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Home Health Telehealth Providers Telethink




Published Jan. 29.2021

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CMS TELEHEALTH AND THE ROAD AHEAD by Telethink. Direct contracting is the payment method moving forward. We provide the services, you reap the benefits.

CMS Telehealth Policies and Reimbursement for 2021

Update: "The Medicare Hospital Insurance (HI) Trust Fund, which pays for Medicare beneficiaries’ hospital bills and other services, is projected to become insolvent in 2024 — less than three years away."

The Center for Medicare and Medicaid Innovation Oct. 30 announced the participation of 51 Direct Contracting Entities in the implementation period of the Global and Professional Options of the Direct Contracting Model with more emphasis on telehealth and outpatient care.

The model's voluntary payment options are aimed at reducing expenditures and improving quality of care for beneficiaries in Medicare fee-for-service. The period started Oct. 1, 2020 and will go through March 31, 2021; the DCEs are serving beneficiaries in 39 states, the District of Columbia and Puerto Rico.

The Centers for Medicare & Medicaid Services also announced new and updated publications on in its Direct Contracting webpage. These resources include: an update to the published DC Rate Book; an updated version of FAQs; and a revised version of the DC Risk Adjustment paper.

The payment model options available under Direct Contracting (also known as containment contracting) are expected to increase beneficiaries’ access to innovative, affordable care while maintaining all Original Medicare benefits. A model participant in any one of the payment model options available under Direct Contracting, referred to as a Direct Contracting Entity (DCE), may offer benefit enhancements and certain beneficiary engagement incentives to beneficiaries with no requirement that beneficiaries accept these incentives. Relative to prior CMS initiatives, the payment model options place an emphasis on voluntary alignment, empowering beneficiaries to choose the health care providers with whom they want to have a care relationship. The payment model options also aim to improve beneficiaries’ experience of care by reducing administrative burdens on practitioners, so that they can focus on what is most important, spending time with patients.

Participation Options

There are two voluntary risk-sharing payment model options:

  1. Professional offers the lower risk-sharing arrangement—50% savings/losses—and provides Primary Care Capitation, a capitated, risk-adjusted monthly payment for enhanced primary care services.
  2. Global offers the highest risk sharing arrangement—100% savings/losses—and provides two payment options: Primary Care Capitation (described above) or Total Care Capitation, capitated, risk-adjusted monthly payment for all services provided by DC Participant Providers and Preferred Providers with whom the DCE has an agreement.

The Professional and Global options aim to attract a range of health care providers operating under a common governance structure, with attention given to advancing primary care as a means to better managing health care overall. CMS expects that the use of voluntary alignment will attract organizations that previously were ineligible because of their previously low volume of Medicare FFS beneficiaries, such as organizations that currently operate in the MA program. Each payment model option includes features aimed at encouraging organizations focused on care for patients with complex, chronic conditions, and seriously ill populations to participate.

Current Medicare ACOs interested in continuing and deepening their participation in Medicare risk arrangements will be eligible to participate in either of the two payment model options.

The payment model options available under Direct Contracting began in 2020 with an initial implementation period for organizations that want to align beneficiaries to meet the minimum beneficiary requirements prior to the start of the first performance year. Six performance years will follow, beginning in April 2021.

Direct Contracting will be an Advanced Alternative Payment Model (APM) starting in its first performance year (2021).

Since the beginning of the pandemic, CMS has added 144 telehealth services to the list of Medicare-covered services. CMS believed adding such services would promote safe access to healthcare during the pandemic. CMS’ action resulted in over 24.5 million Medicare beneficiaries receiving telemedicine services during the pandemic. For comparison, CMS reported that only about 15,000 beneficiaries received Medicare telemedicine services on a weekly basis prior to the pandemic.

Since 1992, Medicare has paid for the services of physicians and other billing professionals under the PFS. Physicians’ services paid under the PFS are furnished in a variety of settings, including physician offices, hospitals, ambulatory surgical centers, skilled nursing facilities and other post-acute care settings, hospices, outpatient dialysis facilities, clinical laboratories, and beneficiaries’ homes.

Through the PFS Final Rule, CMS is making many of these changes permanent. For example, the following services have been permanently added to the Medicare telehealth list on a Category 1 basis:

  • Group Psychotherapy (CPT code 90853);
  • Psychological and Neuropsychological testing (CPT code 96121);
  • Domiciliary, Rest Home, or Custodial Care services for established patients (CPT codes 99334-99335);
  • Home visits for established patients (CPT codes 99347-99348);
  • Cognitive assessment and care planning services (CPT code 99483);
  • Visit complexity inherent to certain office/outpatient E&M (HCPCS code G2211); and
  • Prolonged services (HCPCS code G2212).

CMS also created a new category for telehealth services, Category 3, which will serve as a temporary category for adding services to the list of Medicare telehealth services. CMS finalized the following list of services to be added on a Category 3 basis:

  • Home Visits, Established Patient (CPT codes 99349-99350)
  • Emergency Department Visits, Levels 1-5 (CPT codes 99281-99285)
  • Nursing facilities discharge day management (CPT codes 99315-99316)
  • Psychological and Neuropsychological Testing (CPT codes 96130-96133; CPT codes 96136-96139)
  • Therapy Services, Physical and Occupational Therapy, All levels (CPT codes 97161-97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521-92524, 92507)
  • Hospital discharge day management (CPT codes 99238-99239)
  • Inpatient Neonatal and Pediatric Critical Care, Subsequent (CPT codes 99469, 99472, 99476)
  • Continuing Neonatal Intensive Care Services (CPT codes 99478-99480)
  • Critical Care Services (CPT codes 99291-99292)
  • End-Stage Renal Disease Monthly Capitation Payment codes (CPT codes 90952, 90953, 90956, 90959, 90962)
  • Subsequent Observation and Observation Discharge Day Management (CPT codes 99217; CPT codes 99224-99226)

The expansion of telehealth is not only meant to benefit Medicare beneficiaries during the PHE, but also to expand the availability of health care to beneficiaries in rural areas. The expansion should ensure that rural Medicare beneficiaries are able to continue to have access to the telehealth services they need. This is a key aspect of the Trump Administration’s Executive Order on Improving Rural and Telehealth Access.

The 2021 PFS Final Rule also clarified that licensed clinical social workers, clinical psychologists, physical therapists, occupational therapists, and speech-language pathologists may furnish the following: (1) online assessment and management services; (2) the online assessment; (3) virtual check-ins; and (4) remote evaluation services. Further, CMS has established a payment policy for a new HCPCS G-code for certain E/M services. Under the new HCPCS G-code, CMS will compensate providers for 11-20 minutes of medical discussion with patients to determine the necessity of an in-person visit. CMS is ready to process claims correctly and on time. You don’t need to wait to submit your claims.

Lastly, CMS adopted a temporary policy during the COVID-19 PHE which revised the definition of direct supervision so that it would include the virtual presence of a supervising physician or practitioner using real-time, interactive audio/visual communications technology. CMS adopted this policy to limit beneficiaries’ potential exposure to COVID-19. The 2021 PFS Final Rule extends this temporary revision until the end of the PHE or December 31, 2021, whichever is later.  More: https://innovation.cms.gov/files/x/dc-rfa.pdf


CMS TELEHEALTH AND THE ROAD AHEAD by Telethink We provide the services you reap the benefits under the payment model. Direct Contracting Model: Global and Professional Options https://innovation.cms.gov/files/x/dc-rfa.pdf