Telehealth in Medicare Comprehensive End-Stage Renal Disease Care

Effective October 1, 2018, the Centers for Medicare and Medicaid Services (CMS) will implement a new telehealth waiver within the Comprehensive ESRD Care (CEC) Model, aimed at services provided to Medicaid End Stage Renal Disease (ESRD) beneficiaries. The model was first implemented in October 2015, under authority granted to CMS by Section 1115(A) of the Social Security Act, to test new ways to improve care for Medicare beneficiaries with ESRD.

The CEC Model brings together dialysis clinics, nephrologists and other types of providers to coordinate care of Medicare beneficiaries as an ESRD Seamless Care Organization (ESCO). ESCOs encourage providers to find innovative ways to deliver care both inside and outside of the health clinic, as the organizations are responsible for quality and financial outcomes associated with dialysis services. Separate financial arrangements are used by the CEC Model depending on the size of the organization. Large Dialysis Organizations (LDOs) are liable for higher shared loss and have higher risk compared to non-LDOs.
The telehealth waiver will allow ESCOs to forego Medicare’s originating site requirements for services provided via telehealth and enable beneficiaries to receive telehealth services in non-rural locations, the home, dialysis facilities, and other locations not specified by statute. Beneficiaries will be eligible to receive services via telehealth if they receive them from an eligible ESCO provider and the services qualify for telehealth reimbursement.
Medicare Administrative Contractors (MACs) will begin processing Part B CEC claims, containing demo code 85, beginning October 1, 2018 for telehealth services delivered by ESCO providers. The services provided through the CEC Model are limited to those described under Section 1834(m)(4)(F) of the Act and additional services specified through regulation. However, claims will not be allowed for the following services rendered to a beneficiary’s residence:

  • Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or Skilled Nursing facilities (SNFs) – HCPCS codes G0406-G0408.
  • Subsequent hospital care services, with the limitation of 1 telehealth visit every 3 days – CPT codes 99231-99233.
  • Subsequent nursing facility care services, with the limitation of 1 telehealth visit every 30 days – CPT codes 99307-99310.
  • Telehealth consultations, emergency department or initial inpatient – HCPCS codes G0425-G0427.
  • Telehealth Consultation, Critical Care, initial – HCPCS code G0508.
  • Telehealth Consultation, Critical Care, subsequent – HCPCS code G0509.
  • Prolonged service in the inpatient or observation setting requiring unit/floor time beyond the usual service – CPT codes 99356-99357.

For further information about the CEC Model and which services are included in the Model, access this CMS Medicare Learning Network article