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Proposed CMS rule expands telehealth payments, domain


By Joseph Conn
Posted: July 7, 2014 - 2:00 pm ET
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Wellness and behavioral health visits are among a few telehealth coverage expansions the CMS wants to add to the list of Medicare-reimbursable telehealth activities under a proposal released Thursday.

Providers also would be paid for telehealth services in rural areas nearer big cities under a geographical expansion in the proposed rule.

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Rule writers are also attempting to further harmonize reporting requirements under the Medicare physician quality reporting program and similar “meaningful-use” requirements for clinical quality reporting under the federal EHR incentive payment program created by the American Recovery and Reinvestment Act.

The 609-page proposed rule (PDF) released Thursday principally deals with annual changes to polices under the Medicare Physician Fee Schedule, including eliminating the exclusion for continuing medical education under the Sunshine Act that requires drug companies and medical devicemakers to disclose payments to physicians.

Added to the list of covered telehealth services by the proposal are annual wellness visits, both for an initial visit, and for subsequent visits, if they include a personalized prevention plan of service.

It also proposed to add to the list telehealth sessions for psychoanalysis, family psychotherapy, both with and without the patient being present; and for “prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service.”

The CMS rulemakers also propose to allow payments for telehealth services afforded to patients in “rural census tracts” even if those tracks are within metropolitan statistical areas. Census tracts are composed of smaller census blocks and block groups and have on average about 4,000 inhabitants. Populations of the 388 MSAs in the U.S. and Puerto Rico vary widely, from about 50,000 to nearly 20 million inhabitants.

“Defining 'rural' to include geographical areas located in rural census tracts within MSAs allow for broader inclusion of sites … as telehealth originating sites” and “expands access to healthcare services for Medicare beneficiaries located in rural areas,” the proposal states.

For 2015 and beyond, the CMS proposes to require that physicians and group practices, in submitting data under the Physician Quality Reporting System, should report the certification number of the EHR they use. Certification numbers are issued to complete and modular EHR products if they have passed testing and certification requirements under the EHR incentive payment program.

The proposed rule also would align the clinical quality measures reporting requirements with the Medicare Shared Savings Program (for Accountable Care Organizations) with those of the EHR incentive payment program.

In several respects, existing CMS payment policy as well as the agency’s new telehealth payment proposal match a model telehealth policy guide approved in April by the Federation of State Medical Boards.

The FSMB guidelines say that a physician-patient relationship must be established for physicians to engage in telemedicine, but that a relationship can be initiated “whether or not there has been an encounter in person between the physician (or other appropriately supervised healthcare practitioner) and patient.”

The new CMS rule for approving telehealth for initial wellness visits appears to reflect that.

In defining telemedicine, the FSMB said that, “Generally, telemedicine is not an audio-only, telephone conversation, e-mail/instant messaging conversation or fax. It typically involves the application of secure videoconferencing or store-and-forward technology to provide or support healthcare delivery by replicating the interaction of a traditional encounter in person between a provider and a patient.”

Existing Medicare policy, the new rule says, mandates that telehealth includes “at a minimum, audio and video … permitting two-way, real-time interactive communication.” Telephones and e-mail “do not meet the definition of an interactive telecommunications system.” Medicare permits payments for “store-and-forward” technology in demonstration projects in Alaska and Hawaii.

The American Academy of Family Physicians is studying the details of the rule, said Dr. Reid Blackwelder, its president and a family physician in Kingsport, Tenn. Broadly speaking, he said, “We were pleased to see including more service for Medicare telehealth, including providing more access to care for rural patients.”

Blackwelder also agreed with the CMS and FSMB positions that telehealth ought to include more than simply audio communication. “If all you’re doing is audio, you’re missing out on an important aspect” of seeing the patient, particularly their reactions to questioning, he said.

The use of alcohol is an important health factor, Blackwelder said. “If someone fills out a check box, and they say, ‘No,’ what does that mean?” he said. “Does that mean they’re not drinking today?” It’s different if the doctor in an exam room can ask the question and see the patient’s reaction. “If I notice they look down or they hesitated, I can say, ‘I noticed you hesitated, 'What’s up?’ Then they’ll say, ‘I stopped drinking two months ago because I had a DUI.’

“You risk missing some of that” over the phone and even with videoconferencing. “I’m going to need really good quality video to see some of those nuances,” Blackwelder said.

“That is going to be the challenge for us as we move forward incorporating telehealth,” he said. “We have to be careful what we include and when we include it.”

Follow Joseph Conn on Twitter: @MHJConn


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