Changes to Medicare telehealth coverage may benefit LTC
While arguably late to the telehealth game, long term care and post-acute care providers are now key players in telehealth as its benefits become more and more apparent for their patients and business models. Recent changes in federal law may provide some additional support and momentum for the continued and increased use of telehealth within this industry.
The use of telehealth in the post-acute and long term care setting has steadily grown in recent years. With increased emphasis on the triple aim of healthcare providers to increase quality of care, improve patient satisfaction and reduce costs, telehealth is repeatedly recognized as a service delivery model that can help achieve this "hat trick."
One goal in the PAC and LTC setting is to reduce avoidable resident or patient transfers/admissions to emergency departments and acute care settings. Even when necessary, transfers of the often fragile and compromised patients in this setting can come at a cost when patients are exposed to additional infections or illnesses at the receiving facility. Such movement is, more often than not, highly disruptive and unsettling for patients as well as their caregivers and families. The additional and higher cost of the care in an acute care setting further exacerbates the situation.
Early physician or other practitioner (e.g., nurse practitioners) intervention is recognized as a key mitigating factor to avoidable transfers and admissions. However, nursing facilities do not have medical staffs with physicians readily available, nor are physicians present for patients residing in their homes under the care of providers such as a home health agency. Further, many nursing facilities and PAC providers are located in rural areas. For their patients, the time it takes for a physician to come in or return a nurse's phone call can exceed a nurse's comfort level, leading to the decision to transfer to a hospital or emergency department.
Telehealth resolves these concerns by facilitating more rapid responses from physicians and providers. PAC and LTC providers engaging telehealth providers can require their physicians and practitioners to be available around the clock for consultation. Such consultations can either validate the decision to transfer/admit or provide a clinical alternative that can be addressed while keeping the patient in place.
Telehealth can also provide benefits in the non-facility PAC setting such as for home health agency patients or patients residing at home while receiving care for a chronic condition such as COPD and diabetes. These types of patients, who live at home with sometimes very complicated health conditions, may include some degree of self-monitoring. But patients can be skittish. In those cases, a patient may decide to be "safe rather than sorry" and drive to an emergency department.
The patient then may wait for hours in the waiting room only to be sent home upon finding that the issues did not require the level of care offered by an emergency department – though not before incurring a hefty ED bill. Alternatively, telehealth can provide a patient with a direct and quick communication line to his/her physician or allow the physician to have continual access to the patient's vital signs, biometrics and overall condition. The physician thereby can intervene prior to the self-admission to address any concerns and to validate whether a trip to the ED is necessary. Physicians who are able to remotely monitor their patients can be alerted to issues or changes and either proactively reach out to the patient to address them, or be prepared with such information when a nervous patient calls. In either case, the physician can assess the issue and possibly avoid a hospital visit if clinically appropriate.
Considering this specific and valuable potential for LTC and PAC providers, recent changes to the Medicare telehealth coverage benefit may be promising. Frustrations over the scant Medicare telehealth benefit focus largely on limitations on the types of telehealth providers and the location of the provider. Elimination of those restrictions will require legislative change. However, while limited, CMS already has the authority to ease limitations on the scope of services coded by adding additional telehealth codes which can be reimbursed under the current reimbursement structure. The 2018 CMS Physician Fee Schedule, recently displayed on November 2, 2017, listed additional CPT codes and four "add-on" codes now included in the telehealth benefit.
The two new service codes include HCPCS code G0296 for lung cancer screening and CPT Codes 90839 and 90840 for psychotherapy services in a crisis. Whether or not these codes are prevalent in the long-term or post-acute setting will likely be patient-population specific. However, expansion of mental health services via telehealth is good to see at a time when there is global need for increased mental health services, including in the LTC and PAC setting.
The four new telehealth add-on codes include HCPCS code G0506 (comprehensive assessment of care planning for patients needing chronic care management (CCM) services), which will likely be relevant for a patient population commonly suffering from chronic illnesses. The other codes include: CPT 90785 (interactive complexity) and CPT 96160 and 96161 (administration of health risk assessment, both patient-focused and caregiver-focused for the benefit of the patient, e.g., depression inventory)
Two more routine changes will undoubtedly be welcomed not only by LTC and PAC facilities but by all origination sites. The first such change increases the Originating Facility Fee (HCPCS Q3014) to $25.76. The second eliminates the GT modifier requirement for distant site providers, who now need only apply the POS code (02) describing services furnished via telehealth. The hope is to reduce unnecessary administrative burdens.
Likely the most relevant development for LTC and PAC providers is the recognition of remote patient monitoring and the promise of more to come. In the final rule, CMS discussed how RPM services would generally not be considered telehealth as defined under the Medicare program, but rather they are paid under the same conditions as in-person physician services. Even so, CMS recognized that the bundling of such RPM-type codes with other services under the current reimbursement structure creates an obstacle to billing for RPM services. CMS acknowledged, however, that RPM services "can be a significant part of ongoing medical care and that [CMS] should recognize these services for separate payment as soon as practicable." As a result, in the final rule CMS activated the previously bundled CPT Code 99091 (collection and interpretation of physiologic data stored and transmitted by patient to provider requiring 30 minutes of time).
CMS's decision to activate this monitoring code as opposed to others (e.g., CPT 99090) was influenced by the fact that RVUs were already available for CPT 99091. In order to bill for this service, providers will need to meet certain requirements common to other CCM services, such as obtaining advance beneficiary consent. In addition, for new patients or patients not seen by the billing practitioner within the prior year, the service must be initiated during a face-to-face visit by the billing provider.
This element will likely be considered a step back by telehealth proponents who have been fighting for the ability to establish a relationship via telehealth on multiple fronts, e.g., state licensing law or e-prescribing. The CPT 99091 monitoring code is not to be reported more than once per 30 day-period, but can be billed once per patient during the same service period as certain CCM and other care management codes. Additionally, CMS noted its hope that future changes via the CPT process will better describe the role of RPM in current clinical practice and potentially mitigate the need for additional billing requirements associated with the services.
However narrow, the extension of the Medicare telehealth benefit indicates a growing acceptance of telehealth as a viable – even desirable – means of providing health care services. LTC and PAC providers should take advantage of the improving outlook and continue to investigate the benefits of telehealth in terms of increased efficiencies in their operations, reduced overall costs and increased value of services leading to improved patient satisfaction.
Progress in reimbursement for telehealth services may be moving slowly, but providers should nonetheless position themselves to take full advantage.
Emily Wein is a shareholder at Baker Donelson. She is based in Baltimore.