By Diane Millman and Rebecca Burke

Executive Summary.  Over the past several years, expansions in coverage of non-face-to-face services (especially various types of care management and remote physiological monitoring services(RPM)), has created a new opportunity for ALFs to partner with area hospitals, physicians, and non-physician practitioners to provided needed health care services to residents.  Coverage of care management and RPM has expanded during the COVID-19 Public Health Emergency and coverage is, and will remain, available throughout the country to Medicare patients in their homes.  Assisted Living Facilities are well positioned to partner with area hospitals, physician groups, and non-physician practitioners to facilitate provision of these services

COVID-19 has placed a bright spotlight on the role of Assisted Living Facilities (ALFs) in ensuring the safety of residents.  The pandemic has assuredly magnified and multiplied the issues faced by ALFs throughout the country in fulfilling this obligation.  Less attention has been paid to the to the opportunities posed by recent expansions in Medicare coverage for care management and physiological monitoring services for those ALFs willing to play an active role in providing care to their residents as part of the health care continuum.

Significantly, while some of these coverage expansions are likely to sunset once the Public Health Emergency (PHE) expires, many of the expansions of greatest potential importance to ALFs may extend beyond the PHE, possibly justifying longer term investment in the necessary technology and expertise. And since essentially all of the newly covered remote services must be provided in conjunction with physicians or other practitioners, an ALF that chooses to play an active role in the provision of these services necessarily must do so in partnership with other area providers—partnerships that may strengthen ties with referral sources and lead to other ancillary benefits.

The availability of services through a broader range of more accessible communication technologies was made possible by the Department of Health and Human Services Office of Civil Rights, which, at the beginning of the crisis, issued a “Notification of Enforcement Discretion” under which a provider that wants to use audio or video communication technology to provide telehealth to patients during the COVID-19 public health emergency generally can use any “non-public facing” remote communication product that is available to communicate with patients, without fear of incurring penalties for violation of the Health Insurance Portability and Accountability Act (HIPAA). This effectively paved the way for the use of everyday communications technologies for the provision of health care services, including the transmittal of protected health information, without fear of penalty. The Notification of Enforcement Discretion includes all services that a provider believes can be provided through telehealth in the circumstances of the emergency, including diagnosis or treatment of COVID-19 related conditions, taking a patient’s temperature or other vitals remotely, and diagnosis or treatment of non-COVID-19 related conditions, such as review of physical therapy practices, mental health counseling, or adjustment of prescriptions, among many others. Under this Notice, a provider may use popular applications that allow for video chats, including Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype, to provide telehealth without risk of HIPAA penalties.

Meanwhile, Medicare has not only expanded access to traditional “telehealth” services—which typically substitute for remote professional services for services that otherwise would be provided in person—but also has established coverage for other types of services that may be provided remotely.. For example, Medicare coverage of care management and remote physiological monitoring services is a relatively new phenomenon, having emerged over the past several years and having morphed considerably as the result of the COVID pandemic.  Both types of service are reimbursed under the Medicare Physician Fee Schedule and under the Hospital Outpatient Prospective Payment System, but with some limitations. Medicare Advantage Plans are required to cover the same services covered by Medicare Fee-for-Service, although they may impose their own prior authorization or other restrictions, and other third party payer policies vary based on the payer involved.  These two types of remote services—remote physiological monitoring and care management services—provide considerable opportunity for ALFs to enter into arrangements with area physicians and hospitals to improve the quality of care for residents,

Remote Physiological Monitoring (RPM)

RPM involves the collection and analysis of patient physiologic data that are used to

develop and manage a treatment plan related to a chronic and/or acute health illness or condition. The services involved are described in three CPT codes:

  • CPT code 99453 (Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment). This code is valued to reflect clinical staff time that includes instructing a patient and/or caregiver about using one or more medical devices.
  • CPT code 99454 (Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days). This code is valued to include the medical device or devices supplied to the patient and the programming of the medical device for repeated monitoring.
  • CPT code 99457 (Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes) and its add-on code, CPT code 99458 (Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; each additional 20 minutes) describe the treatment and management services associated with RPM. Like other care management services, CPT codes 99457 and 99458 can be furnished by clinical staff under the general supervision of the physician or NPP.  On-site supervision of clinical staff is not required, and a broad range of personnel may qualify as “clinical staff”, so long as the services they provide are within the scope of applicable state licensure laws..

These codes can only be ordered and billed by physicians and non-physician practitioners (NPPs) that are eligible to bill Medicare independently (such as Nurse Practitioners, Physician Assistants, and Certified Nurse Specialists).  However, CMS recognizes that physicians, NPPs, and hospitals may enter into contracts with third parties to provide certain elements of these services. While care must be taken to structure such arrangements in a manner that complies with federal and state fraud and abuse, self-referral, and other regulatory requirements, there is no provision of the applicable Medicare rules that would preclude an ALF from contracting with area practices or hospitals to provide any or all of these services to the practice’s or the hospital’s patients.

