Augment Therapy Issues Public Comment on Centers for Medicare & Medicaid Services Proposed Rule
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I am the Co-Founder and CEO of
Augment Therapy provides a videogame-based augmented reality telehealth and remote monitoring software platform for use in pediatric physical therapy. Our interactive solution augments traditional pediatric physical and occupational therapy through the use of engaging games and challenges both in the therapist's office and at the patient's home. Therapists use our software to conduct telehealth visits with patients, keep patients engaged in their treatment plan between visits, and to track patients' adherence and progress over time by recording and transmitting step count, repetitions, and other metrics during exercise. Patients and therapists who use Augment Therapy often see better patient engagement and adherence as well as potential long-term improvement in patient mobility.
Although Augment Therapy's main patient base is made up of pediatric patients that may or may not be Medicare beneficiaries, we understand the immense impact the Medicare Physician Fee Schedule can have on reimbursement policies of commercial payors, Medicaid programs, and other health insurance programs that directly affect our pediatric users. For this reason, we believe the changes we request below will both provide access to beneficial treatments for Medicare beneficiaries and set an important example for state Medicaid programs and other insurance payors to follow suit. Augment Therapy's comments to the Proposed Rule are detailed below.
Summary of
In this comment letter, Augment Therapy will provide supporting argument for each of the following key points:
* We urge CMS to extend its efforts beyond the end of the PHE to allow Physical Therapists, Occupational Therapists, and Speech Language Pathologists to deliver covered services via telehealth to the extent of their authority and to support legislation that would allow permanent access to covered telehealth services for PTs, OTs, and SLPs.
* Physical and Occupational Therapy services codes (CPT codes 97161- 97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507) should be added to the Medicare "Covered Telehealth Services" list on a permanent basis.
* PTs, OTs, and SLPs should be eligible to order, bill, and receive reimbursement for RPM services.
* The 20-minute time requirement for CPT Codes 99457 and 99458 should not be limited to include only "interactive communication" with the patient.
* 16-day requirement should be measured by enrollment rather than number of data readings to allow providers professional discretion as to the amount and type of data that is medically necessary.
Section II.D.--Telehealth and Other Services Involving Communications Technology
a. We urge CMS to extend its efforts beyond the end of the PHE to allow Physical Therapists, Occupational Therapists, and Speech Language Pathologists to deliver covered services via telehealth to the extent of their authority and to support legislation that would allow permanent access to covered telehealth services for PTs, OTs, and SLPs.
We understand that under Section 1834(m) of the Social Security Act, physical therapists ("PTs"), occupational therapists ("OTs"), and speech language pathologists ("SLPs") are not included as provider types eligible to provide telehealth services as covered services under Medicare. This restriction severely limits patients' access to services that they would otherwise benefit from, such as virtual physical therapy services that augment in-person care. This is particularly problematic given that patients in need of physical, speech and occupational therapy services are often older, homebound, and/or disabled patients with various comorbidities, many of which do not live within close enough proximity to a clinic to receive services. By offering no telehealth reimbursement to these providers, they will be forced to return to offering only in-person care options or requiring patients that can afford it to pay out of pocket for virtual services, once again restricting access to care to only those who live close enough to a clinic or are affluent enough to afford virtual care. Providing reimbursement to PTs, OTs, and SLPs for therapy services via telehealth will expand this limited access beyond the walls of proximity and/or socioeconomic status so that all patients can receive the care they deserve.
In recognition of the fact that healthcare providers are "developing new approaches to providing care using . . .technology",/1 during the COVID-19 Public Health Emergency (the "PHE") CMS has waived the 1834(m) limitation on provider types to allow for PTs, OTs, and SLPs to furnish covered services via telehealth. This expansion has improved access to care and engagement among patients throughout the COVID-19 pandemic, and as such we applaud CMS for making these important changes during the PHE. Many state Medicaid programs and commercial payors have followed CMS' example and expanded the provider types eligible to deliver telehealth services to include physical therapists as well, which has similarly improved access and engagement among pediatric and other patients. For example, pediatric therapy providers have documented improved patient attendance rates for telehealth sessions versus in-person sessions now that they are able to offer them. When therapists cannot provide covered telehealth services, pediatric patients and patients with multiple comorbidities often have higher cancellation and no show rates primarily due to parents not being able to secure time off from work to drive to a clinic. These interruptions or lapses in care are particularly problematic for pediatric populations as they often result in regressions and difficulty recouping. Through telehealth and RPM options available during the PHE, these patients are receiving care without interruption and providers are now able to deliver new, more beneficial treatment paradigms. Finally, therapists are widely noting higher patient and parental satisfaction with these new remote options than they were for in-person options prior to the PHE.
