CMS Advances Virtual Care, Digital Health Coverage in Proposed 2025 PFS

The proposed Physician Fee Schedule includes, among other things, Medicare coverage for care management using telehealth and digital health tools, as well as coverage for some digital therapeutics devices used in behavioral health treatment

Healthcare providers will have more opportunities to receive Medicare reimbursements for digital health and virtual care programs under the Centers for Medicare & Medicaid Services’ proposed 2025 Medicare Physician Fee Schedule.

In what is roundly considered a positive step forward for healthcare innovation, CMS is showing support for care management programs that embrace new technologies and strategies to meet patients where they are, rather than paying providers to entice them into the doctor’s office or hospital.

Advance Primary Care Management Codes

Perhaps most surprising to analysts is CMS’ efforts to incorporate virtual care into primary care to push the healthcare industry toward value-based care. CMS is proposing three new “Advanced Primary Care Management” HCPCS codes that focus on interactions with patients at the time and place of their choosing.

In a blog post, Carrie Nixon and Kaitlin O’Connor of Nixon Gwilt Law say the new codes are not based on time spent with a patient, but focus on specific activities by clinicians and using technology to address patient needs.

“The Advanced Primary Care Management (or APCM) HCPCS codes bundle elements of the existing Chronic Care Management (CCM) and Principal Care Management (PCM) codes set with Communications Technology-Based Services (CTBS) codes for virtual check-ins, remote evaluation of images, e-visits, and interprofessional consults to create what CMS refers to as an “enhanced care management” bundle,” they wrote. “Unlike CCM and PCM services, the APCM codes are not time-based – meaning, care management services that do not meet the 20 or 30-minute requirements for CCM or PCM would be billable under APCM.”

Nixon and O’Connor also noted that CMS is expanding the rule to allow non-physician care providers, such as nurse practitioners and physician assistants, to order and bill for those services, as long as any practitioner who bills for those services “Intends to be responsible for the patient’s primary care and is the continuing focal point for all needed healthcare services.”

The three new codes are:

• GPCM1: Advanced primary care management services provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month. Approximate reimbursement is $10 per patient per month.
• GPCM2: Advanced primary care management services for a patient with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the elements included in GPCM1, as appropriate. Approximate reimbursement is $50 per patient per month.
• GPCM3: Advanced primary care management services for a patient that is a Qualified Medicare Beneficiary with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, which place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, provided by clinical staff and directed by a physician or other qualified health care professional who is responsible for all primary care and serves as the continuing focal point for all needed health care services, per calendar month, with the elements included in GPCM1, as appropriate. Approximate reimbursement is $110 per patient per month.

Telehealth Flexibilities

In other news, CMS is proposing to continue a Medicare waiver through 2025 that enables providers to bill for telehealth services delivered from their homes while using their practice location for billing purposes.

More than 100 healthcare organizations had lobbied CMS to continue that waiver or even make it permanent, saying it reduces stress and burnout and enables clinicians to design virtual care programs that are more flexible to their lifestyles and that don’t need costly and complex on-site telehealth centers.

Separately, CMS did not create any new CPT codes for telehealth services that duplicate existing telehealth-eligible services covered by Medicare. The Alliance for Connected Care praised that decision, saying, “We believe that telehealth is a modality for providing health care, it is not a different service.

Digital Therapeutics Coverage

Also, the proposed 2025 PFS is showing some love for the digital therapeutics sector, with reimbursement for some behavioral health treatments that use FDA-approved devices. Specifically, the proposed rules offer reimbursement for the first 20 minutes, and then for an additional 20 minutes, of treatment using a “digital mental health treatment” (DMHT) device.

The new codes are:

• GMBT1 (Supply of digital mental health treatment device and initial education and onboarding, per course of treatment that augments a behavioral therapy plan). CMS is proposing contractor pricing for GMBT1 and seeking comments on which national pricing methodologies may be considered, including crosswalks. 
• GMBT2 (First 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment (DMHT). CMS proposes a direct crosswalk to CPT code 98980 (RTM first 20 minutes), that is assigned a work RVU of .62 and has a 2024 National Payment Amount of $50.60 (non-facility) and $30.29 (facility). 
• GMBT3 (Each additional 20 minutes of monthly treatment management services directly related to the patient’s therapeutic use of the digital mental health treatment (DMHT). CMS proposes a crosswalk to CPT code 98981 (RTM each additional 20 minutes), that is assigned a work RVU of .61 and has a 2024 National Payment Amount of $39.95 (non-facility) and $29.96 (facility). 

In an e-mail, the Digital Therapeutic Alliance hailed the proposal as “the first acknowledgement of a pathway for reimbursement for a certain sector of digital therapeutic interventions,” and said they set “a precedent for Medicare coding, coverage, and reimbursement that can be applied to additional therapeutic categories.”

According to Nixon and O’Connor, DMHT devices, also known as digital CBT devices, “refer to software devices cleared by [FDA] that are intended to treat or alleviate a mental health condition, in conjunction with ongoing behavioral healthcare treatment under a behavioral health treatment plan of care, by generating and delivering a mental health treatment intervention that has a demonstrable positive therapeutic impact on a patient’s health.”  

One issue with the proposed rule, Nixon and O’Connor say, is the language used to define what devices will be covered. Because it requires only that the software meet the FDA’s definition of a device but doesn’t specifically state that a device be FDA-cleared, the rule could disqualify and device that is subject to FDA enforcement discretion or exempt from FDA pre-market clearance.

Clearing Up Coding for FQHCs and RHCs

The proposed 2025 PFS didn’t offer any good news for federally qualified health centers (FQHCs) or rural health centers (RHCs), which have been lobbying for increased use of and reimbursement for telehealth and digital health services for years. In the proposed rule, CMS is eliminating HCPCS G0511, under which FQHCs could bill for remote physiological monitoring and remote therapeutic monitoring services, and telling FQHCs and RHCs to bill under existing CPT codes for care management (including the proposed APCM codes).

The change is designed to clear up reported confusion over what services could be billed under HCPCS G0511, but Nixon and O’Connor noted that it could mean less reimbursements for FQHCs and RHCs.

Other Proposals

Finally, the proposed 2025 PFS includes the following:

• Permanent coverage of two-way, real-time, audio-only telehealth services, such as the telephone, “for any telehealth service furnished to a beneficiary in their home if the distant site physician or practitioner is technically capable of using an interactive telecommunications system but the patient is not capable of, or does not consent to, the use of video technology.” This would enable providers to expand treatment services in rural and remote areas where broadband is limited, as well as for patients who can’t access audio-video telemedicine.
• Reimbursement for audio-only telehealth services for periodic assessment of patients undergoing substance abuse disorder (SUD) treatment when video is not available.
• Reimbursement for audio-only telehealth services used in initial intake for SUD patients seeking methadone treatment when video is not available.
• Extending the definition of “direct supervision” to include access by audio-video telemedicine, rather than requiring everyone to be in the same room. CMS is also proposing to add audio-visual telemedicine access to a permanent definition of direct supervision.
• Coverage for remote supervision (such as telehealth) of physical therapists and occupational therapists over PT assistants and OT assistants as permitted by state laws. This would open the door to more telehealth therapy services.
• A continuation of the policy to “allow teaching physicians to have a virtual presence for purposes of billing for services furnished involving residents in all teaching settings, but only in clinical instances when the service is furnished virtually (for example, a three-way telehealth visit, with the patient, resident, and teaching physician all parties in separate locations) through December 31, 2025.”

CMS will accept public comments on the proposed 2025 PFS through September 9.