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Author: Amber Ray

What’s on the horizon for Medicare technology-based healthcare in 2019

Part 1 of our blog about technology-based services and the role of pharmacists

In the age of convenience and connectivity, information has become accessible in quantities and at speeds that were once inconceivable. Modern technology has empowered us to virtually conduct everyday activities, from ordering food and goods to connecting instantly with friends from high school and hailing transportation right to our doors. Simply put, life is more efficient. However, healthcare has struggled to implement accessible technology-based services, despite our quick societal adoption of other technological advancements. This problem has lent itself to the establishment of “Telehealth” – the remote delivery of clinical care through technology – an emerging field that can utilize things like videoconferencing, streaming media, mobile communication, and store-and-forward imaging. It has the promise of making healthcare more convenient, equalizing healthcare access disparities, and giving people more control over when, where, and how they receive healthcare. Even still, several obstacles – lack of adequate reimbursement, the significant upfront cost of implementation, and regulatory restrictions– have proven to be insurmountable in the past. So, how do we move forward?

In an effort to expand technology-based healthcare services, in 2019 CMS will make it a lot easier for healthcare providers to offer virtual communication and remote patient monitoring services through the establishment of new reimbursement policies. CMS has worked hard to recognize payment disparities and to refine billing mechanisms to accurately reflect the amount of time and resources that providers put into their services. So, these new reimbursement pathways might increase the likelihood that healthcare practices will incorporate technology into their practices and provide more technology-based services. Although reimbursement policies and billing might seem technical, boring, or inconsequential, they are important in healthcare because they often guide providers in where to invest their time, resources, and attention. Therefore, these are a much-needed next step in increasing more convenient access to patient-centered care.

Virtual Communication and Remote Patient Monitoring (RPM)

Virtual Communication:

If you’ve ever felt the frustration of going to the doctor, only to be told you likely overreacted and probably didn’t need to go to the doctor, these new virtual communication services might be appealing. Starting in 2019, Medicare providers will have more reimbursable avenues to assess patients to determine if an office visit is necessary through recorded or live video, telephone calls and pictures created and sent by patients. This will be facilitated by two new billing codes: HCPCS G2012 and G2010. Of note, providers could have already been offering these services, however, these new payment opportunities incentivize practices to make more robust investments in these benefits.

  • Code HCPCS G2012 can be used for “brief communication technology-based services”, which includes things like virtual check-ins. Virtual check-ins allow providers to evaluate a patient’s condition through real-time telephone or two-way video to assess if a visit is necessary. Virtual check-ins could be useful, for example, when used as part of a treatment regimen for opioid use and other substance use disorders. Struggling patients would be able to videoconference with their doctors to discuss the need to escalate care.

  • Code HCPCS G2010 allows providers to evaluate patient-initiated recorded videos and/or pictures to assess a patient’s condition. Consider how this service could be useful, for example, by someone with an irritated eye who is unsure if she should go to the doctor. This service would enable her to send a video or picture of her eye to her doctor, who could then evaluate her need for treatment from the comfort of her own home.

Fitbit 30 day weight trends

Chronic Care Remote Physiologic Monitoring and Management:

Health monitoring technology is increasing in abundance with the advent of Fitbits, apple watches, and smartphone apps. Now, providers will be allowed to more efficiently manage patients using this data via three new chronic care remote patient monitoring codes (CPT 99457, 99545, 99453). These codes will enable qualifying providers to be reimbursed for monitoring and managing things like weight, blood pressure, pulse oximetry, respiratory flow rate, as well as pay for the set up and patient education on the use of necessary equipment. Although the exact kinds of technology that may be involved are not yet specified, things like Fitbits, smart phones, Holter-Monitors, artificial intelligence messaging, and wellness data from behavioral health apps could be among those approved. This service could be especially useful for those dealing with chronic conditions and for those needing extra reassurance in managing their everyday diseases. For example, consider a heart failure patient whose physician notices her weight creeping up. This could trigger a call or app notification telling her to increase her Lasix, which could prevent a future heart failure exacerbation. Remote monitoring has the potential to facilitate early interventions that help prevent future, more serious events.


Although these new codes are great next steps in realizing the potential that electronic communication can have, there are several important considerations that should be noted. First, because these services are now separately recognized Medicare services, patients will be responsible for cost sharing. This could be problematic because some practices who already communicate with their patients electronically fear that patients might not like having to pay for a service they were previously receiving for free. Additionally, some patient advocates believe that the 20% cost sharing might remain an obstacle to acceptance of these services. In response of these concerns, CMS has indicated that they do not have the authority to waive fees. Secondly, these services can only be provided to patients who already have an established relationship with the healthcare practice. Therefore, if it’s been a while since a patient has seen a healthcare provider at a participating practice, he may not be able to take advantage of these virtual communication services.

Moving Forward

Finally, after realizing that the way we interact with people is different than it was 20 years ago, CMS has worked towards giving Medicare patients more control over when, where, and how they receive healthcare. CMS has been working feverishly to reduce the regulatory and reimbursement barriers to technology-based healthcare utilization to help better weave technology and healthcare into modern culture. Although the aforementioned services only apply to Medicare patients, Medicare is often thought of as a standard setting pioneer. So even if you are not covered by Medicare, other healthcare payers may soon follow suit. There is much to look forward to regarding technology-based services, but, in our next blog we will discuss several areas where these new rules have fallen short.


Next on our blog: Why Pharmacist Exclusion from Virtual Patient Engagement is Bad for Patients


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