The Proposed 2021 Physician Fee Schedule and Hospital Outpatient Prospective Payment System (HOPPS) allowances for these services are:

Code PFS Rate OPPS Rate
99453(set up) $18.77 $120
99454 (monitoring) $62.44 $38 (and bundled if billed with 99453
99457(RPM management) $61.81 N/A
99458 (RPM management, add-on) $42.22 N/A

Care Management

In recent years, CMS has recognized and provided payment for a wide range of care management services, the main elements of which may be provided remotely.   Because these services are not technically considered “telehealth” services, they have not been subject to statutory restrictions on telehealth—restrictions that, pre-COVID, limited the availability of “telehealth” services to patients in the home and outside of rural areas.

CMS has adopted a number of specialized care management services, including for example, care management services for mental health conditions, opioid -related conditions, and smoking cessation.  The care management services of greatest  interest to ALFs, however, are likely to be more general, including for example, Transitional Care Management (TCM) (CPT codes 99495, 99496), Chronic Care Management (CCM) (CPT odes 99487,99489, 99490) and Principal Care Management (PCM) (HCPCS codes G2064, G2065).

Transitional care management (TCM) includes services provided to a patient with medical and/or psychosocial problems requiring moderate or high-complexity medical decision making who transitions from, among other things, an inpatient acute care hospital or skilled nursing facility. The TCM CPT codes provide payment for a broad range of services provided during a 30 day  post-discharge period. While these services must be billed by a physician or qualified NPP, the TCM services may include non-face-to-face services provided by other types of clinical staff under the direction of the physician or other qualified health care professional, such as communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge; communication with community services utilized by the patient, patient and/or family/caretaker education to support self-management, independent living, and activities of daily living; assessment and support for treatment regimen adherence and medication management, and facilitating access to care and services needed by the patient and/or family.  An ALF may enter into an arrangement to provide these types of services to a physician, physician group,or NPP who may be incentivized to provide TCM services in lieu of other evaluation and management services by the higher payment rates associated with TCM.  In addition, area hospitals may be interested in partnering with ALFs under arrangements that utilize hospital-employed physicians or NPPs in conjunction with other clinical staff provided by the ALF to provide TCM services, in order to reduce post-discharge readmissions that may result in significant financial penalties to the hospital  under Medicare’s Hospital Readmission Reduction Program.

The role of ALF staff may be even more crucial to the provision of Chronic Care Management (CCM) and PCM services.  CCM activities include those that support comprehensive care management for patients outside of the office setting. Services include interactions with patients by telephone or secure email to review medical records and test results or provide self-management education and support. Services also include interactions with the patient’s other healthcare providers to exchange health information, as well as management of care transitions and coordination of home- and community-based services. CCM requires that patients have 24/7 access to physicians or other qualified healthcare professionals or clinical staff to address urgent needs.

The two principal codes used to report chronic care management services are CPT 99487 (complex CCM) and CPT 99490 (CCM) and beginning in 2021, there will be a new CPT Code 99439 which will function as an add-on code to 99490 for each additional 20 minutes.  Again, these codes can be billed only by physicians and NPPs that are otherwise authorized to bill the Medicare program; however, these CCM codes each require different time expenditures by other clinical staff –clinical staff that  ALFs may be in a position to provide. In addition, ALFs, either alone or in connection with co-located SNFs, may be able to provide the 24/7 access to a health care professional that is required for physicians, NPPs, and hospitals to bill for CCM.    Please note, too, that while CCM historically has been reportable only for patients with two or more chronic conditions, CMS has recently made it clear that, at least for the duration of the Public Health Emergency  and potentially beyond, CCM may be billable for acute conditions, such as COVID-19.

Similar code(s) for principal care management (HCPCS codes G2064, G2065) are reportable  for a patient who has a diagnosis expected to last between three months and a year (or until the death of the patient), may have led to a recent hospitalization, and/or place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.   ALFs may serve a critical role in facilitating the billing of these services by physicians, other NPPs, and hospitals that employ physicians and NPPs.

Other Telehealth Services

Finally, CMS has significantly expanded the extent to which physicians and certain other practitioners are authorized to bill for services provided remotely in lieu of in-person services.  At least so long as the PHE lasts, these services can be reported for a wide range of audio-visual and audio-only technologies (including telephones), and regardless of the geographic location of the patient.  Some larger ALFs or entities that operate numerous ALFs may wish to consider providing residents with remote access to independent physicians or NPPs functioning as independent contractors, although care must be taken to ensure that any such services do not interfere with established resident-physician relationships.

In summary, recent expansions of Medicare coverage of various categories of remote services have the potential to substantially increase ALF resident access to medically necessary health care services, without leaving the facility.  This expansion also has the potential to place ALFs in a position to serve a critical role in the provision of these services and to forge new links with other area providers to reduce readmissions and coordinate care.

*Diane Millman (Diane.Millman@PowersLaw.com) and Rebecca Burke (Rebecca.Burke@PowersLaw.com/ ) are attorneys with the Washington DC law firm, Powers, Pyles, Sutter & Verville, 1501 M. Street, NW Washington DC (https://www.powerslaw.com/ ).

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