Unfortunately, CMS noted in the Proposed Rule that the waiver allowing for PTs, OTs, and SLPs will expire at the conclusion of the PHE,/2 and we fear that state Medicaid and commercial payors will follow suit, thereby cutting off access to services providers and patients have become accustomed to relying upon. To combat this potential loss to the healthcare system, the
To ensure that Medicare beneficiaries have continued access to virtual physical therapy services, we urge CMS to do the same.
While we understand that permanent changes to the Social Security Act to allow for PTs, OTs, and SLPs to deliver covered Medicare services via telehealth would require legislative changes that are outside of CMS' purview, we believe that CMS' voice is important and impactful in encouraging congress to make those necessary changes. We commend CMS' recognition and support of virtual PT services throughout the duration of the PHE. We urge CMS to extend those efforts beyond the end of the PHE and continue to allow PTs, OTs, and SLPs to deliver covered services via telehealth to the extent of their authority and to support legislation that would allow permanent access to covered telehealth services for PTs, OTs, and SLPs.
b. Physical and Occupational Therapy services codes (CPT codes 97161- 97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507) should be added to the Medicare "Covered Telehealth Services" list on a permanent basis.
To further improve patient access to therapy services during the PHE, CMS temporarily added Physical and Occupational Therapy services codes (CPT codes 97161- 97168; CPT codes 97110, 97112, 97116, 97535, 97750, 97755, 97760, 97761, 92521- 92524, 92507)(the "PT Codes") to the Medicare "Covered Telehealth Services" list (the "Telehealth List") to allow for these services to be reimbursed via telehealth during the PHE. This was an important parallel expansion to implement alongside the allowance for PTs, OTs, and SLPs to provide telehealth services to ensure that those providers were able to continue delivering essential services to patients during the PHE. In a short amount of time, allowing for these services to be delivered virtually has spurred innovation, improved patient engagement, and helped to protect a high-risk population from COVID-19.
On pages 103-104 of the Proposed Rule, CMS stated that the PT Codes will be removed from the Telehealth List following the COVID-19 PHE because the services represented by the codes are predominantly furnished by PTs, OTs, and SLPs who are not eligible under the Social Security Act to render services via telehealth. CMS is concerned that keeping the PT Codes on the Telehealth List will cause confusion about who is authorized to furnish the services. However, CMS is soliciting comment on whether it is appropriate to add the PT Codes to the Telehealth List on a permanent basis to allow for eligible practitioners to bill and receive payment for the services represented by the codes. Importantly, CMS also clarified on page 104 of the Proposed Rule that if the PT Codes were added to the Telehealth List, the services could be furnished by a PT or OT "incident to" a billing practitioner.
We believe that legislative changes allowing for PTs, OTs, and SLPs to furnish and receive payment for telehealth services are imminent. On
Additionally, legislation has already been introduced at the federal level that, if passed, would remove certain restrictions that apply to telehealth outside of the PHE/5 and we expect to see broader proposals as the end of the PHE approaches. In anticipation of these imminent changes, we believe that the PT Codes should be added to the Telehealth List on a permanent basis.
Section II.E. - Care Management Services and Remote Physiologic Monitoring Services
a. PTs, OTs, and SLPs should be eligible to order, bill, and receive reimbursement for RPM services.
On page 133 of the Proposed Rule, CMS stated that CPT codes 99453, 99454, 99091, 99457, and 99458 (the "RPM Codes") "can be ordered and billed only by physicians or nonphysician practitioners (NPPs) who are eligible to bill Medicare for E/M services. In our experience, remote patient monitoring is beneficial for patients in a broad range of clinical settings that do not necessarily involve a physician or NPP. As mentioned above, the Augment Therapy software platform tracks patients' adherence and progress over time through 3D depth sensing technology that records and transmits specific objective exercise metrics, step counts, exercise repetitions, as well as frequency and duration of exercise sessions. Patients and therapists who use Augment Therapy often see better patient engagement, higher rates of satisfaction, and improved adherence to daily exercise programs resulting in a potential long-term improvement in patient mobility. Furthermore, many consumers of physical and occupational therapy services suffer long-term conditions resulting in prolonged episodes of care. As discussed above, solely offering in-person care with no remote options between visits often results in sporadic interruptions and lapses in care. With technology (and reimbursement support) in place that assists therapists and patients in positively shifting adherence to therapeutic exercise in between visits, patients' overall duration of care could be significantly reduced over time resulting in reduced overall cost of care for patients and, ultimately, the healthcare system.
