New G codes proposed for telehealth, but no pay

As Medicare looks to begin tracking the number of telehealth visits by discipline without offering any reimbursement to home health providers, SimiTree consultants say providers need to find other value in virtual visits.

Savvy providers can see a return on investment in terms of greater patient engagement and satisfaction, reduced risks for rehospitalization, and staffing flexibility that helps address retention issues.

"Although CMS wants reporting to begin in 2023, it looks as if it could be another few years before agencies see any actual payment for the visits being tracked,” said SimiTree Managing Director Laura Wilson, Clinical Operations Consulting. Wilson works with agencies to develop robust and compliant telehealth programs as part of organizational structuring and workflow.

Required reporting in 2023

In its 2023 proposed payment rule for home health, The Centers for Medicare and Medicaid Services (CMS) outlined a phased-in approach requiring agencies to begin reporting all telehealth visits and which discipline made the visits.

If approved in the final rule this fall, CMS will begin collecting telehealth information Jan. 1, 2023. Reporting would become mandatory six months later in July.

Agencies would report telehealth services in line-item detail, with revenue codes to differentiate disciplines such as physical therapy, occupational therapy, speech language pathology, skilled nursing medical social services or home health aide.

CMS has said it will issue new codes and program instructions with sufficient notice to enable agencies to make necessary changes in their electronic health records and billing systems.

“But CMS made it clear that even though it wants to track telehealth service delivery, it does not view virtual visits as visits for purposes of eligibility or payment,” Wilson said.

Data collected will not be used or factored into case mix weights or count toward outlier payments or the LUA threshold per payment period, she said.

However, CMS does allow agencies to report administrative costs associated with telehealth as part of Medicare cost reporting, and SimiTree consultants encourage providers to do so carefully and accurately. Telehealth information on cost reports will be used to determine future reimbursement amounts for virtual visits, they say.

Timeframe for billing

Plans to begin tracking telehealth services with differentiating revenue codes may be the first step toward providing reimbursement for telehealth services, but SimiTree consultants caution that due to the collection and evaluation process, it will likely be two or more years before billing is allowed.

CMS will almost certainly want to review and evaluate a full year’s worth of data once mandatory reporting begins in 2023, and possibly more than one year, SimiTree Cost Reporting Director Mike Simione said.

“Realistically, that means at the very earliest we might see a proposal to allow reimbursement in 2025,” Simione said.

How much differentiation?

The level of detail required for telehealth reporting was not specified in the proposed rule, with CMS saying it would rely on public input to make decisions such as whether G codes should be refined to differentiate between a therapist or a therapist assistant.

CMS is also reviewing comments about the level of detail which should be required for differentiating the types of service being performed.

“For example, should skilled nursing services that are performed for care plan oversight be broken down into management and evaluation or observation and assessment versus teaching?” Wilson asked. “For physical therapy, should there be a differentiation between maintenance therapy and other types of restorative PT services?”

The future is virtual

New G codes proposed for home health are one of many ways CMS is signaling its intent to embrace telehealth more fully across the post-acute care spectrum, including some rule relaxation as it grapples with ongoing healthcare staffing shortages.

Other proposed rules this summer have also demonstrated the intent to expand telehealth usage and loosen the rules governing it. In a proposed rule for the 2023 Physician Fee Schedule, for example, CMS proposes to pay for the initiation of buprenorphine (which treats opioid use disorder) via telehealth instead of in person.

Current telehealth flexibilities enacted during the COVID 19 Public Health Emergency are expected to remain in place even after the PHE ends, with legislation currently before Congress to separate waivers and flexibilities from the PHE that created them.

The Advancing Telehealth 3 Beyond COVID-19 Act of 2022 would allow telehealth waivers to remain in effect at least through Dec. 21, 2024, even if the PHE ends before that.

The value in virtual

SimiTree consultants say home health agency leaders need to reevaluate how they view their unpaid telehealth services, recognizing the full value in virtual visits.

“From better patient outcomes to star ratings, the value to the agency is definitely there, even though they can’t actually bill for virtual visits,” Wilson said.

“Agencies need to focus on that value, concentrating on developing strong telehealth programs that improve disease self-management for patients and lower hospital admission rates, and deliver more value in the eyes of referral sources.”

She and other SimiTree consultants also recommend allowing clinicians to work from home at least one day per week, having virtual visits with patients.

“What a great way to offer more flexibility to staff, save on fuel costs and increase patient engagement at the same time,” Wilson said.

All telehealth services provided must be ordered as part of the plan of care certified by a physician, Wilson said. Documentation in the POC must describe how the use of the technology is tied to patient-specific needs which have been identified in the comprehensive assessment and will help achieve the goals outlined on the plan of care.

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SimiTree works with agencies to create effective telehealth programs, determine ROI, set up organizational structure, processes and workflow, and strengthen clinical operations for peak performance. Use the form below to reach out to us today to ask how we can help your organization operate more efficiently.

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