CMS clarifies use of Remote Patient Monitoring during COVID-19 and further expands Telehealth for Physical Therapists, Occupational Therapists, Speech Pathologists, other practitioners
The Centers for Medicare and Medicaid Services (“CMS”) has issued a second Interim Final Rule (“IFR2”) that includes additional expansions and clarifications relating to the provision and reimbursement of telehealth, remote patient monitoring, and telephone services during the COVID-19 Public Health Emergency (“PHE”). While these expansions are another step forward for the adoption of digital technologies and services in healthcare, there are additional changes needed in the near-term, as detailed below. We urge digital health companies and healthcare providers to submit their comments in response to this Interim File Rule, detailing their suggestions for changes based on their own experiences. Please contact us if you would like assistance in drafting and submitting comments to CMS.
Monitoring period for Remote Patient Monitoring codes during the COVID-19 PHE
In the IFR2, CMS acknowledges confusion around the duration of monitoring required for reimbursement of the remote patient monitoring CPT codes. This confusion pre-dates the PHE and stems from prefatory language in the 2019 and 2020 CPT Manuals stating, “Do not report 99453 or 99454 for monitoring of less than 16 days.” In the first Interim Final Rule issued on March 30, 2020, CMS clarified that use of the RPM codes is not limited to patients with chronic conditions, and is appropriate for use in monitoring acute conditions such as COVID-19 – or presumably, for that matter, for acute post-surgical episodes of care. Prior to and during the PHE, some healthcare providers and remote patient monitoring companies have questioned the intended meaning of the “monitoring of less than 16 days” language in the CPT Manual, wondering whether the language is meant to distinguish the ordering and use of the RPM codes as care management services from shorter-term use for a diagnostic purpose such as identifying a heart condition – or, alternatively, whether the language indicates an expectation that a patient record and transmit readings via an RPM device for at least 16 out of 30 days in order for the RPM codes to be reimbursable.
In response to this confusion as it relates to use of the RPM codes for suspected or confirmed COVID-19 patients, CMS states that it will allow RPM monitoring services for those patients to be reported for reimbursement by Medicare “for periods of time that are fewer than 16 days of 30 days, but no less than 2 days, as long as the other requirements for billing the code are met.” This response does not address the actual confusion around the intended meaning of the language in the CPT Manual. We reached out to CMS directly regarding its intent for purposes of reimbursement of CPT Codes 99453 and 99454, and a representative indicated that, under non-PHE normal circumstances, CMS expects that a patient will record and transmit readings for at least 16 out of 30 days in order to have a reimbursable claim. IFR2 further states that payment amounts for CPT Codes 99453, 99454, 99457, and 99458 will remain the same regardless of the duration of monitoring.
Blanket Waiver Allows Therapists and other Medicare Practitioners to Provide Telehealth
The existing list of practitioners eligible to provide Medicare telehealth visits leaves out some important healthcare providers who are otherwise eligible to bill Medicare, including Physical Therapists, Occupational Therapists, and Speech Language Pathologists. This omission has left many Medicare beneficiaries without much-need therapy services that can readily be provided via telehealth during the COVID-19 PHE. Utilizing its authority during a Public Health Emergency, CMS has now waived limitations on which providers can “furnish and bill” for telehealth visits, specifically indicating that PTs, OTs, and SLPs can now submit claims and receive payment for telehealth services to patients. While CMS calls out Physical Therapists, Occupational Therapists, and Speech Language Pathologists in its announcement, it also notes that the waiver extends to ANY practitioner who can bill and furnish services to Medicare – for example, a qualified Audiologist. The waiver has a retroactive effective date of March 1, 2020, allowing these practitioners to submit claims for telehealth services during this time.
Interestingly, the waiver contains no specific language referencing Respiratory Therapists. Respiratory services are typically ordered by a physician or non-physician practitioner, and respiratory services CPT codes are reimbursed by Medicare. However, it is not entirely clear whether CMS intends the waiver to encompass ONLY those practitioners who can furnish AND bill for those services independently. Respiratory therapists have an important role to play during the COVID-19 PHE in providing the assessment and diagnostic evaluation, treatment, management, and monitoring of COVID-19 patients (among others) who are suffering from respiratory distress or dysfunction. Additional clarification on this issue would be helpful, and should be requested in comments submitted in response to IFR2.
CMS Allows “Audio-Only” for select Telehealth Services
In order to be reimbursed by Medicare, telehealth services are required by statute to be conducted via interactive communications technology that includes audio AND video capability. The healthcare provider community brought to CMS’ attention that use of audio/video technology is still constrained by availability of broadband/cellular services in some areas of the US, and many older Medicare beneficiaries find it difficult, if not impossible, to use such technologies. As a result, the complexity of care being delivered to Medicare patients via telephone. In response to these concerns, CMS used its waiver authority to allow use of audio-only communications technology – including a simple telephone – to conduct certain designated Evaluation/Management services and certain behavioral health counseling and education services, reimbursable as telehealth visits. This means that, whereby previously audio-only/telephone services were reimbursed at a significantly lower rate than their audio/video telehealth equivalent, select services will now be reimbursed at the equivalent telehealth/in-person services rate, increase payments for these services from approximately $14 -- $41 to approximately $46 -- $110. The payment increase will apply retroactively to March 1, 2020. See this link for a list of eligible telehealth services, including those that may be conducted via audio-only communications technology.
Adding new CPT codes to the Medicare Telehealth Services list
In the first Interim Final Rule, CMS added more than eighty CPT codes to the list of services that could be provided by telehealth and reimbursed by Medicare. Recognizing that additional codes will likely be needed during the course of the PHE, CMS has determined that the Medicare Telehealth Services list – typically updated once per year – will be modified on an ongoing, as-needed basis during the COVID-19 National Emergency. This means that services codes may be modified or added to the list via postings on the CMS website and/or other CMS notifications. Codes may be added to the list upon request by stakeholders or when identified as necessary telehealth services during internal CMS review, taking into consideration infection control, patient safety, and other public health concerns resulting from the emergency. This presents an opportunity for healthcare providers and other stakeholders to make their case, through comment to the IFR2 or otherwise, that a particular service should be made available by telehealth. CMS makes clear in the IFR2 that any telehealth services added by this new process will remain on the list only during the COVID PHE. Please contact us if you would like assistance in presenting a code to CMS for addition to the Medicare Telehealth Services list.
Additional Changes to Medicare Telehealth Policy
In the IFR2, CMS recognized that times used to report E/M telehealth services as set forth in the first IFR do not align with times set forth in the relevant CPT code descriptors, and accordingly announced that, for the duration of the PHE, the typical times for purposes of level selection for an office/outpatient E/M visit are the times listed in the CPT code descriptors.
Finally, the IFR2 states that hospitals may now bill as the originating site for telehealth services furnished by hospital-based practitioners to Medicare patients registered as hospital outpatients even when the patient is located at home. CMS considers hospital outpatient therapeutic services in three categories: (1) hospital outpatient therapy, education, and training services, including partial hospitalization program services, that can be furnished other than in-person, and are furnished in a temporary expansion location (which may be the patient’s home) that is a PBD of the hospital or an expanded CMHC; (2) hospital outpatient clinical staff services furnished in-person to the beneficiary in a temporary expansion location; and (3) hospital services associated with a professional service delivered by telehealth.
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Read our previous post “CMS issues Interim Rule on use of Telehealth, Remote Patient Monitoring, e-visits, and Virtual Check-Ins during COVID-19” on The Latest.
Please visit our webpage, Responding to COVID-19: Resources for Telehealth and Remote Patient Monitoring, for up to date information and breaking news.