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Through several recently published rules, the Centers for Medicare & Medicaid Services (CMS) is making it possible for Medicare beneficiaries to have greater access to health care services provided remotely through telehealth or “telehealth-like” methods and to implement telehealth provisions included in the Bipartisan Budget Act of 2018 (BBA). The recently posted Medicare physician fee schedule (PFS) and home health prospective payment system (HH PPS) final rules and the Medicare Advantage and Prescription Drug Benefit proposed rule all included provisions that establish or would establish new rules concerning telehealth or related services. Viewed together, this demonstrates CMS’ belief that telehealth and related communication technology-based services can provide expanded access to high-quality and cost-effective health services and that CMS will be providing more flexibility to encourage the use of these services. These changes recognize growing beneficiary and health care professional comfort with the use of communication technology in the provision of health services. The changes also implicitly acknowledge the growing demand for the convenience of telehealth services. It remains to be seen whether these Medicare program developments will result in expanded coverage of telehealth services under any state Medicaid programs.

Medicare physician fee schedule final rule

On November 1, CMS posted the Medicare physician fee schedule final rule. Because the Medicare statute limits payment for telehealth services to beneficiaries in certain geographic  areas (primarily rural) and limits the “originating sites” where beneficiaries can get access to telehealth services, CMS has used its rule-making authority to bypass these restrictions by identifying and paying for certain telehealth-like services described below as “communication technology-based services” outside the telehealth benefit. CMS also is paying for new remote monitoring services, as described below. Medicare will begin paying separately for all of these new services in January 2019. CMS has expressed interest in recognizing innovations in the use of new communication technologies. CMS also noted that several of these new services are aimed at avoiding the scheduling of office visits that may not be necessary by providing a lower level payment for a separate service. The rates for these new services are provided in a chart below.

Virtual check-in (HCPCS code G2012)

Under Healthcare Common Procedure Coding System (HCPCS) code G2012, Medicare will pay separately for “brief communication technology-based services,” also referred to as a “virtual check-in,” provided certain conditions are met. This five to 10-minute non-face-to-face telephone or computer-based interaction can be provided only to established patients in order to assess whether the patient’s condition warrants an office visit. If the visit is in follow-up to a related evaluation and management (E/M) service provided within the past seven days, or if it results in an office visit within the next 24 hours or the soonest available appointment, then CMS will consider it to be bundled into those visits and it will not be separately reimbursed. The payment will be lower than the rate for the lowest level E/M in-person service, and because these “visits” will be subject to Medicare coinsurance, the patient’s verbal consent (oral consent, as opposed to written or electronic consent) must be obtained and noted in the medical record. CMS has said it will monitor utilization of this code to determine whether frequency limits are warranted.

Remote evaluation of prerecorded patient information (HCPCS code G2010)

Similar to the virtual check-in, Medicare also will pay separately for professional evaluation of prerecorded images or video transmitted by established patients for the purpose of determining whether an office visit is warranted. After reviewing the images or video sent by patients, the clinician must follow up with the patient within 24 business hours by phone, email, text message, or other mode of communication. As with the virtual check-in, if this remote evaluation originates from a related E/M service within the past seven days or results in an office visit within the next 24 hours or the next available appointment, the service will be considered bundled and not separately payable. Beneficiary consent (oral, written, or electronic) to the service must be documented because the service would be subject to coinsurance.

Interprofessional internet consultation (CPT®1 codes 99446-49 and 99451-52)

CMS also finalized its proposal to pay separately for four existing and two new Current Procedural Terminology (CPT®) codes describing consultations between physicians or other qualified health professionals when they are for the benefit of a specific patient. These consultations occur when a treating physician seeks the opinion and/or treatment advice of a consulting physician or other health professional with specific expertise, and CMS noted that the current lack of reimbursement for these interactions often leads to the scheduling of an office visit for the patient even though the patient’s presence is not necessary and a telephone or internet consultation between health care professionals would be sufficient. CMS views its recognition of these services as part of the movement away from a strictly fee-for-service-based system and toward a more care management-based approach to providing quality care to beneficiaries with multiple complex conditions. CMS is requiring documentation of beneficiary consent to receive these services because they will be subject to coinsurance, and it will monitor use of the consultations and consider refinements in documentation and billing policies if warranted.

