CMS proposes new payments for digital health under CY2025 PFS draft rule

The Centers for Medicare & Medicaid Services’ (CMS’) proposed calendar year 2025 physician fee schedule rule, out Wednesday, proposed an assortment of new payments and coverage for digital health services, including digital therapeutics, telehealth and audio-only telehealth services. It did not, however, address the bulk of Medicare telehealth waivers expiring at the end of the year, which need to be extended by Congress. 

The draft rule contains significant proposals for rural health clinics and federally qualified health centers to continue receiving payment for audio-only telehealth, waive the in-person visit requirement for telemental health services and report remote monitoring codes outside of catch-all code G0511. 

CMS’ proposal also gives opioid treatment programs more flexibility in their use of telehealth and audio-only telehealth services, which the agency says will improve health equity. 

Digital therapeutics

CMS provided a lengthy section on digital therapeutics used in the course of behavioral health care treatment. The section proposes to create three new codes for digital mental health treatment devices like digital therapeutics, though it’s unclear whether the new codes would substantially change the status quo. 

CMS proposes in its CY2025 physician fee schedule draft rule that three new codes, GBMT1-3, pay for the supply of a digital mental health treatment device and for physician time spent interacting with the patient regarding the device. The proposal would allow providers to receive reimbursement for the use of FDA-cleared devices that leverage software to provide behavioral health therapies.

CMS says the new codes are direct crosswalks of existing remote therapeutic monitoring codes 98980 and 98981 and that they refine the language of its 2021 cognitive behavioral therapy code, all of which have allowed for some payment for digital therapeutics over the last several years. 

A payment and coding expert told Fierce Healthcare that the new codes don’t seem to substantially differ from existing RTM and CBT codes. 

The PFS notes that other digital therapeutics require the creation of a new Medicare benefit category and are not covered under the proposal. It also said that digital mental and behavioral health apps and interventions cannot use this code. 

Telehealth 

CMS proposed some extensions of pandemic-era telehealth provisions and even proposed to make a few telehealth line items permanent in its calendar year 2025 physician fee schedule draft rule. 

Congress must extend or make permanent the majority of Medicare telehealth waivers through legislation, which is likely to happen in the lame duck session. Because CMS does not have the authority to extend the bulk of Medicare telehealth waivers, the proposed CY2025 draft rule omits the core waivers that enabled telehealth flexibilities, such as allowing telehealth visits to be conducted from anywhere, allowing an expanded set of providers to bill for telehealth, waiving the need for an in-person visit for telemental health and allowing hospitals to launch acute hospital care-at-home programs. 

CMS proposed to permanently allow virtual direct supervision for some services with established patients and extended virtual direct supervision for all services through the end of CY2025. It also extended through the end of 2025 the ability for a teaching physician to be present for critical parts of the visit via a three-way telehealth visit for billing purposes. 

CMS declined to include the 17 new telehealth evaluation and management (E&M) codes, which the agency said were duplicative of existing E&M codes used for in-person visits. The Alliance for Connected Care has advocated that CMS reject the telehealth codes and instead use a modifier on existing in-person codes to signify the use of telehealth. 

CMS proposed to delay the requirement that telehealth providers report their home address on publicly available Medicare documentation through the end of CY2025.

The American Telemedicine Association (ATA) told Fierce Healthcare that the telehealth wins in the fee schedule proposed rule would be significantly impacted if Congress does not act to continue waiving geographic and originating site restrictions. 

“That’s the difference between under 1% of Medicare beneficiaries having access to telehealth services, which would be the case if you were to re-implement those geographic and originating site restrictions … you’re cutting out urban and suburban America in one fell swoop,” Kyle Zebley, senior vice president of the ATA, said.

Rural health clinics and federally qualified health centers 

CMS proposes to allow rural health clinics (RHCs) and federally qualified health centers (FQHCs) to use audio-only for telehealth visits. It also proposes RHCs/FQHCs be able to waive the required in-person visit for the provision of telemental health through the end of 2025. 

CMS proposes to split catch-all code G0511 into distinct payments based on the service rendered. G0511 has been used as an add-on code for care coordination and management services like chronic care management, remote monitoring and nearly 20 other related codes. 

CMS clarified in the CY2024 PFS rule that G0511 could be billed as many times as needed to get proper payment for the services, but rural health payment experts still were skeptical of how and if Medicare administrative contractors would pay the multiple G0511 claims out. 

Remote monitoring 

CMS proposed to cut reimbursement for remote therapeutic monitoring, continuing a multiyear trend. Otherwise, remote monitoring did not receive significant attention in the draft physician pay rule. CMS did not address concerns digital health stakeholders have over the 16-day data reporting requirement to bill RPM and RTM codes or any of the other myriad billing restrictions for the codes. 

CMS discussed remote monitoring in its proposed Advanced Primary Care Model. As proposed, the model would encourage billing of remote monitoring on top of the monthly advanced primary care payment.

Opioid treatment programs

CMS proposes to make significant changes to opioid treatment programs’ ability to use telehealth and audio-only visits. The agency proposes allowing audio-only assessments permanently starting in CY2025 along with audio-visual assessments. 

The agency also proposes to permanently allow audio-visual and audio-only telehealth visits to be used to induct patients into buprenorphine treatment at opioid treatment programs. The agency is also proposing to allow audio-visual telehealth visits used to induct patients into methadone treatment, in accordance with a Substance Abuse and Mental Health Services Administration final rule published in February.