Stay Compliant While Unlocking Digital MSK’s Potential  

When discussing the tools and solutions that lie beneath the digital MSK umbrella — services like telehealth, remote therapeutic monitoring (RTM), digital home exercise programs, direct messaging, etc. — value is often defined through benefits that indirectly impact revenue. 

Patients value the ability to better access rehab therapy clinicians and their services, for example. Clinicians appreciate tools that help them engage and monitor patient progress outside the clinic, helping secure more visits and plan-of-care completions. And owners and operators like how digital tools can connect their clinics to new patient populations while differentiating their services within local healthcare markets. 

Each of these benefits can and should develop into additional revenue opportunities for a practice. When thoughtfully and strategically applied, they offer strong return-on-investment (ROI) potential. Unfortunately, most digital tools and services are not directly reimbursable by private or public payers. 

Telehealth and RTM are exceptions to this rule. 

Thanks to increased demand during the COVID-19 pandemic combined with efforts by payers to improve care management through the expansion of virtual services, both telehealth and RTM are currently reimbursable (albeit in different ways) by Medicare and a widening number of private payers. That’s good news for practice operators investing in one or both services. 

With reimbursement, however, comes greater compliance oversight, and this is where things can get complicated. 

While Medicare and a growing number of private payers cover both telehealth visits and RTM services, this isn’t universal. Depending on a clinic’s payer mix, some patients may be covered for these services (fully or partially) while others may not. 

And as laws, rules, and guidelines are continually changing, so too are payer coverage and compliance. Thus, staying abreast of all these moving parts can become overwhelming. 

This section — the final of Net Health’s digital MSK e-book — will attempt to guide rehab therapists through some of these complexities. This will include an assessment of what practice operators should consider from a legal and compliance standpoint when implementing digital services at their clinics. 

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Reimbursable Digital MSK Services 

According to Kate Gilliard, Director of Health Policy and Payment with the American Physical Therapy Association (APTA), the genie is out of the bottle when it comes to digital rehab therapy care. And, payers have played and will continue to play an active role in establishing standards and trends within this area. 

This is what happened during the pandemic when the Centers for Medicare and Medicaid Services (CMS) made telehealth reimbursable for Medicare patients as part of the public health emergency (PHE) declaration. Many private payers followed suit, and today 43 states, Washington D.C., and the Virgin Islands have legislated that private insurers must reimburse for telemedicine.¹ 

It’s also what happened when RTM codes were first introduced in 2022. This introduction resulted in a wider adoption of RTM programs and solutions within rehab therapy, and today more private insurers offer plans that include coverage of RTM.  

“At this point, you kind of just don’t want to get left behind,” Gilliard said. “It’s a lot easier to keep up than to catch up, and regardless of where the pressure comes for you to provide these services, you need to be ready.” 

When considering the general insights and guidelines below, be aware that it’s the responsibility of each operation, practice, clinic, and clinician to review and understand individual patient coverage guidelines before considering the use of telehealth, RTM, and other digital MSK tools and services. 

Compliance Considerations for Telehealth in Rehab Therapy  

With Medicare as well as most private insurance companies, telehealth rehab therapy visits are reimbursed at the same rates as in-person visits. This provides clinicians with a high level of flexibility when considering patients’ needs throughout their full plans of care, enabling them to offer telehealth or a hybrid model of care (i.e., a mix of in-person and telehealth visits) to qualified patients without financial penalty. 

For these efforts to be legal and prudent, however, Rick Gawenda, PT, Founder and President of Gawenda Seminars & Consulting, suggests rehab therapy providers consider the following: 

• Get Enrolled and Credentialed: All rehab therapists who plan to offer and bill for telehealth services via Medicare must have a National Provider Identifier (NPI) number and be enrolled as a Medicare provider. They must also be credentialed with any private payer from whom they plan to get reimbursed for these services. 
• Invest in a HIPAA-Compliant Platform: All digital platforms used to connect with patients via a telehealth visit must comply with the HIPAA Security Rule. This indicates the platform has policies and procedures in place to ensure electronic protected health information (ePHI) is not improperly altered or destroyed.
• Update Your Consent Forms: Prior to offering telehealth services, Gawenda suggests rehab therapy clinic owners and/or operators consult with their healthcare attorneys to update or add language to their patient consent forms about providing telehealth, recording video, etc. 
• Check Insurance Liabilities: As it’s impossible to predict what may go wrong during a telehealth session — perhaps a patient suffers an injury or a serious emergency event — Gawenda also suggests practice owners/operators check their liability insurance to ensure they are covered when unforeseen events occur. 

Medicare’s Telehealth Cliff 
In addition, it’s important to note that while most private payers have made telehealth coverage permanent for rehab therapy patients, reimbursement for telehealth through Medicare is scheduled to sunset at the end of this year — that is, unless Congress takes action. 