Remote patient monitoring (HCPCS codes 99453, 99454, and 99457)

Having already established payment for chronic care management services in 2016, which are non-face-to-face, in 2019 CMS will establish payment for three codes to report “Chronic Care Remote Physiologic Monitoring.” These include a code for the initial setup and patient education regarding use of remote monitoring of physiologic parameters such as weight, blood pressure, pulse oximetry, and respiratory flow rate, and another code that can be billed monthly for the costs associated with the supplies and transmission of data. A separate code can be reported for 20 minutes or more of a physician or other health care professional’s time on treatment management during the month, but this service cannot be provided by auxiliary personnel and billed “incident to” a professional’s service. CMS will be issuing further guidance on the specific kinds of technology and scope of services covered under these codes.

Medicare telehealth services (HCPCS codes G0513 and G0514)

In addition to the new types of services described above, CMS annually updates the list of approved Medicare telehealth services, and this year added two codes for reporting “prolonged preventive services.” These codes, which are similar to existing E/M codes, are for reporting preventive services that require direct patient contact beyond the typical service time.

1 CPT Copyright 2018 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.

Use of telehealth in treatment of substance use disorders

The physician fee schedule final rule also implements provisions in the recently passed Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which is focused on addressing the opioid crisis, expanding the use of telehealth for treatment of substance use. Effective July 1, 2019, the geographic restrictions applicable to most telehealth services will not apply to use of telehealth for the treatment of diagnosed substance use disorders or co-occurring mental health disorders. The patient’s home will also be an acceptable originating site, although no facility fee will be paid. Implementation of this SUPPORT for Patients and Communities Act provision was issued as an interim final rule with a 60-day comment period, and CMS solicits comments on this provision.

Medicare home health prospective payment system final rule

On October 31, CMS posted the HH PPS final rule, which will allow home health agencies to include the costs of remote patient monitoring as an allowable administrative cost (e.g., operating expense) on their cost report if the remote monitoring is used to assist in the care planning process. This will allow such expenses to be factored into the costs per visit. Commenters on the proposed rule suggested that CMS should take an even broader approach to telehealth and include payment for virtual visits. CMS declined to do so, but described the inclusion on the cost report of costs associated with remote patient monitoring as a necessary first step in determining whether the use of such technology improves outcomes for home health patients.  This suggests CMS may further expand payment for the use of telehealth in home health in the future.

Expanded coverage of telehealth by Medicare Advantage plans

In implementing the Bipartisan Budget Act of 2018, CMS also is proposing to allow Medicare Advantage (MA) plans to offer expanded coverage for “clinically appropriate additional telehealth benefits” beginning in plan year 2020. CMS would allow the plans to treat them as “basic benefits” for purposes of bid submission and payment, making it more likely that plans will offer them. Under the proposal, MA plans could offer Part B covered services as “additional telehealth benefits” outside the scope of services currently allowed under the Medicare telehealth benefit and not subject to the location restrictions applicable to telehealth services. To preserve beneficiary choice, any Part B service covered by plans as an “additional telehealth benefit” must also be available through an in-person visit and not only via telehealth. In addition, CMS is proposing to continue allowing plans to offer supplemental benefits (e.g., benefits not covered by original Medicare) via remote technologies or telemonitoring services that do not qualify as “additional telehealth benefits.”

CMS is not proposing to define which services are “clinically appropriate” to be offered as “additional telehealth benefits,” but would instead allow MA plans the flexibility to make that determination for themselves each year, consistent with professionally recognized standards of care. The MA plan would have to use contracted providers to provide these additional telehealth benefits and other MA regulations, including those regarding provider credentialing and selection would apply. Plans would be responsible for ensuring that the telehealth provider was in compliance with applicable licensing requirements and other state laws for the state in which the enrollee is located. CMS has solicited comments on its proposed approach and on the impact such telehealth providers should have on determinations of MA network adequacy.

