HIMSS and PCHAlliance Submit Comments on Proposed 2021 Medicare Physician Fee Schedule Regulation

On Sept. 21, HIMSS and PCHAlliance provided comments to the Centers for Medicare & Medicaid Services (CMS) Proposed 2021 Medicare Physician Fee Schedule Regulation, focusing on responding to changes on connected health, the Quality Payment Program (QPP), and broader quality measures.

The main points of emphasis relate to a transition to permanence for the waivers, temporary healthcare standards and policies that have been adopted for Medicare, Medicaid, private payers and professional licensure as a result of the nation’s COVID-19 Public Health Emergency (PHE) declaration. 

The HIMSS and PCHAlliance letter emphasized the importance of utilizing connected care to enable resilient healthcare delivery that improves quality and access for consumers while reducing complexity and cost, and advances evidence-driven, value-based and patient-centered healthcare. Building upon the temporary policy waivers that have made telehealth and connected care accessible and sustainable during the COVID-19 pandemic, CMS proposed a number of changes to the reimbursement of telehealth and communication technology-based services in the Medicare Program.

Specifically, HIMSS and PCHAlliance supported CMS’s proposal to add new services to the list of Medicare Telehealth Category 1 Services and to establish a third category of services covered on a temporary basis to allow providers to collect evidence to support adding these services on a permanent basis. The letter also urged CMS to cover physical therapy, occupational therapy and speech-language pathology services, which can effectively be provided via two-way audio-video telecommunications technology.

On the use of communication technology-based services, such as virtual check-ins and remote evaluation of patient-submitted video or images, HIMSS and PCHAlliance supported CMS’s proposal to allow certain practitioners who cannot bill for E/M services to use these codes, including physical therapists, occupational therapists and speech and language pathologists. The letter also supported CMS’s proposal to establish coverage for audio-only services, noting that these services can be both effective and an important means of care delivery, particularly when factors outside of a beneficiary’s control make the audio-video requirements for a telehealth interaction difficult or impossible.

CMS also proposed a number of changes to coverage of remote physiologic monitoring (RPM). HIMSS and PCHAlliance noted that CMS’s clarification that medical devices billed under CPT Code 99454 should digitally collect and transmit patient physiologic data could create a gap between physiologic and non-physiologic medical device monitoring, as some devices utilize non-physiologic data to enable services like pain and side-effect monitoring. Further, the letter urged CMS to clarify that 99454 could be billed once per month per provider, rather than once per patient. This would allow beneficiaries with multiple chronic conditions, who may have multiple providers and specialists monitoring those conditions, to better utilize evidence-based RPM.

HIMSS and PCHAlliance also raised concerns with certain CMS proposals for CPT Codes 99457 and 99458. Specifically, CMS’s proposed definition of “interactive communications” requiring 20 minutes of real-time communication between clinical staff and the patient would seem to exclude any billing for time spent on clinical management services such as review of digitally delivered physiologic data, medication history or care coordination, which are at the very heart of care management.

In response to COVID-19, CMS announced a number of policy changes around RPM to expand access to these services. HIMSS and PCHAlliance supported the clarification that RPM may be provided for both acute and chronic conditions on a permanent basis and urged CMS to retain two additional changes on a permanent basis. The letter asked CMS to permit billing of RPM if there is a minimum of two days of data collection over a 30-day period (rather than the current 16-day requirement), and to permit RPM to be provided to any beneficiary, not just those with whom the provider has an established relationship.

Finally, CMS proposed a first of its kind code, CPT Code 9225X, which would provide AI-driven retinal disease detection and monitoring. HIMSS and PCHAlliance were supportive of this proposal and, while noting that such a service can only be used if providers are reimbursed for the associated practice expense, urged CMS to approve the RUC valuation of CPT Code 9225X.

On QPP, HIMSS and PCHAlliance supported how this proposed regulation continues to build upon and advance patient-centered digital, interoperable, connected healthcare in several areas, including: care management service coverage, virtual substance use disorder treatment provisions, and the Merit-based Incentive Payment System (MIPS) Value Pathways (MVP) Program. QPP will remain an essential component to incenting interoperability to ensure provider and patient access to the information needed for healthcare delivery, healthcare improvement and healthcare decisions. 

HIMSS and PCHAlliance expressed support for a delay in the timeline for starting the implementation of the MVP Program to at least the 2022 Performance Period. Fundamentally, HIMSS and PCHAlliance supported the MVP Program concept connecting quality, cost and improvement activity measures around specific chronic conditions or specialty cohorts, but encouraged the change primarily due to the lack of information currently available about the development of the MVP Program. 

HIMSS and PCHAlliance also urged consideration of this recommendation in an effort to ensure that the electronic clinical quality measures (eCQMs) assigned to each MVP are meaningful, actionable and have been fully-tested to ensure they produce an accurate reflection of the quality of care being delivered and are available to populate MVP for specialists. HIMSS and PCHAlliance also recommended CMS provide substantive feedback to the industry on how collaborative efforts to develop clinically-driven measures similar to MVP (such as the work currently being undertaken by the National Quality Forum (NQF) Core Quality Measures Collaborative) and other specialty organizations can be incorporated into the MVP framework. To effectively reduce burden, it is critical that MVP reporting align as closely as possible with the reporting requirements for states, private payers and accreditation bodies. Efforts like the NQF Collaborative aim to align the current disparate reporting requirements and should be built upon in the development of the MVP Program.  

In addition, HIMSS and PCHAlliance supported changes to ensure greater alignment and integration between QPP and the Shared Savings Program, including revising the Shared Savings Program’s Performance Year 2021 quality performance standard. 

For Qualified Clinical Data Registry (QCDRs) and Qualified Registries, HIMSS and PCHAlliance supported the proposed changes and continue to recommend that CMS require measure testing and harmonization before QCDR quality measures are the allowed format for measuring quality for MVP.

Moreover, HIMSS and PCHAlliance recommended that CMS align with the previous ONC Guidance and clarify that developers have until August 2, 2022, to make the 2015 Cures Edition Update certified EHR technology (CEHRT) available to their healthcare provider clients.  HIMSS members have been working closely with ONC on implementing these certification program changes, and ONC previously advised that the newly certified 2015 Cures Edition Update technologies must be made available to the community by the August 2022 date, versus what CMS has proposed as the date by which healthcare providers must have adopted and be using the updated certified technologies.

For health IT developers, the difference in dates between ONC and CMS’s Guidance is extremely significant. Under CMS’s draft guidance, developers would have to finalize all development and certification efforts by the summer of 2021 to meet its summer of 2022 requirement around the Cures Update. That extra year would be required by developers to allow sufficient time for implementation, testing and training so that ECs could have adopted and be using certified technologies by the summer of 2022, according to CMS’s Guidance in this Proposed Regulation.