Medicare Advances Virtual Check-ins in Physician Pay Rule

Kerry Dooley Young

November 06, 2018

Medicare will create a path for electronic "check-in" visits through the update of an annual payment rule, and it seeks feedback on a possible future use of bundled reimbursement for substance abuse treatment.

The Centers for Medicare & Medicaid Services (CMS) last Thursday released its 2019 physician fee schedule (PFS). In this rule, CMS is holding off on implementing a major overhaul of evaluation and management (E/M) services. The delay has won praise from medical groups such as the American Medical Association and the American Academy of Neurology. The physician fee rule carries with it changes in electronic health record requirements, as well as a path for more physicians who don't see many Medicare patients to participate in the Merit-based Incentive Payment System .

For the virtual check-in, CMS is using the code G2012 for brief interactions via "communication technology-based service" by a physician or other qualified healthcare professional. This check-in visit should not originate from a related E/M service provided within the previous 7 days, nor should it lead to an E/M service or procedure within the next 24 hours or at the soonest available appointment.

CMS described the creation of the payment for a check-in visit as the agency's recognition of how patients and physicians have different expectations about the practice of medicine over a distance than they did in recent decades.

"From the ubiquity of synchronous, audio/video applications to the increased use of patient-facing health portals, a broader range of services can be furnished by health care professionals via communication technology as compared to 20 years ago," CMS wrote.

In this initial rollout of the check-in visit, CMS opted not to limit how many times this code can be used by the same practitioner with the same patient.

"However, we plan to monitor utilization with the intention of determining whether such a limitation is warranted. In that case, we would consider proposing a limitation in future rulemaking," CMS said in the final rule. "We note that, like all other physicians' services billed under the PFS, each of these services must be medically reasonable and necessary to be paid by Medicare."

With this new check-in approach, CMS intends to address a situation in which clinicians stood to lose money by offering their patients more convenient service.

"Effectively, the better practitioners are in leveraging technology to furnish effective check-ins that mitigate the need for potentially unnecessary office visits, the fewer billable services they furnish," CMS wrote in the rule. "Given the evolving technological landscape, we believe this creates incentives that are inconsistent with current trends in medical practice and potentially undermines payment accuracy."

Bundles for Substance Abuse?

Medicare officials are seeking ways to better address the national opioid epidemic, which is taking a rising toll on older Americans. In the final physician fee schedule, CMS signaled its continued interest in creating bundled Medicare payment, with an aim of preventing some hospitalizations.

From 1993 to 2012, hospital inpatient stays related to opioid abuse grew at a faster rate for older Americans than for younger ones, according to an Agency for Healthcare Research and Quality (AHRQ) report cited by CMS in the physician fee schedule.

The average annual percentage change in rate of stays for all adults in that period was 5.0%. AHRQ found that the highest rate of growth, at a 9.1% average annual increase, was for people aged 85 years and older. The rate of growth was 8.9% for those aged 45 to 64 years and those aged 65 to 84 years.

In contrast, the rate for those aged 18 to 24 was 6.2%. For those aged 25 to 44, it was 2.7%.

Medicare now pays for one third of opioid-related hospital stays, CMS said. From 1993 to 2012, the number of inpatient stays covered by Medicare grew from 30,900 to 211,200. That far outpaced the growth in stays covered by Medicaid, which increased from 95,600 to 226,000 in the same period.

Several physicians' groups, including the AMA, have expressed interest in bundled Medicare payments while raising concern about how their members would fare financially. In a comment to CMS in September, James L. Madara, MD, chief executive officer of the AMA, argued for the need for "adequate, flexible payments" in a potential bundle that wouldn't force physicians to accept high levels of financial risk or administrative burdens.

Treating people for substance abuse is already challenging for many medical practices, commenters told CMS.

"Many of the physicians who work with opioid-dependent patients already devote significant time and resources to helping them address their addiction and health, often at a financial loss to their practice," wrote Clyde "Bud" Chumbley, MD, chief executive officer of the Wisconsin Medical Society, in September.

In the final rule, CMS acknowledged the questions about creating a bundled payment of care for substance abuse. Such care typically involves ongoing treatment without a definitive end point. In this respect it is quite different from surgery, in which the course of treatment is more defined.

"While we do not necessarily believe these characteristics preclude payment bundles and/or global periods, we do understand they would need to be taken into account," CMS wrote. "We reiterate that our intention as we consider these issues for future rulemaking is to increase access to necessary care, and that any potential bundled payment would be developed in consideration of these comments."

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