Although Augment Therapy is typically used for children, RPM can be valuable to Medicare beneficiaries that require physical therapy as well. For example, patients recovering from hip replacements or other orthopedic surgery could benefit from their therapists remotely tracking muscle strength and movement while completing their exercises at home between visits. As is similarly true for physicians prescribing medication, physical therapists often prescribe daily home exercise programs that are imperative for patient progress. However, research suggests that less than 30% of patients adhere to prescribed protocols, significantly prolonging and negatively impacting their trajectory of care. Allowing therapists to leverage technology that can remotely monitor patient adherence and specific performance metrics between in-person visits adds patient accountability and has been shown to positively impact adherence and in turn, patient progress. Without reimbursement for these services, though, providers cannot afford to offer them to patients and most patients cannot afford to pay for them out of pocket. Access to and Medicare coverage of the RPM codes for PTs, OTs, and SLPs would enable these clinicians to offer hybridized services where it is appropriate and in a patient's best interests.
Without the ability to order and bill for RPM services, therapists are limited in their ability to furnish RPM services to all patients that can benefit from it because many patients cannot afford it. As a result, specialized RPM services like those used in the physical therapy space are exclusive to more affluent patients that can afford to pay cash or that have private insurance coverage that covers the cost for them. This is particularly harmful to an aging population that relies on Medicare to stay healthy. In light of the above and to ensure that patients have access to RPM in clinical settings other than with a physician or NPP, we urge CMS to clarify in the final rule that PTs, OTs, and SLPs are eligible to order and bill RPM services for patients.
While we strongly believe that PTs, OTs, and SLPs should have access to ordering and billing for the existing RPM codes (CPT codes 99453, 99454, 99091, 99457, and 99358), we understand that CMS may be limited in its ability to grant such access because those codes are categorized as Evaluation & Management codes. In the alternative, we suggest that CMS introduce new HCPCS codes specific to therapists for "sometimes therapy" RPM services similar to the codes that have been introduced for Virtual Check-ins and Remote Evaluation of Patient-Submitted Image or Video (G20X2 and G20X0, respectively) and similar G-codes for e-Visits (G2061, G2062, and G2063). Importantly, though, these codes should be reimbursed at the same rate as the current RPM codes, just as G20X2 and G20X0 are proposed to be reimbursed at the same rates as G2012 and G2010. RPM technology providers do not change their pricing based on the type of provider, so therapists incur the same costs in providing RPM technology and services to patients as physicians and NPPs.
b. The 20-minute time requirement for CPT Codes 99457 and 99458 should not be limited to include only "interactive communication" with the patient.
On page 136 of the Proposed Rule, CMS stated that for purposes of CPT code 99457, "the interactive communication must total at least 20 minutes of interactive time with the patient over the course of a calendar month" and that 99458 requires an additional "20 minutes of interactive communication between the patient and the physician/nonphysician practitioner/clinical staff" delivering the service. In arriving at this proposal, CMS relies upon the 2020 American Medical Association CPT Professional Edition codebook (the "CPT Codebook") and draws a parallel between RPM codes 99457 and 99458 and HCPCS code G2012, Brief Communication Technology Based Service ("Virtual Check-In"). However, RPM services are comprehensive care management services that involve much more than simply communicating with patients, as evidenced by the code descriptors for 99457 and 99458, and are much more similar in nature to e-Visits and Chronic Care Management services than Virtual Check-Ins. CMS should revise its proposal such that the 20-minute time requirement captures all of the services included in the delivery of RPM such as data monitoring and review, communication between the clinical staff and the billing practitioner, and clinical decision making relative to the monitored data.
For reference, the code descriptors for CPT codes 99457 and 99458 are as follows:
CPT Code 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month
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; additional 20 minutes
As CMS noted in the Proposed Rule, page 10 of the CPT Codebook provides that when a particular code includes a time basis for billing as is the case for codes 99457 and 99458, the "time" requirement refers to face-to-face time with the patient "unless there are code- or code-range specific instructions, parenthetical instructions, or code descriptors to the contrary." Based on this principle, CMS determined that the 20-minute requirement under CPT codes 99457 and 99458 refer to the "interactive communication" component of RPM services. However, CPT codes 99457 and 99458 are listed in the "Non-Face-to-Face Services" section of the CPT Codebook, suggesting that the codes are inherently remote and contradicting the notion that there is any applicable face-to-face requirement. Further, the code-range instructions for 99457 and 99458 in the CPT Codebook state that codes 99457 and 99458 require "a live, interactive communication" as part of the treatment management services provided under the codes, which contradicts CMS' conclusion that the time requirement refers only to live, interactive communication as stated in the Proposed Rule. Without a face-to-face component and given the code-range instructions and general categorization of CPT codes 99457 and 99458, the general principle that time requirements refer to face-to-face time is not applicable.
