Federal Government Expands Medicare FFS Telehealth Services for Stroke, ESRD and Substance Use Disorder Services

The New Year is off to a good start for those involved in telehealth as changes to the Medicare Fee-For-Service program will bring expanded services to beneficiaries needing care related to stroke, End Stage Renal Disease (ESRD) and substance use disorder (SUD) and co-occurring mental health disorders.

The U.S. Department of Health and Human Services (DHHS) Center for Medicare and Medicaid Services (CMS) is in the process of modernizing the use of telehealth for both Medicare Fee-For Service (FFS) and Medicare Advantage (MA). The agency is focused on removing or reducing restrictions on what qualifies for reimbursement with the understanding telehealth can improve access and address disparities in a cost-efficient manner.   Through CMS’ recent activities, it is clear that the agency perspective on telemedicine programs is evolving by making these services more available to Medicare beneficiaries.

As part of this move, CMS included a number of proposed, interim and final rules in the CY 2019 Physician Fee Schedule notice published November 23, 2018. Among the changes now finalized and effective January 1, 2019, are an expansion of telehealth services for stroke and End Stage Renal Disease (ESRD). By adding to approved originating sites (where the patient is located and where they receive care) and lifting the application of geographic requirements – previously, rural areas – telehealth services will now be reimbursed and provided to a much broader group of Medicare FFS beneficiaries.

In addition, CMS issued an interim final rule which will expand the availability of telehealth services to those with a substance use disorder as required by the SUPPORT for Patients and Communities Act with changes effective July 1, 2019.

Evidence-based research shows that telehealth has played a major role in expanding access for stroke care and behavioral health care including SUD. In fact, a recent CMS report revealed the highest telehealth utilization among Medicare FFS beneficiaries was for those with a mental health diagnosis including SUD. For a summary of other CMS changes, see CHQI blogs here and here.

Telestroke Services

As required by the Bipartisan Budget Act of 2018, geographic restrictions and limits on originating sites are eliminated for telestroke and ESRD. This means telestroke services – diagnosis, evaluation or treatment – of acute strokes may now be delivered and reimbursed within urban areas. Mobile stroke units also now also qualify as an originating site along with any hospital or critical access hospital or any other site the Secretary of DHHS deems appropriate without regard to any geographic limits.

CMS proposes to create a new modifier to the HCPCS code to identify acute stroke services when delivered through telehealth. ­e practitioner and originating site (where appropriate) for billing or the originating site facility fee. The facility fee will continue to only be available to sites that meet the standard telehealth services criteria.

ESRD Services

ESRD patients who receive home dialysis will be able to have their monthly clinical assessment appointment via telehealth while they are at home or a renal dialysis facility. These newly approved originating sites will not have any geographic restrictions applied under the final CMS rule. Geographic limits will no longer apply to previously approved originating sites: hospital-based services or critical access hospital-based renal dialysis centers. An originating site fee will not be paid when the beneficiary is at home.

Some in-person visits will be required for ESRD patients: for the first three months of home dialysis, an individual must have a monthly face-to-face visit – without the use of telehealth – and an in-person visit at least once every 3 months, consecutively, after the initial 3 months.

Substance Use Disorder Treatment

Under an interim final rule published November 23, 2018 (in the CY 2019 Physician Fee Schedule Notice) with a 60-day comment period, CMS would add the patient’s home to the list of approved originating sites and lift geographic restrictions on originating sites. The first change applies only to those beneficiaries being treated for substance use disorders or a co-occurring mental health disorder.

While these may not seem like sweeping changes that will result in accelerated telehealth utilization as in the commercial sector, the new policies actually represent a dramatic departure from what telehealth services previously qualified for reimbursement under Medicare FFS. As some commercial payers still follow Medicare’s lead, this modernization will make a difference. Under Medicare FFS, providers will now be able to reach more patients across all demographics for key conditions.

Additional Medicare Telehealth Coverage

In the near future, CHQI will discuss the proposed rules published on November 1, 2018 (comments were due December 31, 2018) that apply to telehealth and Medicare Advantage (MA) plans. Among other proposed changes, plans would be able to offer clinically-appropriate telehealth services not currently available to Medicare beneficiaries.

To learn more about CHQI’s accreditation program and on-going telehealth standards development activities,  please visit us at www.chqi.com or call us at (410) 756-1300.


Leave a Reply

Your email address will not be published. Required fields are marked *