Millions of Americans live in areas of the country with limited access to broadband internet service. Even if they have broadband available, they may not have the appropriate technology to access it, or if they do own a laptop or smartphone, they may lack ability to use it in a meaningful way. Many others struggle with housing instability, transportation access, and mobility. In all these cases and many more, access to audio-only health care services has been a lifeline throughout the pandemic.
Audio-only access means these individuals do not have to travel long distances, in sometimes challenging weather conditions, while missing work, struggling with child care issues, and even putting their health further at risk, just to be “seen” by a physician, when many services, particularly for well-established patients, can be provided over the telephone.
CMS has been covering the audio-only evaluation and management (E/M) services (CPT codes 99441, 99442, and 99443) throughout the COVID-19 public health emergency (PHE), but that coverage was set to sunset 151 days after the PHE ends, which is currently scheduled to happen on April 11, 2023. In a significant win for ACP and our members, the Consolidated Appropriations Act, 2023, signed into law in December 2022, now requires CMS to continue coverage of audio-only E/M services through the end of 2024.
This law helped break through CMS’ reluctance to provide coverage for these services. As recently as November 2022, CMS stated that its hands were tied due to statutory limitations in its ability to waive the audio-video standard that it believes must be met to provide telehealth services. As articulated in the final 2023 Medicare Physician Fee Schedule rule, CMS reasoned that “the statute requires that telehealth services be so analogous to in-person care such that the telehealth service is essentially a substitute for a face-to-face encounter” and said that in its view, audio-only is inherently non-face-to-face. However, ACP views this as a debatable point, particularly given our members' extensive feedback to the contrary.
ACP recently posted an inquiry for our members regarding their experience with audio-only E/M services over the course of the PHE. We have received hundreds of responses, with remarkably consistent feedback. When asked about the amount of time an audio-only visit takes relative to a telehealth or in-person visit, most said it was about the same although with somewhat less practice expense, as there is no need for rooming the patient or for initial vitals to be taken.
Respondents also noted how important audio-only access is, particularly for patients in rural areas, older and/or frail patients, and those facing significant challenges with social drivers of health. Even when patients had access to broadband and appropriate technology, ACP members noted that some still struggled due to the stress of ensuring that the technology worked, which made it challenging for all involved to fully concentrate on the needs of the visit.
Audio-only also has a positive impact on physicians. Some in rural areas noted that they must travel several miles to simply have enough Wi-Fi to be able to conduct video telehealth visits with their patients, and others discussed how having the option of providing covered audio-only services helped reduce their own stress and burnout. The bottom line, as stated by one respondent, is that “audio-only visits can be an absolutely essential tool in delivering care,” while another noted: “As we are moving into the 21st century, it has become part of care delivery. It is part of the toolbox. Denying its use will only bring patient harm, lack of access, and ultimately bad outcome(s).”
Researchers have also begun to identify positive impacts on health equity due to coverage of audio-only E/M services. A study published by the Journal of General Internal Medicine in April 2022 found that several groups will disproportionately lose the ability to access telehealth from their homes if audio-only is eliminated. This includes approximately one in five Hispanic individuals, one in 10 non-Hispanic Black individuals, one in five individuals with household incomes under $25,000, and three in 10 individuals ages 80 years and over. Additionally, the study noted that about one in 200 United States residents—or 1.6 million people—did not have access to either telephone or internet service in their homes in 2019. It is clear that audio-only services provide critical and more equitable access to care for individuals who would have no or extremely limited access otherwise.
Additionally, ACP has pointed out to CMS that a 2022 Office of the Inspector General (OIG) report found that 99.8% of physicians and other “providers” showed no evidence of worrisome billing practices—so any concerns the agency may have about fraud, waste, and abuse related to audio-only services are also not sufficient justification for discontinuation of coverage.
With this said, the College has recognized that further data collection is needed to determine the most appropriate way to cover these services over the longer term and how they should be valued for payment purposes. The current payment for audio-only services is lower than for telehealth or in-person care, even though these visits seem to take just as long as the other modalities, albeit potentially without the same amount of in-office staff support. Given this, we have called on CMS to work with ACP and other societies to collect data regarding the benefit, importance, and appropriate utilization of telephone visits—something that can now be done in a more robust manner due to the new law requiring coverage of these services through 2024.
To help further this effort, ACP is actively working to ensure that audio-only E/M services are appropriately defined and valued via our participation in the Current Procedural Terminology (CPT) Editorial Panel and the Relative Value Scale Update Committee (RUC). The results of this work will be critically important after 2024, when the new legal requirement to cover these services, per the recent consolidated appropriations bill, expires.
While the RUC, in particular, is often criticized as having outsized participation by non-internal medicine/non-primary care specialists, past ACP engagement in both the CPT and RUC processes played a significant role in achieving the recent increases in valuation of and reduced documentation burden for both the outpatient and inpatient E/M codes. We hope to see further positive changes for audio-only E/M services, as well as others that are regularly provided by internal medicine physicians.
However, even though Medicare is now required to cover audio-only E/M services through 2024, by and large private payers are not following suit. Many have stopped payment for these services altogether over the past year—if they covered them at all during the worst of the pandemic—and those that are covering them may or may not be paying at the same rate as CMS. From a practice perspective, this makes for a very inconsistent experience and creates uncertainty as to if or how much physicians will be paid for offering audio-only services to their patients. Therefore, ACP plans to work at both the federal and state level to ensure that private payers understand the importance of providing coverage and adequate payment for audio-only E/M so that all Americans, not just those covered by Medicare, will benefit.
Health equity is a top advocacy priority for ACP—something that cuts across all of our actions on Capitol Hill, with the Biden Administration, in individual states, and beyond—and we need our members engaged to help us make progress toward a health care system where disparities in care based on where one lives, the color of one's skin, or another social driver of health are significantly reduced and ideally eliminated. Coverage of audio-only E/M services is clearly one approach that has been shown to help and is therefore something that must be continued by all payers even when the PHE is behind us.
If you have a story to share regarding your utilization of audio-only E/M services, please let us know by sharing it via our website inquiry form and keep an eye out for other opportunities to engage. As the old saying goes, “Tell me and I forget. Teach me and I remember. Involve me and I learn.” We want you all to be involved in ACP's advocacy in 2023, for it is by working together that we can truly create change.