Though CMS was the first to approve telehealth as a reimbursable service for physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists (SLPs) in 2020, it turns out its power has limits. CMS does not have the statutory authority to permanently add PT, OT, and SLP as reimbursable telehealth services under Medicare, so legislation is needed. 

Gilliard said that despite the difficulties the current session of Congress faces in finding common ground, she remains confident lawmakers will pass a telehealth extension for rehab therapists. 

“It seems like they are poised to do something, from what we hear on [Capitol] Hill,” she said. “It’s not a controversial issue, and we assume that they will do something once we start to see the clock really tick down on telehealth.” 

Compliance Considerations for Remote Therapeutic Monitoring (RTM) 

Remote therapeutic monitoring (RTM) is another digital service that is reimbursable through Medicare and a growing number of private insurance companies. Modeled after the successful rollout of remote patient monitoring (RPM) in 2019, the need for RTM was solidified during the pandemic and through efforts to move toward value-based care models of therapy. 

So in 2022, five new Current Procedural Terminology (CPT®) codes were released along with rules and guidelines that must be followed by rehab therapists who wish to get reimbursed for RTM services. The goal is to offer incentives (i.e., payment) for clinicians to engage with their patients through RTM programs as doing so can lead to better outcomes. 

“My belief and my stance have always been RTM does not replace in-person therapy visits — and when I say ‘in-person therapy visits,’ that can be you coming to my clinic, I come to your house, or we have a telehealth visit,” Gawenda said. “I think if done right, we’re going to see improved patient compliance with attending the in-person visits.” 

The original five CPT® codes for RTM are: 

• 98975 – Initial Set-Up and Patient Education: Clinics bill this one time per episode of care for setting the patient up with the RTM app/device and teaching them how to participate in the program. Billing for 98975 cannot occur until the clinician has collected 16 days of patient data/measures, which can be self-reported. (Average reimbursement: $19 – $20) 
• 98976 – Respiratory System Monitoring: Clinicians can bill this code once every 30 days for supplying one or more devices (i.e., the self-reported monitoring app) for respiratory system monitoring. (Average reimbursement: $47-49) 
• 98977 –Musculoskeletal System Monitoring: Clinicians can bill this code once every 30 days for supplying one or more devices (i.e., the self-reported monitoring app) for musculoskeletal system monitoring. (Average reimbursement: $47-49) 
• 98980 – First 20 Minutes of RTM Services: This code is billed at the end of each calendar month for providing the first 20 minutes of care management, which includes interactive communication by rehab therapists and/or assistants. (Average reimbursement: $49-$50) 
• 98981 – Additional 20 Minutes of RTM Services: This code is billed at the end of each calendar month for providing an added 20 minutes of care management, which includes interactive communication by rehab therapists and/or assistants. (Average reimbursement: $38-$39) 

As these CPT® codes and guidelines indicate, Gawenda notes, RTM as a reimbursable service is not a therapy visit, nor is it simply checking in with a patient to see if he or she has been doing their exercises. It involves using FDA-approved devices (which can include digital apps patients use to self-report) to collect information about things like pain, activity, sleep patterns, home exercise compliance, etc. 

It also involves clinicians regularly reviewing the data transmitted through these devices and interacting with patients via phone or video call to discuss progress. 

As long as these guidelines are followed, though, practices are free to establish an RTM program that best meets the needs of its staff and its patients. 

“If you just look at it as what’s best for the patient, I think every one of us would say, ‘Yep, we’re going to implement RTM,’” Gawenda said. “Some programs are more profitable than others, and some are more successful than others when it comes to patient engagement and [patient] compliance. It’s just how you implement it in your practice [will be] different than how somebody else implements it in a practice based on staffing and other factors.” 

RTM with Private Payers 
As is often the case, once Medicare stepped up to reimburse clinicians for RTM services, many private payers followed suit. However, determining which insurers — and which benefit plans offered by these insurers — cover RTM services can take some digging. 

According to Gawenda, RTM services often do not show up on benefit plans when reviewing patients’ insurance. So, he suggests calling payers directly to ask if RTM is covered and if the patient is required to pay co-insurance or a copay. Also, how might their RTM program differ from Medicare’s version? 

The process can seem time-consuming, but with RTM reimbursements plus the potential to improve patient compliance while increasing visits, it’s likely worth the effort. 

“You may not like all the rules and regulations [of Medicare], but you know the rules and regs and what services are paid for,” Gawenda said. “It’s the other payers, whether it’s the Medicare Advantage plans or the private commercial payers… It’s like that country song goes, ‘Sometimes life’s a dance you learn as you go.’” 

Other Considerations When Adopting Digital MSK  

Even though other digital MSK services are not reimbursable under Medicare or other insurers, which means they’re not subject to payer compliance issues, considerations must still be made to ensure the tools are legal and successfully applied. 

