Incorporating Telehealth into Home Health Care Part 2: Reimbursement Status
Don’t miss part one of this series, Incorporating Telehealth into Home Health Care Part 1: Practical Strategies.
Amid COVID-19, both Congress and CMS have been actively working to protect Americans’ health and “equip the American health care system with maximum flexibility to respond to the 2019 novel coronavirus (COVID-19) pandemic.”
The Coronavirus Aid, Relief, and Economic Security (CARES) Act, signed into law on March 27, 2020, requires the Secretary of Health and Human Services (HHS) to issue clarifying guidance encouraging the use of telecommunications systems, including remote patient monitoring, to furnish home health services consistent with the beneficiary care plan during the COVID-19 emergency period.
Coincidentally, the CMS interim final rule released March 30, 2020, indicated that CMS would allow HHAs to use additional telecommunications technologies in conjunction with in-person visits but stopped short of allowing telecommunications-delivered communications to replace in-person visits.
CMS is statutorily prohibited from paying for home health services furnished via a telecommunications system if such services substitute for in-person home health services ordered as part of a plan of care and for paying directly for such services under the home health benefit. Pursuant to Medicare Benefit Policy Manual Chapter 7 Section 110:
Section 1895(e) governs the home health prospective payment system (PPS) and provides that telehealth services are outside the scope of the Medicare home health benefit and home health PPS… As stated in 42 CFR 409.48(c), a visit is an episode of personal contact with the beneficiary by staff of the home health agency (HHA), or others under arrangements with the HHA for the purposes of providing a covered service.
However, for the duration of the public health emergency for the COVID-19 pandemic, CMS is amending the regulations at 42 CFR § 409.43(a) on an interim basis to provide HHAs with the flexibility, in addition to remote patient monitoring, to use various types of telecommunications systems (that is, technology) in conjunction with the provision of in-person visits.
At the time of this writing, remote visits do not count as in-person visits as it relates to reimbursement, and thus, telehealth visits do not count toward the LUPA threshold. That said, we are awaiting the release of another interim final rule from CMS, which is currently pending review with the Office of Management and Budget. It is possible that through this rule, CMS will afford additional telehealth flexibilities to HHAs.
Remote Patient Monitoring
Remote patient monitoring is the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver to the provider. As described in the Medicare Benefit Policy Manual Chapter 7 Section 80.10:
Remote patient monitoring can be ordered as part of a home health plan of care but such services cannot be reported as a visit without the provision of another skilled service. Visits to a beneficiary’s home for the sole purpose of supplying, connecting, and/or training the patient on the remote patient monitoring equipment, without the provision of another skilled service, are not separately billable. However, HHAs may include the costs of remote patient monitoring as an allowable administrative cost (that is, operating expense), if remote patient monitoring is used by the HHA to augment the care planning process.
Specifically, CMS is amending the regulations at 42 CFR § 409.43(a) on an interim basis to state that the use of technology must be related to the skilled services being furnished by the nurse/therapist/therapy assistant to optimize the services furnished during the home visit or when there is a home visit. CMS also is amending the regulations at 42 CFR § 409.43(a) on an interim basis to state that the use of technology must be included on the home health plan of care along with a description of how the use of such technology will help to achieve the goals outlined on the plan of care without substituting for an in-person visit as ordered on the plan of care. In addition, HHAs may also provide services based on verbal orders in accordance with the regulations at §§ 484.60(b) and 409.43(d). Finally, CMS is allowing, on an interim basis, HHAs to report the costs of telecommunications technology as allowable administrative and general (A&G) costs.
Although the use of technology may not substitute for an in-person home visit ordered as part of the plan of care and services furnished via a telecommunications system cannot be considered a home health visit for purposes of eligibility or payment, the use of such technology may result in changes to the frequency or types of visits outlined on the plan of care, especially to combat the COVID-19 pandemic.
Medicare Advantage
Medicare Advantage (also known as “Part C”) is an “all-in-one” alternative to Original Medicare. Medicare Advantage plans must cover all medically necessary Part A and B services covered under Original Medicare for all enrollees. Medicare Advantage plans can also cover items and services beyond those covered by Original Medicare, including over-the-counter products and telehealth services. These items and services are typically referred to as “supplemental benefits.”
In light of COVID-19, CMS issued guidance to Medicare Advantage Organizations on March 10, 2020, stating that:
…should a Medicare Advantage Organization wish to expand coverage of telehealth services beyond those approved by CMS in the plan’s benefit package for similarly situated enrollees impacted by the outbreak, CMS will exercise its enforcement discretion regarding the administration of Medicare Advantage Organizations’ benefit packages as approved by CMS until it is determined that the exercise of this discretion is no longer necessary in conjunction with the COVID-19 outbreak. CMS consulted with the HHS OIG and HHS OIG advised that should a Medicare Advantage Organization choose to expand coverage of telehealth benefits, as approved by CMS herein, such additional coverage would satisfy the safe harbor to the Federal anti-kickback statute set forth at 42 CFR 1001.952(l).
Thus, we encourage HHAs to reach out to the MA plans they contract with to determine whether the plans have expanded their benefit packages to include telehealth furnished by HHAs.
Communication-Technology-Based Services
Medicare routinely pays for many kinds of services that are furnished via telecommunications technology but are not considered Medicare telehealth services. These communication technology-based services (CTBS) include, for example, certain kinds of remote patient monitoring (either as separate services or as parts of bundled services) and interpretations of diagnostic tests when furnished remotely. These services are not the kind of services that are ordinarily furnished in person but are routinely furnished using a telecommunications system.
