On July 12, the Centers for Medicare & Medicaid Services (CMS) released the Medicare Physician Fee Schedule (MPFS) proposed rule. CMS also released an accompanying fact sheet that summarizes the major policy areas addressed in the rule. The MPFS proposed rule sets Medicare payment rates for calendar year (CY) 2019, and addresses other Medicare policies including, but not limited to, improving Medicare recognition of telehealth services, coding and payment changes to evaluation and management (E/M) services, and updates to the Quality Payment Program (QPP). The proposed changes will be finalized in early November 2018 and will apply to Medicare Part B services furnished on or after January 1, 2019.
The proposed rule is open for comment through September 10, 2018. AADE conducted a full analysis of the proposed rule and submitted comments to CMS addressing areas relevant to diabetes educators. AADE has provided a summary of the proposed rule below.
Payment Conversion Factor
CMS estimates a conversion factor of $36.05, an increase from the 2018 conversion factor of $35.99. The conversion factor is used to calculate the payment rate for services paid under the MPFS.
Increased Valuation for Diabetes Self-Management Training Codes (G0108 and G0109)
AADE was pleased to see that the rule proposed an increase in the payment rates for codes G0108 (Diabetes outpatient self-management training services, individual, 30 minutes) and G0109 (Diabetes outpatient self-management training services, group session (2 or more patients), per 30 minutes). The estimated CY 2019 rates are $57.31 for G0108 and $15.86 for G0109. In CY 2018, the payment rates were $54.19 and $14.71 respectively.
In 2017, CMS flagged HCPCS codes G0108 and G0109 for being billed over 100,000 times to the Medicare program. This is a standard screen that CMS applies to many codes to assess utilization of services. Identification in the screen meant that codes needed to be reviewed and surveyed by AADE members and presented to the American Medical Association (AMA) Relative Value Scale Update Committee (RUC) for revaluation. Based on this review, the AMA RUC submitted valuation recommendations to CMS, which included a recommended reduction to the practice expense values for these codes. CMS did not accept the RUC’s recommendation and maintained the current practice expense values.
CMS’ actions have helped to preserve the value of these codes and reflect ongoing advocacy and outreach to CMS by AADE on behalf of its members. AADE urged CMS to increase the payment rates for G0108 and G0109 to maintain the viability of DSMT programs. This type of decision-making represents advocacy in action! AADE members also played an important role in increasing the valuation of these codes by completing RUC surveys. This process ensured diabetes educators have a say in how their professional services were valued.
Improving Medicare Recognition of Communication Technology-Based Services
The MPFS proposed rule contains provisions that would pay physicians or other qualified health care professionals for the use of communication technology. CMS proposes to pay separately for two newly defined physician services to determine whether an office visit or other services are needed:
- Brief Communication Technology-based Service (e.g., virtual check-in) (HCPCS code GVCI1): and
- Remote Evaluation of Recorded Video and/or Images Submitted by the Patient (including interpretation with verbal follow-up with the patient) (HCPCS code GRAS1).
These new codes are focused on providers who bill for evaluation and management (E/M) services, which typically includes physician and nonphysician practitioners (NPPs) like physician assistants (PAs), nurse practitioners (NPs), clinical nurse specialists (CNSs), and certified nurse-midwives (CNMs). As a result, we believe these changes will have a limited impact on diabetes educators, but still feel that this is important step forward in expanding opportunities to provide services to Medicare beneficiaries via telehealth.
Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)
CMS is also proposing changes to how certain communication technology-based services are billed in RHCs and FQHCs. RHC and FQHC visits are in-person encounters between a patient and an RHC or FQHC practitioner furnishing a qualifying service. Of note, not all covered Medicare services qualify as an RHC or FQHC service. A DSMT service or a Medical Nutrition Therapy (MNT) service furnished by a certified DSMT or MNT provider qualifies as an FQHC visit.
The RHC and FQHC payment models are distinct from the MPFS payment model in that RHC and FQHC payment rates reflect the cost of all services and supplies that an RHC or FQHC furnishes to a patient in a single day. Currently, if a service is provided via a communication-based technology and it results in a face-to-face billable visit, that service would be considered part of the RHC or FQHC visit and is not separately billable. If the service did not result in an in-person visit, there would be no payment for the service.
