By Sarianne Gruber
On October 31, 2014, the Centers for Medicare and Medicaid Services (CMS) released the Final Rule for the 2015 Physician Fee Schedule, the annual 1,100 page list of what the Federal Government pays physicians for Medicare patient visits and services. Let’s take a closer look at the changes and what they may mean for clinicians interested in using telehealth and digital health technology in their day-to-day practice. And thank you, Donna, for providing us with comprehensive and applicable information on the submitted questions.
What patients are eligible for telehealth as part of the Chronic Care Management program under the 2015 Rule?
First, let’s establish the context for telehealth services. At its most basic, telehealth is remote asynchronous (not real time) monitoring of patient physiologic data. It is part of data collection serving the complete Chronic Care Management of the patient. In other words, telehealth services are part of the Chronic Care Management program established under the Final Rule for Medicare FFS (fee-for-service) patients. Let’s first look at what patients qualify for CCM.
Patients qualifying for Medicare reimbursement have to receive Medicare FFS, also known as Original Medicare. They cannot be in existing CMS programs such as CPCI (Comprehensive Primary Care Initiative) or similar grant programs which provide reimbursement for chronic care services. Other requirements are:
- Having multiple (2+) chronic conditions. CMS does not list qualifying chronic conditions in the Final Rule, but CMS has a list of 27 as part of their research website, the Chronic Condition Data Warehouse.
- The chronic conditions have to last at least 12 months or until death–permanent. This eliminates short term disease.
- There has to be present high risk of functional decline, acute exacerbation/decompensation of condition or death, if they are not in a CCM program.
- The practice has to integrate the comprehensive care plan and patient consent in a certified EHR (to 2011 or 2014 criteria)
CMS created a new CPT (current procedural terminology) evaluation and management (E&M) code, 99490, for CCM. The payment is an average of $42 per patient per calendar month.
What are some of the requirements for CCM services for the patient?
CMS requirements are rigorous around establishing, coordinating and managing a comprehensive care plan for the patient, and need to be built step by step in a practice. This can only be a topline summary.
A face-to-face patient visit always comes first. This can be an annual wellness visit, a comprehensive E&M visit or initial preventative physical exam (IPPE). This assists in identifying the patient as eligible for CCM, but there are other practice tools available and of course, the practice staff’s judgment.
The practice then provides a comprehensive care plan to the patient. The patient must give consent to the care plan, provide a written or electronic copy of the plan, and document both patient consent and the plan in the EHR. Many practices that are enrolling patients in CCM are providing ‘welcome kits’ that include a copy of their care plan and explain how they coordinate care with the patient.
Typically included in the care plan, available 24/7 to all care team members furnishing CCM services, are:
- Problem list; expected outcomes and prognosis; measurable treatment goals
- Symptom management and preventative care services
- Community and social services that may be accessed
- Plan for care coordination with other providers
- Medication management
- Responsible individual for each intervention
- Requirements for periodic review and revision
How can telehealth services fit into a CCM care plan?
Where telehealth—not only vital signs physiologic monitoring, but also qualitative information gathering and patient education that most telehealth systems now include—integrates well is in the 20 minute minimum of time spent in non-face-to-face care. This can be performed by licensed clinical staff subject to the general supervision of a physician or even a third party with access to the care plan. The time spent by staff individually reviewing remotely monitored data and speaking to the patient is what Medicare counts as eligible for reimbursement, not the time that the patient spends under monitoring. Beyond furnishing physiologic data, telehealth can also play a vital part in the total provision of CCM in other ways:
- Asking questions, providing education and patient self-management skill building according to disease management protocols (DMPs)
- 24/7 patient access to care management services–patients can use telehealth hubs for secure messaging and sending their vital data to providers
- Ongoing assessment of medical, functional and psychosocial needs that may not be readily apparent on the face-to-face visit
- Notification and recording of preventative services through telehealth scheduling functions–e.g. appointment scheduling, which also improve patient access
- Medication scheduling, reminders to take medication, reconciliation and review–alerts for refilling medication
- Care plan documentation through telehealth platform reporting
- Documentation of need for adjustments in care
- Easy sharing of care plan and patient information with other providers, without going through an EHR. Many telehealth platforms also integrate with EHRs.
It should be noted that virtual audio and video doctor-patient consults, a/k/a telemedicine, being synchronous, are not included in CCM reimbursement.
What’s important for practices, doctors and providers to understand is that once the care team of clinical staff, or a third party provider is contracted, that CCM including telehealth monitoring can be a great plus for the practice in improving wellness of patients, longer term outcomes and their own quality scores. What is critical is the ability to identify those eligible, gain their consent and create care plans. Those don’t appear to be a problem. What is reportedly daunting to many practices is to ensure that the care team follows all the steps, documents care, tracks time spent on all care and knows if the time per month- the 20 minute minimum- has been filled and in fact, how much time is actually being spent with patients and why. There is also a requirement that only one practitioner can be paid per month.
About Donna Cusano
Donna Cusano is a strategic marketer, consultant and writer/editor who has been part of the world of digital health and healthcare since 2006. As a marketer, she has headed marketing and provided independent advisory services on marketing and communications strategy + programs for several early-stage companies pioneering in telehealth and telecare (behavioral/activity monitoring for care). Since 2009, Donna has also observed digital health developments and the healtherati from an editorial perspective, as New York-based Editor in Chief of Telehealth & Telecare Aware, the only internationally-focused independent professional review of healthcare technology news and issues. LinkedIn profile