Taken together, these recent changes by Congress and CMS indicate significant interest in making more health services available to Medicare beneficiaries via telehealth and similar technologies and to continue testing whether and when such services can be used to expand access to high-quality, cost-effective care, and to improve care coordination.

Appendix: Remote monitoring services payment rates

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The finalized Patient-Driven Groupings Model will transition home health agencies to more of a value-based payment system by 2020, CMS announced.

November 01, 2018 – CMS recently finalized a new value-based payment system for home health agencies that would move Medicare reimbursement away from the volume of therapy delivered.

Medicare will start to reimburse home health agencies under the Patient-Driven Groupings Model (PDGM) in the Home Health Prospective Payment System (HH PPS) by January 2020. The reimbursement model will pay the agencies based on patient characteristics rather than the number of therapy visits.

“The PDGM removes the current incentive to over-provide therapy, and instead, is designed to reflect CMS focus on relying more heavily on clinical characteristics and other patient information to allow payments to more closely reflect patients’ needs,” CMS stated in a fact sheet on the rule.

“Using patient characteristics to place home health periods of care into meaningful payment categories is more consistent with how home health clinicians differentiate between home health patients in order to provide needed services,” the federal agency continued. “The improved structure of this case-mix system would move Medicare towards a more value-based payment system that puts the unique care needs of the patient first while also reducing the administrative burden associated with the HH PPS.”

Shifting the Medicare reimbursement system to value-based payments will also save home health agencies (HHAs), CMS added.

“Changes in data collection under the new case-mix system, coupled with the changes below regarding meaningful measures and the Home Health Quality Reporting Program, will reduce burden for HHAs by approximately $60 million annually, beginning in CY 2020,” the fact sheet stated.

CMS will also update the home health reimbursement by paying for innovation.

The final rule on the 2019 HH PPS will also allow home health agencies to report the cost of remote patient monitoring as allowable costs on the Medicare cost report form.

“This is expected to help foster the adoption of emerging technologies by home health agencies and result in more effective care planning, as data are shared among patients, their caregivers and their providers,” CMS explained in the fact sheet. “The use of such technology can allow for greater patient independence and empowerment. Supporting patients in sharing their data will advance the MyHealthEData initiative, led by Jared Kushner and the White House Office of American Innovation.”

Other changes to the HHS PPS included in the final rule from CMS included:

• 2.2 percent, or $420 million, increase in home health Medicare reimbursement in CY 2019
• Implementation of temporary transitional payments for home infusion therapy services for CYs 2019 and 2020
• Establishment of health and safety standards for qualified home infusion therapy suppliers of the new permanent home infusion therapy service benefit
• Removal of the requirement that certified physicians estimate how much longer home health services are needed when recertifying the need for continued home health care
• Elimination of seven Home Health Quality Reporting Program measure

CMS pointed out that the removal of the recertification requirement should save physicians $14.2 million each year and allow providers to spend more time with patients rather than on paperwork.

The elimination of seven quality measures from the Home Health Quality Reporting Program should also reduce costs for home health agencies by $60 million annually starting in CY 2020.

“This home health final rule focuses on patient needs and not on the volume of care,” CMS Administrator Seema Verma stated in an official press release. “This rule also innovates and modernizes home health care by allowing remote patient monitoring. We are also proud to offer new home infusion therapy services.”

“Using new technology and reducing unnecessary reporting measures for certifying physicians will result in an annual cost savings and provide home health agencies (HHAs) and doctors what they need to give patients a personalized treatment plan that will result in better health outcomes,” she said.

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Despite industry concerns, the Centers for Medicare & Medicaid Services (CMS) has finalized the Patient-Driven Groupings Model (PDGM) planned to start in 2020. The agency has also finalized several other changes to how home health providers are reimbursed for their services starting in 2019, tweaking remote patient monitoring rules and refining the Value-Based Purchasing Model (VBPM).

CMS projects that Medicare payments to home health agencies in calendar year 2019 will be increased by 2.2% — or $420 million — based on its finalized policies, announced Wednesday.

The reimbursement rate increase is the first the home health industry has received in a decade — and slightly more than what CMS initially suggested in July’s proposed payment rule. The agency originally projected that home health payment changes would increase Medicare payments to home health agencies by $400 million.