To address this, CMS is proposing to establish a separate payment for certain communication technology-based services beginning in CY 2019. This includes what is referred to as “Brief Communication Technology-based Service” for a “virtual check-in” and a remote evaluation of recorded video and/or images. The virtual check-in visit would be billable when a physician or nonphysician practitioner has a brief, non-face-to-face check-in with communication technology to assess whether a patient’s condition necessitates an office visit. This virtual check-in cannot be related to an E/M service provided in the previous 7 days or result in a service or procedure in the next 24 hours or soonest available appointment. CMS is also proposing a separate payment for remote evaluation services, such as the remote evaluation of patient-transmitted video and/or images. CMS proposes to create a new Virtual Communication G code for both communication technology-based services and remote evaluation services. AADE is seeking clarification from CMS to determine if these services can be used by physicians or other nonphysician practitioners to assess whether DSMT is needed.
Medicare Telehealth Services and Implementation of the Balanced Budget Act of 2018
In the MPFS proposed rule, CMS also announces plans to implement provisions of the Balanced Budget Act of 2018 (BBA) including adding mobile stroke units, renal dialysis facilities, and the homes of end-stage renal disease (ESRD) beneficiaries as Medicare telehealth originating sites (i.e., the location of the patient receiving the telehealth service).
AADE has been closely monitoring changes to Medicare telehealth policies, especially as they relate to paving the way for new models of care. AADE has reviewed the telehealth policies set forth in the MPFS proposed rule, and the BBA, passed in February 2018. The BBA enacted significant changes to Medicare’s telehealth policy beginning January 1, 2019. Overall, the changes outlined in the BBA may have a direct impact on diabetes educators practicing in Accountable Care Organizations (ACOs). AADE encourages diabetes educators in ACOs to consult with their employers on how these policies may affect how they deliver services.
The key telehealth provisions in the BBA include the following:
- ACOs: Most notable for diabetes educators, the BBA provides that ACOs can expand the use of telehealth services. Under the BBA, certain ACOs may utilize the existing Next Generation ACO telehealth waiver. This waiver removes restrictions related to geographic location criteria and allows the beneficiary’s home to serve as the originating site. There are limited exclusions in the services that may be provided via telehealth. The ACOs eligible to use this telehealth waiver include the Medicare Shared Savings Program (MSSP) Track II, MSSP Track III, and other two-sided risk ACO models with prospective assignment that are tested or expanded through the Center for Medicare & Medicaid Innovation (CMMI). If you are diabetes educator that provides services within an ACO, AADE urges you to consult with your ACO to determine how this policy will affect your ability to deliver services via telehealth.
- ESRD: Medicare beneficiaries with ESRD on home dialysis may receive their monthly clinical assessment via telehealth at home rather than in-person. The provision also eliminates geographic restrictions for all originating sites and allows both freestanding dialysis facilities and the beneficiary’s home to serve as originating sites.
- Tele-Stroke: Acute stroke telehealth services can be furnished in any hospital, critical access hospital, mobile stroke unit, or any other site as determined by the Secretary of the Department of Health and Human Services (HHS), including existing originating sites, without regard for geographic location. Medicare currently only covers telehealth services for patients located in certain rural areas.
- MA Plans: Starting in plan year 2020, the BBA allows Medicare Advantage (MA) plans to offer additional, clinically appropriate telehealth benefits in their annual bid amount beyond the services that receive payment under traditional Medicare. The law requires the Secretary of HHS to solicit comments on the types of telehealth services and the requirement of the related benefits.
The revisions set forth in the MPFS proposed rule and the BBA reflect a recent trend toward expanding the coverage of telehealth and remote patient monitoring and evaluation services under the Medicare program. AADE continues to advocate for policy changes that improve access to services for people with diabetes, including requesting that CMS recognize virtual DSMT services. AADE will keep members updated on any items related to the MPFS rulemaking process and will inform diabetes educators on what to expect in 2019 once the final rule is released in November.