Summary: Under COVID, the use of Communication Technology-Based Services (CTBS) has become essential to the delivery of safe, affordable and high quality care. Telehealth services (synchronous technology-enabled care) has grown exponentially, but we now have an opportunity to go to the next level of CTBS: Automated Virtual Care. With Automated Virtual Care, and in particular through the automated collection and analysis of Patient-Generated Health Data (PGHD), we can proactively identify those patients who need synchronous services, avoid unnecessary care and deliver automated guidance that helps keep patients healthy. Click to see an overview of PGHD.
In response to CMS’ invitation regarding new CTBS that can be used to improve care, it is our recommendation that the Virtual Check-in codes be expanded to include the remote collection and review of Patient-Generated Health Data and allow the patient-facing time used by these automated services to count toward the time requirements.
In the 2021 Proposed Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) is inviting comments on the following related to Communication Technology-Based Services (CTBS):
- Services that fall outside the scope of telehealth services… where it would be helpful for us to clarify that the services are inherently non-face-to-face, so do not need to be on the Medicare telehealth services list in order to be billed and paid when furnished using telecommunications technology rather than in person with the patient present.
- Physicians’ services that use evolving technologies to improve patient care that may not be fully recognized by current PFS coding and payment, including, for example, additional or more specific coding for care management services, and
- Any impediments that contribute to healthcare provider burden and that may result in practitioners being reluctant to bill for CTBS. We appreciate the ongoing engagement and additional information from stakeholders as we work to improve coding and payment for these services that utilize telecommunications technology.
Today, physicians and hospitals are reimbursed for their time spent with patients, or for materials they’ve used in the care of patients. The initial reimbursement for use of CTBS has kept in line with this philosophy, reimbursing physicians only when their time is expended. With the advent of automated technologies, however, patient monitoring can occur automatically, and patients who are in need of greater support can be escalated quickly and safely into higher levels of care as needed. Such technologies now include automated, personalized conversations (chatbots) that automate the collection and analysis of a wide array of patient-generated health data (PGHD) to 1) deliver guidance and feedback to the patient to keep them healthy, and 2) to identify which patients might need escalation to a higher level of care.
In response to the CMS invitation to comment on the 2021 Physician Fee Schedule, we share our experience to show that additional / more specific coding is warranted to support automated virtual care services.
The following diagram depicts the spectrum of health care services, from in-person care, to technology-enabled synchronous care (Telehealth and Virtual Check-ins), to technology-enabled asynchronous care (eVisits and Remote Patient Monitoring, all the way to the proposed automated virtual care.
Realizing the Potential of Automated Virtual Care
Deployed for patients managing chronic disease, recovering from a hospitalization or trying to achieve a health-related goal, automated technologies – inclusive of some beginning to utilize artificial intelligence or AI – transform the care process to being proactive rather than reactive; continuous and collaborative rather than episodic. Over the past several years, these technologies have been shown to reduce unnecessary care utilization, improve quality and improve the efficiency of care. Especially important during COVID, these technologies have enabled high quality care to be provided remotely, escalating to telehealth whenever possible, and reserving the need for in-person visits to just those who need it.
The key to automated virtual care is the collection and analysis of PGHD. The variety of self-reported PGHD, combined with passively gathered physiologic data, as well as derived data is able to reflect upon whether a patient needs to be seen. As this diagram shows, PGHD complements the episodic data collected during clinical encounters to allow automated insights between visits:
- The automated technologies are used as an extension of an existing patient-provider relationship, whether established in-person or via telehealth
- The logic driving the technology, and any patient-facing messaging, should be approved by the provider
- The technology is used to gather and analyze PGHD to 1) Automate the delivery of provider-approved guidance to keep patients health, and 2) Based on provider-determined thresholds determine if a visit is required
- The resulting PGHD is brought back into the clinical workflow to drive alerts (although structured PGHD does not have a clear and discrete home today in EHR systems)
- Patients verbally or electronically opt into participation, which also allows onboarding to describe the service and make patients feel comfortable with it
Provider-initiated vs. Patient-initiated Interactions
In order to achieve the benefits of automatically collecting and analyzing PGHD, it is critically important to do so proactively. Being reactive to concerns or issues after the fact means that treatment side effects or complications have progressed further than could have been detected if evaluated proactively. For example, we’ve found an over 60% reduction in oncology patients being taken off of therapy due to treatment complications when using automated chatbots to collect and analyze PGHD. This is due to notifications being sent to patients automatically (“It’s time for your Northwell Health Chat”), the collection of PGHD from the patient proactively, the identification of complications early, the adjustment of therapy accordingly, and keeping patients on therapy. For Medicare beneficiaries discharged from the hospital for a diagnosis subject to the readmission penalty, we found a 32% reduction in readmissions, again due to providers proactively reaching out and collecting and analyzing PGHD specific to the patient’s health condition, delivering personalized guidance to keep patients on track, and automatically escalating patients to a higher level of care when needed.
For this reason, we strongly recommend that provider-initiated services be accommodated in the expansion of CTBS. In our experience, the frequency of these PGHD check-ins will vary based on the patient’s health condition(s). Patients who are on track may need monthly or less frequent check-ins, while others may be weekly. For this reason, we also recommend supporting up to weekly PGHD check-ins.
