7th Global Gastroenterology and Artificial Intelligence Summit (Live)

6 - Tullia

Pdf Summary

This document provides an overview of Medicare reimbursement considerations for digital health technologies (DHT) and artificial intelligence (AI) in healthcare. Key reimbursement components include: whether a service falls under a benefit category prescribed by law, its coverage based on being “reasonable and necessary,” appropriate coding for service description and claims, and payment amounts determined by Medicare.<br /><br />Coverage assessments for AI and digital tools focus on the function of the technology, whether it is integral or an associated device, usage settings, specialty applications, workflow integration, regulatory factors such as FDA approval, available evidence, cost, and whether it aligns with standard of care.<br /><br />Regarding coding, since January 2022, the AMA’s Current Procedural Terminology (CPT) includes a taxonomy for AI tools, classifying them by the level of autonomy:  <br />- Assistive: detects data but requires provider interpretation,  <br />- Augmentative: analyzes data meaningfully requiring provider report,  <br />- Autonomous: independently interprets data and generates conclusions without provider involvement.<br /><br />Medicare coverage and payment vary by setting:  <br />- Inpatient hospitals (IPPS) cover AI, including New Technology Add-On Payments (NTAP) recognizing subscription models,  <br />- Outpatient hospitals (OPPS) cover AI with New Technology Ambulatory Payment Classifications (APCs) but face concerns about payment stability,  <br />- Physician services (PFS) cover autonomous AI, remote patient monitoring (RPM), remote therapeutic monitoring (RTM), and some digital therapeutics,  <br />- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) generally does not cover some digital therapeutics but may cover virtual reality solutions with equipment,  <br />- Medicare Advantage plans, using capitated payments, may include AI/software as supplemental benefits but are not required to provide NTAP payments.<br /><br />Recent 2026 rulemaking updates show expansion of digital medical health technology proposals, coding and payment updates for RPM/RTM, and solicit public comments regarding Software as a Service (SaaS) for physician and hospital outpatient settings.

Keywords

Medicare reimbursement

digital health technologies

artificial intelligence

coverage assessment

FDA approval

Current Procedural Terminology

AI autonomy levels

New Technology Add-On Payments

Remote Patient Monitoring

Software as a Service