Among its provisions, PDGM is designed to remove current incentives to over-provide therapy services by more strongly weighting clinical characteristics and other patient information, according to CMS. PDGM would also mean that the traditional 60-day unit of payment would be halved to 30 days.

PDGM — mandated to be budget neutral by the Bipartisan Budget Act of 2018 — takes into account certain behavioral changes that policymakers expect home health providers to make after the model is implemented. In particular, they include assumed changes to clinical and co-morbidity coding behavior, along with how Low Utilization Payment Adjustment (LUPA) claims are handled.

If no behavioral assumptions are made, CMS estimates that the 30-day payment amount needed to achieve budget neutrality would be $1,873.91. With the behavioral assumptions, that amount drops to $1,753.68 — a 6.42% decrease.

Home health stakeholders have widely criticized the behavioral assumptions, even teaming up with several members of Congress to get them changed or removed in PDGM via multiple pieces of legislation — S. 3545, S. 3458 and H.R. 6932.

“While we had hoped CMS would consider modifications outlined by the home health provider sector when finalizing this rule, this announcement reinforces the need for the industry to continue our advocacy to get the new home health payment system right,” LHC Group (Nasdaq: LHCG) CEO and Chairman of the Partnership for Quality Home Healthcare Keith Myers said in a statement. “We will continue to work collaboratively with CMS and lawmakers in Congress to refine this new payment system to ensure it is based on a data-driven approach and will support the delivery of uninterrupted, high quality home healthcare to older Americans.”

Although language for PDGM is included in CMS’ final home health payment rule for 2019, that does not mean the payment model is set in stone, Amedisys, Inc. (Nasdaq: AMED) CEO Paul Kusserow told investors during a conference call Tuesday. Stakeholders will likely have until Jan. 1 2020 to secure modifications on the model, he said.

The final rule’s implementation language differs than the proposal’s, Joy Cameron, vice president of policy and innovation for ElevatingHOME, told Home Health Care News via email. The proposed rule stated PDGM will be implemented on Jan. 1, 2020, while the final rule states “on or after” Jan. 1, 2020.

“Time to make sure we have it right and necessary vendors and CMS are fully online,” Cameron said.

The final rule’s PDGM language includes 216 more Home Health Resource Groups (HHRGs) than originally proposed because of a Medication Management Teaching and Assessment (MMTA) split, she said.

In addition to the rate increase and finalization of PDGM, the home health final rule also solidifies CMS’ proposal to define remote patient monitoring in regulation for the Medicare home health benefit and to include the cost of remote patient monitoring as an allowable cost on agencies cost reports.

“This home health final rule focuses on patient needs and not on the volume of care,” CMS Administrator Seema Verma said in a statement. “This rule also innovates and modernizes home health care by allowing remote patient monitoring.”

The Partnership for Quality Home Healthcare supports the final rule’s move to include costs associated with tele-monitoring. The Washington, D.C.-based organization also supports changes in the final rule aimed at better payment accuracy related to the MMTA clinical group.

The home health final rule also solidifies substantial changes to rural add-on payments, namely by categorizing counties and equivalent areas into one of three new buckets with varying add-on levels.

The full rule can be accessed here.

Written by Robert Holly

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CMS finalizes calendar year 2019 and 2020 payment and policy changes for Home Health Agencies and Home Infusion Therapy Suppliers

On October 26, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule [CMS-1689-F] setting out finalized Calendar Year (CY) 2019 Medicare payment updates, finalized quality reporting changes for home health agencies (HHAs), and finalized case-mix methodology refinements and a change in the home health unit of payment from 60 days to 30 days for CY 2020.  This final rule also discusses the implementation of temporary transitional payments for home infusion therapy services to begin on January 1, 2019 and summarizes public comments related to full implementation of the new home infusion therapy benefit in CY 2021.