Existing vs. New Reimbursement Mechanisms Applicable to Automated Virtual Care
How can reimbursement be expanded to support the use of Automated Virtual Care Technologies? What are their current barriers? The following is an outline of the mechanisms already made available by CMS, along with their use cases and challenges.
HCPCS: G2012 and G2010
Time: 5-10 minutes
Intended Use: A brief check-in using CTBS, e.g. telephone or other modality, that can help determine the need for an office visit or referral. An image or video can also be submitted for review, again determining if an office visitor or referral are needed.
Requirements: Initiated by the patient , co-pay / deductibles apply, verbal consent allowed
Fit for Automated Virtual Care Services: Automated Virtual Care services fit well within the spirit of the Virtual Check-In, as they are used to support the patient as much as possible through automated means, but with a goal of identifying those who must be escalated into a higher level of care.
Administration of patient-focused health risk assessment instrument
Time Requirement: n/a
This “add-on” code has to accompany an E/M visit, and has the following requirements:
- Practice expense is incurred to administer the instrument (such as nurse time or for purchase of the screen).
- The instrument is standardized.
- The instrument is scorable.
- The results are documented in the medical record.
PFS 2019 Response to Comments on G2010: A few commenters suggested that CMS consider inclusion of email/messaging or questionnaires/ assessments that do not include an image or other visual item in the scope of this code. We note that there is separate coding under the PFS for several types of formal assessments, such as CPT code 96160 (Administration of patient-focused health risk assessment instrument (e.g., health hazard appraisal) with scoring and documentation, per standardized instrument), many of which can be reported when the form is completed by the patient and submitted using remote communication technology for subsequent evaluation by the clinician. Additionally, behavioral health assessments are included in coding and payment for the behavioral health integration services that were finalized for separate payment beginning in CY 2017.
Fit for Automated Virtual Care Services: While standardized questionnaires can facilitate the collection of PGHD, this code does not align with the objective of automated virtual care: To stay in touch with patients to determine when a visit is needed. In other words, CMS should pay providers to deliver these types of services to avoid unnecessary care, not to be paired with usual care. For this reason, the CPT code 96160 would not be appropriate for supporting automated virtual care.
Time Requirement: 5-10 minutes
Intended Use: Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals.
Requirements: Must be conducted through patient portals, initiated by the patient, and co-pay / deductibles apply
Fit for Automated Virtual Care Services: Automated Virtual Care fits within the spirit of an E-Visit, but only initiated by the patients makes this more appropriate for triaging new concerns as opposed to the care of existing conditions.
Remote Patient Monitoring (RPM)
CPT: 99091, 99453 (setup), 99091, 99457, 99458
Time Requirement: 30 minutes (99091) and 20 minutes (99457 and 99458)
Intended Use: Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional
Requirements: Must be a medical device as defined by the FDA, and used for measuring “physiologic data.” Consent acquired and must be initiated during a face-to-face visit
Fit for Automated Virtual Care Services: While collection and analysis of PGHD fits the spirit of Remote Patient Monitoring, the requirement that this be the collection of physiologic data using FDA approved devices, along with the 20-30 minute requirement for review, makes RPM less of a fit for PGHD collection and use.
We see the Virtual Check-in as an appropriate model for supporting automated virtual care processes because the goals are aligned: To interact with the patient using low cost CTBS to identify if a visit is warranted. If a visit is not warranted, and as long as the patient has not had a visit in the last 7 days, then the service more than pays for itself.
Proposal: A New Virtual Check-in Code: Create a new HCPCS code, aligned with the Virtual Check-In and Remote Evaluation of Pre-Recorded Information, that supports the collection and evaluation of Patient-Generated Health Data (PGHD)
Proposed Description: Remote collection and evaluation of pre-recorded patient-generated health data (PGHD) submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.
- May be provider-initiated or patient-initiated, as modern systems are automating this outreach to patients on behalf of providers in order to stay in touch and avoid unnecessary visits and provider-initiated outreach is supportive of value-based care goals.
- Because it may be provider-initiated, we recommend limiting billing frequency to avoid fraud or abuse. We believe that 1 time per week achieves the objectives while keeping costs low.
- The logic used to solicit the PGHD should be reviewed and approved by the provider, but does NOT need to adhere to standardized survey instruments or questionnaires as these are limiting, not patient friendly, and many of the most important PGHD such as social determinants are not available in standardized survey instruments
- Because modern systems are automating the follow-up with the patient in response to their PGHD (support, guidance and education to keep them healthy and avoid unnecessary care) we recommend recognizing that the follow-up may be automated in addition to the other modalities of follow-up already supported for G2010
We believe that Automated Virtual Care will help our health care system to be proactive rather than reactive; Continuous and collaborative rather than episodic. With a Virtual Check-in for the remote evaluation of Patient-Generated Health Data (PGHD), providers can be partners in deploying these new technologies to improve outcomes, improve satisfaction, and reduce costs, all while keeping patients safe at home.
We encourage our customers and others in the Automated Virtual Care space to join us in submitting comments to CMS (before October 5th) to expand the use of the Virtual Check-in codes to include the collection and review of Patient-Generated Health Data (PGHD), and work together to forge a consensus in how Automated Virtual Care could be valued and reimbursed long-term.