General Overview:
This announcement describes the process for adding or deleting services to
the list of Medicare telehealth services and the information required to submit a request
for addition. These instructions only apply to the addition or deletion of Medicare
telehealth services, not to services delivered face-to-face.
We make any additions or deletions to the services defined as Medicare telehealth services
effective on a January 1st basis. The annual physician fee
schedule proposed rule published in the summer and the final
rule (published by November 1) is used as the vehicle to make these changes. The public
has the opportunity to submit requests to add or delete services on an ongoing basis.
Because CMS intends to use the annual physician fee schedule
as a vehicle for making changes to the list of Medicare telehealth services, requestors
should be advised that any information submitted, are subject to disclosure for this
purpose.
Process Described:
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Who may submit a request?
Any interested parties from either the public or private sectors may submit
requests for adding services to the list of Medicare telehealth services, for example, from
medical specialty societies, individual physicians or practitioners, hospitals, and State or
Federal agencies.
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What items must be included when submitting a request for addition?
Each request for adding a service to the list of Medicare telehealth
services must address the items outlined below.
- Name(s), address(es) and contact information of the
requestor.
- The HCPCS code(s) that describes the service(s) proposed for addition or deletion to
the list of Medicare telehealth services. If the requestor does not know the applicable
HCPCS code, the request should include a description of services furnished during the
telehealth session.
- A description of the type(s) of medical professional(s) providing the telehealth
service at the distant site.
- A detailed discussion of the reasons the proposed service should be added to the
definition of Medicare telehealth.
- An explanation as to why the requested service cannot be billed under the current
scope of telehealth services, for example, the reason why the HCPCS codes currently on
the list of Medicare telehealth services would not be appropriate for billing the service
requested.
- If available, data showing that the use of a telecommunications system does not change
the diagnosis or treatment plan as compared to the face-to-face delivery of the
service.
- If available, data showing that patients who receive this service via a
telecommunications system are satisfied with the service that is delivered.
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What are the criteria that CMS uses to review submitted requests?
Requests for adding services to the list of Medicare telehealth
services are assigned by CMS to one of the following categories:
- Category #1: Services similar to office and other outpatient visits,
consultation, and office psychiatry services.
- Category 1 services are reviewed to ensure that the services proposed
for addition to the list of Medicare telehealth services are similar to the services
listed above. For example, in reviewing these requests for addition, we look for
similarities between the proposed and existing telehealth services in terms of the
roles of, and interactions among, the beneficiary, the physician (or other
practitioner) at the distant site and, if necessary, the telepresenter. We also look
for similarities in the telecommunications system used to deliver the proposed service,
for example, the use of interactive audio and video equipment. If a proposed service
meets the criteria set forth above, we would add it to the list of Medicare telehealth
services.
- Category #2: Services that are not similar to an office or other outpatient visit, or
office psychiatry services, for example, physical therapy services, endoscopy services,
and distant monitoring of patients in intensive care units.
- Our review of these requests includes an assessment of whether the use of a
telecommunications system to deliver the service produces similar diagnostic findings
or therapeutic interventions as compared with a face-to-face "hands on" delivery of the
same service. In other words, the discrete outcome of the interaction between the
clinician and patient facilitated by a telecommunications system should correlate well
with the discrete outcome of the clinician-patient interaction when performed face to
face. Requestors must submit evidence indicating that the use of a telecommunications
system does not affect the diagnosis or treatment plan as compared to a face-to-face
delivery of the service.
- If the evidence shows that the proposed telehealth service is equivalent to the face
to face delivery of the service, we would add it to the list of telehealth services.
However, if we determine that the use of a telecommunications system changes the nature
or outcome of the service, for example, the nature of clinical intervention, as
compared with the face-to-face delivery of the service, we would view the request as a
new service, rather than a different method of delivering an existing Medicare
service.
- Under Medicare, new services: (1) Must fall into a benefit category; (2) must be
reasonable and necessary in accordance with section 1862(a)(1)(A) of the Act; and (3)
must not be specifically excluded from coverage. As with any service, the requestor
has the option of applying for a national coverage determination. Information on
applying for a national coverage determination may be found on our website at http://www.cms.hhs.gov; then select
"Coverage," under the topics heading, then
"Process."
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What are the possible outcomes of CMS' review?
Our review of submitted requests to add services may result in the
following outcomes:
- Adding an existing HCPCS code to the list of Medicare telehealth services.
- Determining that the requested service is already described by an existing telehealth
service.
- Creating a new HCPCS code to describe the requested service and adding it to the list
of Medicare telehealth services.
- Requesting further information.
- Notifying the requestor that a national coverage determination is necessary before a
decision to accept or reject a proposal can be made.
- Rejecting the request.
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When would CMS delete a service from the list of Medicare telehealth
services?
Services currently on the list of Medicare telehealth services would be
removed if, upon review of the available evidence, we determine that a Medicare telehealth
service is not safe, effective, or medically beneficial. A decision to remove a service
would not be made under section 1862(a)(1)(A) of the Social Security Act. The decision to
remove a service under this process would only apply to the list of Medicare telehealth
services.
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How will CMS make changes to the list of Medicare telehealth services?
Additions or deletions to the list of Medicare telehealth services are
effective on a calendar year basis. Changes to the list of Medicare telehealth services
are made using the annual physician fee schedule proposed rule published in the summer and
the final rule published by November 1 each year.
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When can a request be submitted?
Requests for adding services to the list of Medicare telehealth services
may be submitted on an ongoing basis; requests must be submitted and received no later than
December 31 of each Calendar Year to be considered for the next proposed rule.
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