The final rule includes policies that are based on three pillars: empowering patients, increasing competition, and fostering innovation.  The focus of the final rule is on patients and their needs, and not on increasing process for process sake. CMS continues a commitment to shift Medicare payments from volume to value, with continued implementation of the Home Health Value-Based Purchasing Model and the Home Health Quality Reporting Program, as well as a new case-mix adjustment methodology for the Home Health Prospective Payment System (HH PPS) that focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment. The final rule also modernizes Medicare through innovations in home health and the new home infusion therapy benefit, meaningful quality measure reporting, reduced paperwork, and reduced administrative costs.

The final rule can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection.

Payment Rate Changes under the HH PPS for CY 2019

CMS projects that Medicare payments to HHAs in CY 2019 will be increased by 2.2 percent, or $420 million, based on the finalized policies.  The increase reflects the effects of a 2.2 percent home health payment update percentage ($420 million increase); a 0.1 percent increase in payments due to decreasing the fixed-dollar-loss (FDL) ratio in order to pay no more than 2.5 percent of total payments as outlier payments (a $20 million increase); and a 0.1 percent decrease in payments due to the new rural add-on policy mandated by the Bipartisan Budget Act of 2018 for CY 2019 ($20 million decrease). The new rural add-on policy requires CMS to classify rural counties (and equivalent areas) into one of three categories based on: 1) high home health utilization; 2) low population density; and 3) all others.  Rural add-on payments for CYs 2019 through 2022 vary based on counties’ (or equivalent areas’) category classification.

Modernizing the HH PPS Case-mix Classification System and Promoting Patient-Driven Care

The Bipartisan Budget Act of 2018 requires a change in the unit of payment under the HH PPS, from 60-day episodes of care to 30-day periods of care, to be implemented in a budget neutral manner on January 1, 2020.  Also for 2020, the Bipartisan Budget Act of 2018 mandated that Medicare stop using the number of therapy visits provided to determine home health payment. Therapy thresholds encourage volume over value and do not acknowledge that all patients are not the same, with some patients having complex needs that do not involve a lot of therapy.  CMS is finalizing the implementation of these changes required by the Bipartisan Budget Act of 2018.

CMS is finalizing the implementation of the Patient-Driven Groupings Model, or PDGM, for home health periods of care beginning on or after January 1, 2020.  The PDGM removes the current incentive to overprovide therapy, and instead, is designed to reflect CMS focus on relying more heavily on clinical characteristics and other patient information to allow payments to more closely reflect patients’ needs. Using patient characteristics to place home health periods of care into meaningful payment categories is more consistent with how home health clinicians differentiate between home health patients in order to provide needed services. The improved structure of this case-mix system would move Medicare towards a more value-based payment system that puts the unique care needs of the patient first while also reducing the administrative burden associated with the HH PPS.

To support an assessment of the effects of the PDGM, CMS will provide, upon request, a Home Health Claims-OASIS Limited Data Set (LDS) file to accompany the CY 2019 HH PPS final rule.  The Home Health Claims-OASIS LDS file can be requested by following the instructions on the following CMS website:  https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/Data-Disclosures-Data-Agreements/DUA_-_NewLDS.html, and a file layout will be available.

Additionally, CMS will make available agency-level impacts, as well as an interactive Grouper Tool that will allow HHAs to determine case-mix weights for their patient populations. These materials are available on the HHA Center webpage at https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

Fostering Innovation

The Use of Remote Patient Monitoring under the Medicare Home Health Benefit

CMS is finalizing its proposal to define remote patient monitoring in regulation for the Medicare home health benefit and to include the cost of remote patient monitoring as an allowable cost on the HHA cost report. Studies note that remote patient monitoring has a positive impact on patients as it allows patients to share more live-time data with their providers and caregivers, which will lead to more tailored care and better health outcomes. CMS believes that defining remote patient monitoring and including such costs as allowable costs on the HHA cost report could encourage more HHAs to adopt the technology.