The services delivered under HCPCS code G2012 are quite different than those delivered under 99457 and 99458. G2012 refers to a single 5-10-minute discussion focused on a particular presenting problem. According to the 2019 Physician Fee Schedule Final Rule, the services should be patient-initiated and serve as a brief "check-in" to determine whether the patient needs to come in for an office visit./6
RPM services, on the other hand, serve as ongoing monitoring of digitally transmitted patient data and treatment management services associated with that data to ensure that patients are staying healthy. More similar to the RPM codes are CPT codes 99487-99491 which represent Chronic Care Management or "CCM" services.
CCM services are time-based services that include several service components that must be present in order to bill the relevant codes, including medication reconciliation, creation, revision, and/or monitoring of a person-centered treatment plan, among others - all of which count toward the time requirements for CCM. Similarly, RPM services require data review and analysis, revision and/or monitoring of a patient's treatment plan, and other non-face-to-face components that do not involve interacting with the patient but that are essential to the clinical value of the services. Additionally, CMS established in the 2020 Medicare Physician Fee Schedule that, like CCM, RPM is a "designated care management service" due to the similar nature of the two services categories./7
In furtherance of recognizing the similarities between RPM and CCM, the RPM time requirements should be treated the same as the CCM time requirements and capture all service components of RPM.
c. 16-day requirement should be measured by enrollment rather than number of data readings to allow providers professional discretion as to the amount and type of data that is medically necessary.
On page 138 of the Proposed Rule, CMS stated that once the COVID-19 pandemic ends, CPT codes 99453 and 99454 will only be billable if 16 days of data are collected within 30 days. CMS later asked whether it makes sense to establish coding and payment rules that would allow practitioners to be reimbursed for RPM services with shorter monitoring periods and how RPM services are delivered in clinical practice to better reflect those services in the Medicare Physician Fee Schedule. Augment Therapy supports the establishment of coding and payment rules that allow for reimbursement after shorter monitoring periods.
As CMS noted in the Proposed Rule, there are instances in which capturing 16 days of data within 30 days is not medically necessary or clinically appropriate. In scenarios where 16 separate days' worth of data are not necessary, finalizing the requirement as proposed has the potential to lead to overutilization of monitoring devices to ensure that the 16-day requirement is met. Further, 16 separate readings could, in some instances, result in patient harm. For example, patients that suffer from Muscular Sclerosis or Muscular Dystrophy may benefit from a provider tracking their exercise between visits to monitor certain physiologic parameters such as muscle movement. However, exercising 16+ days per month could lead to over-exertion of a patient's muscles and seriously injure the patient, perhaps permanently. Therefore, we believe that finalizing the 16-day requirement as proposed is over prescriptive and that providers should have discretion to determine how many days of readings are appropriate for each particular patient.
We understand that the CPT Codebook states that "99453, 99454 are not reported if monitoring is less than 16 days." While we understand the importance of ensuring that patients are enrolled in an RPM program for a sufficient amount of time to ensure that sufficient data is collected, we have previously understood this requirement to mean that patients should be monitored for at least 16 days rather than that 16 separate days' worth of data be collected in a 30-day period. Based on our experience and conversations with other stakeholders in the RPM industry, we believe that the former is a more clinically appropriate requirement, as it allows providers to determine in their professional medical judgment the amount of data that is medically necessary in order to make informed decisions about a patient's care.
In light of the above, Augment Therapy urges CMS to clarify in the final rule that CPT codes 99453 and 99454 do not require 16 separate days' worth of data readings but rather that a patient is enrolled in an RPM program for at least 16 days in order for the codes to be billable.
Thank you for your consideration of these comments as you work to finalize the CY 2021 Medicare Physician Fee Schedule.
Sincerely,
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Footnotes:
1/ See page 86 of the Proposed Rule.
2/ See page 87 of the Proposed Rule.
3/ Ohio Medicaid begins process to permanently expand telehealth services,
4/
5/ See "Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019", https://www.congress.gov/bill/116th-congress/senate-bill/2741.
6/ Footnote not showing
7 84 FR 62697 through 62698
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The proposed rule can be viewed at: https://www.regulations.gov/document?D=CMS-2020-0088-1604
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