The CTBS that are eligible for furnishing and billing by PTs, OTs, and SLPs under Medicare Part B during the COVID-19 public health emergency are:
- HCPCS G2010 (Remote evaluation of recorded video and/or images submitted by an established patient)
- HCPCS G2012 (Brief communication technology-based service, such as virtual check-in)
- E-Visits (G2061-G2063)
- CPT 98966 (Telephone assessment and management service; 5 to 10 minutes of medical discussion)
- CPT 98967 (Telephone assessment and management service; 11 to 20 minutes of medical discussion)
- CPT 98968 (Telephone assessment and management service; 21 to 30 minutes of medical discussion)
In the Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency interim final rule [CMS-1744-IFC] issued by CMS on March 30, CMS described e-visits and other communication technology based services (CTBS) as “sometimes therapy” services that would require the private practice occupational therapist, physical therapist, and speech-language pathologist to include the corresponding GO, GP, or GN therapy modifier on claims for these services. Although CTBS are a Part B benefit reimbursable under the Medicare Physician Fee Schedule, given this statement and reference to “private practice” therapists, it is unclear whether HHAs and other institutional settings can bill these codes under Medicare Part B.
As we continue to seek clarification from CMS, we encourage providers to check with their Medicare Administrative Contractor. We also anticipate CMS will be releasing additional guidance in the very near future that will hopefully better address this question. See pages 57 and 130 in the interim final rule.
Medicare Part B
Prior to the COVID-19 public health emergency, distant site physicians and practitioners submitted professional telehealth service claims using the appropriate CPT or HCPCS codes and used Place of Service (POS) “02” to indicate they furnished the billed service as a professional telehealth service from a distant site.
CMS has since revised its policy in light of the pandemic and stated in an April 3, 2020, special MLN Matters article that when billing professional claims for all telehealth services with dates of services on or after March 1, 2020, and for the duration of the public health emergency, bill with the POS equal to what it would have been had the service been furnished in-person and Modifier 95, indicating that the service rendered was actually performed via telehealth.
During the public health emergency, beneficiaries are eligible to receive telehealth services in their homes. If and when CMS chooses to use its Social Security Act 1135(b)(8) waiver authority, as amended by the CARES Act, to expand the provider types eligible to furnish and bill for telehealth services, CMS likely will recognize physical therapists in private practice (and possibly also physical therapist assistants under the supervision of physical therapists) as distant site practitioners eligible to furnish telehealth and submit claims using the professional claim form. However, given the limitations of billing by distant site practitioners, it is unclear, although certainly possible, that CMS will recognize institutional settings, including HHAs, as eligible to bill under the Medicare Physician Fee Schedule for telehealth services furnished by physical therapy practitioners.
Private Payers
Do other payers cover telehealth services furnished by HHAs? It depends.
Whether an institutional setting, such as an HHA, can furnish and bill for telehealth services is dependent on each payer policy. It is possible that depending on the payer, an HHA may not be eligible to furnish and bill telehealth as a distant site.
For example, under Medicare, physicians and practitioners can furnish telehealth services as the distant site provider and bill Medicare for such services. While it is possible that some payers may be developing a revenue code so that therapists’ services can be billed on the UB-04 when furnished via telehealth in HHAs and other institutional settings, many payers may not be moving in that direction. Moreover, you will need to check if the patient is eligible to receive care via telehealth in the home (meaning a patient’s home is eligible to be an originating site).
These are all things that need to be verified with each carrier as well as which codes and modifiers need to be used. For guidance on what questions to ask your payers regarding telehealth coverage, please see APTA’s guidance.
CTBS and Private Payers, Including MA
According to Definitive Healthcare, nearly 73 percent of HHAs offer remote patient monitoring with clinical grade devices, and nearly 42 percent plan to add or expand this service in the next two years.
While we are aware that many HHAs continue to expand their services in the arenas of remote patient monitoring and other similar services, much like the guidance provided above, it is critical that HHAs verify with each payer the extent to which the payer is covering “CTBS,” including remote patient monitoring, telephone assessment and management services, e-visits, virtual check-ins, remote evaluations, and so forth, as well as the codes that are eligible for use and modifier requirements. It is also essential for PTs to carefully review payer policies, ask questions, and obtain information shared by the payer in writing.
CMS is potentially allowing agencies to contract with a physician to provide telehealth services to patients. By going this route, a physician could bill for the telehealth service and possibly pay a contracted rate to the agency.
Additionally, CMS announced that home health agencies can provide more services to beneficiaries through telehealth as long as it is part of the patients’ plan of care and does not replace essential in-person visits as ordered in the care plan. If an agency wants to replace any in-person visits that are ordered by the physician with telehealth, they must get new orders from the physician for those telehealth visits. The payment for the 30-day episode would include payment for telehealth visits.
Outside of the visits that are ordered by the physician, CMS does encourage telehealth to be used with patients as a cost-saving measure. At this point in time, there is no additional reimbursement for home health providers.
For agencies looking for reimbursement in the short term, CMS does allow for home health agencies to contract with a physician or non-physician practitioner (NPP) to provide telehealth services to patients. This should be done outside of a covered home health episode. The physician or NPP would then bill for the telehealth service and pay the contracted rate to the home health agency. HRS has seen many agencies take advantage of this option by contracting for reimbursement with physician groups, hospitals, and even commercial carriers.
The APTA and CMS both offer additional resources on billing and telehealth, so be sure to review the links below.
APTA Resources
CMS Resources
- Telehealth Services booklet
- Interim Final Rule: Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
- Press Release: CMS Issues Guidance to Help Medicare Advantage and Part D Plans Respond to COVID-19
Disclaimer: The information in this blog post (“Post”) is provided for general informational purposes only, and may not reflect the current law in your jurisdiction. No information contained in this Post should be construed as legal advice from MedBridge, Inc., or the individual author, nor is it intended to be a substitute for legal counsel on any subject matter.