New Home Infusion Therapy Services Temporary Transitional Payment and Home Infusion Therapy Benefit

For CYs 2019 and 2020, as required by section 50401 of the Bipartisan Budget Act of 2018, CMS is implementing a temporary transitional payment for home infusion therapy services that pays eligible home infusion therapy suppliers for associated professional services for administering certain drugs and biologicals infused through a durable medical equipment pump, training and education, and remote monitoring and monitoring services.  Section 5012 of the 21^st Century Cures Act creates a new permanent Medicare benefit for home infusion therapy services beginning January 1, 2021.  This rule finalizes elements of the permanent home infusion benefit including the health and safety standards for home infusion therapy, an accreditation process for qualified home infusion therapy suppliers and an approval and oversight process for the organizations that accredit qualified home infusion therapy suppliers.  Additionally, we recognize the concerns from stakeholders and members of Congress on our interpretation of “infusion drug administration calendar day”, including with respect to professional services that may be provided outside of the home and, as applicable, payment amounts for such services.  It is our intention to ensure access to home infusion therapy services in accordance with section 50401 of the BBA of 2018.  Therefore, we believe the best course of action is to monitor the effects on access to care of finalizing this definition and, if warranted and within the limits of our statutory authority, engage in additional rulemaking or guidance regarding this definition for temporary transitional payments. We seek comments on this interpretation and on its potential effects on access to care.

Home Health Quality Reporting Program (HH QRP) Provisions

In furtherance of the Meaningful Measures Initiative and to further align with the policies of other CMS quality programs, CMS is finalizing its policy for removing previously adopted HH QRP measures based on eight measure removal factors.  CMS is also finalizing the removal of seven quality measures based upon one of these eight finalized measure removal factors.  Lastly, CMS is finalizing an update to its regulations to clarify that not all OASIS data is used to determine whether an HHA has satisfied the HH QRP reporting requirements for a program year.

Home Health Value-Based Purchasing Model

In addition to providing an update on the progress towards developing public reporting of performance under the Home Health Value-Based Purchasing (HHVBP) Model, CMS is finalizing the following changes to the HHVBP Model, beginning with Performance Year 4:  removal of two Outcome and Assessment Information Set (OASIS)-based measures, Influenza Immunization Received for Current Flu Season and Pneumococcal Polysaccharide Vaccine Ever Received, from the set of applicable measures; replacement of three OASIS-based measures with two new composite measures on total change in self-care and mobility; changes to how we calculate the Total Performance Scores by changing the weighting methodology for the OASIS-based, claims-based, and HHCAHPS measures; and a change to the scoring methodology by reducing the maximum amount of improvement points and HHA can earn.

Regulatory Burden Reduction

The cost impact related to OASIS item collection as a result of the implementation of the PDGM and finalized changes to the HH QRP as outlined above, is estimated to be a net $60 million in annualized cost savings for home health agencies.

In an effort to make improvements to the health care delivery system and to reduce unnecessary burdens for physicians, CMS is eliminating the requirement that the certifying physician estimate how much longer skilled services are required when recertifying the need for continued home health care. This policy is responsive to industry concerns about regulatory burden reduction and could reduce claims denials that solely result from an estimation missing from the recertification statement.  CMS estimates that this would result in annualized cost savings to certifying physicians of $14.2 million beginning in CY 2019.

CMS is also finalizing amendments to current regulations to align them with current sub-regulatory guidance to allow medical record documentation from the HHA to be used to support the basis for certification and/or recertification of home health eligibility, consistent with the Bipartisan Budget Act of 2018.

These burden reduction efforts would allow providers to spend more time on their chief responsibility: improving the health outcomes of their patients.

Advancing MyHealthEData: Request for Information from stakeholders

Through a Request for Information in the CY 2019 HH PPS proposed rule, CMS gathered stakeholder feedback on revising the CMS patient health and safety standards that are required for providers and suppliers participating in the Medicare and Medicaid programs to further advance electronic exchange of information that supports safe, effective transitions of care between hospitals and community providers.  CMS will carefully consider all comments received in developing future regulatory proposals or future sub-regulatory guidance.

For additional information about the Home Health Value-Based Purchasing Model, visit https://innovation.cms.gov/initiatives/home-health-value-based-purchasing-model.

For additional information about the Home Health Prospective Payment System, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/index.html.

For additional information about the Home Health Quality Reporting Program, visit https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-Requirements.html 

The final rule can be viewed at https://www.federalregister.gov/public-inspection.

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