According to Gilliard, here are the top five things to consider when investing in digital MSK tools and services: 

Comply with HIPAA 
We have already discussed HIPAA compliance as it relates to choosing a telehealth platform, but as a federal law, HIPAA permeates every aspect of healthcare. And while it’s widely understood that HIPAA exists to protect private information, Gilliard points out there’s another side to it: information blocking rules. 

“If you’re not familiar with information blocking rules, I kind of like to describe them as the other side of the coin of HIPAA,” she said. “HIPAA requires you to protect records and not give them away and not release patient data if it’s not appropriate. Information blocking is the opposite. It says you have to release it when it is appropriate. You can’t prevent people from accessing information if they have a legal right to it.” 

This is something to keep in mind, she adds, when considering the use of patient portals. 

Keep Up with Federal Laws 
Beyond HIPAA, federal laws regulating the world of healthcare still consist of a wide swath of knowledge. Gilliard reminds clinicians to keep federal laws in mind when rolling out an RTM program, specifically relating to the tools used to connect with patients. 

“When it comes to RTM, I think a lot of people are forgetting the requirement that these RTM [programs] use an FDA-approved medical device … or should I say, a device that meets the definition of a medical device as promulgated by the FDA,” she said. “So, it can’t just be any app you download from the App Store. You need to do your research and make sure you’re using something appropriate.” 

Consider Patient Usability 
To establish digital services that are profitable and successful, including reimbursable services like telehealth and RTM, it’s critical to choose digital tools and platforms that primary patient populations are willing and able to use. 

“Younger generations may be more tech-savvy; older generations may not be,” she said. “If you’re a pediatric therapist, what are your patients’ parents or guardians comfortable with? Because ultimately, if your patients don’t use it or don’t like it, you’re wasting your time.” 

Review Payer Coverage 
As always, it’s important that practice owners and operators consider payer mix when looking to expand digital MSK capabilities and services. Do their patients’ insurance plans cover RTM and telehealth? What are their guidelines, and do patients cover some of the costs? 

Even if payers do not cover specific services, operators may still find other long-term cost benefits to implementing digital MSK tools. Being able to fully assess value and ROI, however, requires owners and operators to go into new ventures with their eyes wide open. 

Practice Defensible Documentation 
Many digital MSK services, including telehealth and RTM, are still so new to private insurers that requirements like documentation (or expectations around said requirements) are continually changing. Or, they’re inconsistent from payer to payer. 

To ensure documentation is least likely to cause issues with reimbursement, Gilliard suggests clinicians practice defensible documentation. This is detailed documentation that is written with consideration that payers and others may be looking for fault (i.e., incomplete patient story, medical history, assessment results, why treatment/service is medically necessary, etc.) at a later date. 

“We’re kind of in a brave new world with a lot of these services,” Gilliard said. “We know what the medically necessity standards are and what the [Medicare Administrative Contractors] are looking for. We’re not quite as sure when it comes to these brand-new services or brand-new ways of delivering services. So, when in doubt over documentation, use defensive documentation practices. 

“Make sure you’re talking about why something’s being delivered virtually or digitally, why that particular component of your total plan of care is necessary, to make sure that you don’t get audited later and have your payments recouped. 

The Future of Digital MSK 

While signs point to a digital rehab therapy future that includes elements of artificial intelligence (AI), predictive analytics, wearable devices, and so on, Gawenda admits it’s difficult to truly predict what the future holds when it comes to digital MSK. 

“Obviously, the way things are changing and being developed … has happened at a way faster pace nowadays than it was 10 years ago,” he said. “And I just think one thing: I do feel confident saying whatever may come out in the future, whether it’s the near future or 10 [or] 12 years from now, I think new technology is going to come out and go into use before payers will pay for it.” 

And though CMS has often taken the lead when it comes to determining when and how services (including digital services) are covered, Gilliard could see that changing at some point. 

“Where is patient demand going to fit into this?” she said. “And if the tech savviness of a patient is going to inform whether or not they’re demanding telehealth, you’re going to expect that from younger populations. That’s not going to be the Medicare population. So, I’m curious to see in the future if private payers will overtake CMS as sort of the trendsetter in digital health and telehealth in the rehab space if their patients are more demanding of it.” 

This could include efforts to force the adoption and delivery of digital care at all rehab therapy providers, especially as they get more serious about providing value-based care.

“It’s possible that in the future we could see private payers [and] insurance companies requiring you to offer some level of digital care,” Gilliard added. “It’s possible that Medicare could do that, as well.” 

In the more immediate future, though, both Gawenda and Gilliard say that getting Congress to permanently add rehab therapists as telehealth providers before coverage sunsets at the end of this year is a top priority. To learn about ways to support this effort, connect with your national or state association — the APTA, for example, or the American Occupational Therapy Association (AOTA) – to research lobbying efforts already set in motion. 

SOURCES: 
¹ CHG Healthcare, “Telehealth Rules and Resources: 2024 Healthcare Toolkit,” Jan. 8, 2024