Dr. Barry Franklin Joins Chanl Health as an Advisor
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Why is an alternative delivery model even needed?
Cardiovascular disease is the leading cause of death and largest healthcare expense in the U.S. Patients who are hospitalized from a cardiac event have a 30% readmission rate within 30-days and cost health plans 2-3x more. Cardiac rehab after a cardiac event is the standard of care. It is a clinically validated program that reduces readmissions, costs, and future events, but 80% of patients do not participate in cardiac rehab. For the past several years, AACVPR, AHA and ACC have been working to increase participation in cardiac rehab. The Million Hearts initiative has a goal of 70% by 2027. This ambitious goal requires us to have new innovative delivery models of care, one being, virtual remote rehab.
The ONLY thing different about a virtual program component is the delivery mechanism. Adding a virtual option using both synchronous and asynchronous sessions is a way to reach the 80% of patients that cannot or will not attend traditional center-based CR/PR. Our goal remains to get as many patients as we can in our "tried and true" center-based program. We can NOT be satisfied to reach only 20% of patients eligible. A virtual delivery option is a compliment to your center-based program.
What is meant by an “asynchronous” task?
This refers to the patient doing either an exercise or education session without being observed by staff. Think of what you ask your center-based patients to do on off days. These are not reimbursable.
What is meant by a hybrid program?
Hybrid means the patient receives their rehab through a variety of ways. Onsite, asynchronous and synchronous sessions. There is no perfect number of how many of each and is dependent upon each individual patient’s needs.
Is there a difference between remote delivery and virtual delivery?
No, the difference is in whether or not the session is synchronous or asynchronous. Only synchronous real-time audio-visual sessions meeting the CMS criteria are billable.
Which patients is VCR intended for?
A hybrid virtual solution can be delivered to any patient as an option to traditional onsite rehab. It is intended for low to moderate risk patients and can with proper guidance and instruction serve a higher risk patient.
Does the VCR model replace center-based delivery?
No, we want as many patients as possible to attend the proven evidence-based CR/PR program. That being said, only 22% of eligible do attend. Offering a hybrid virtual option is a compliment to the center-based program for those that cannot or will not attend.
Are the core components and requirements of VCR the same as center-based?
Yes, all requirements remain the same. The only change is HOW we deliver the services
Location - hospital (on or off campus) or physician office (PHE and Hospital’s Without Walls allows us to deliver at the home)
No. The FDA has addressed regulation of “digital health” solutions and apps directly. Chanl’s software does not require FDA approval because it is not “intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment or prevention of disease.” While treatment of a disease from a certified care provider may be delivered through our software, the software itself is not a treatment. This is similar to MyChart portal.
Additionally, the FDA clarifies that even if software is considered a medical device and subject to the FD&C Act, they define “minimal risk” apps, and the FDA “does not intend to enforce compliance with its regulatory requirements” for these apps. You can find more information by clicking here.
Billing, Insurance, and CMS Requirements
What is a PO modifier?
A PO modifier is for on-campus and excepted off-campus CR/PR services; payment will be at OPPS rate.
Are secondary insurances covering virtual synchronous sessions?
Yes, some may be. You need to verify by each payer group. This is similar to what you would do to pre-authorize a patient for onsite cardiac rehab sessions.
Are both audio and visual components needed for the session to be billable?
Yes, both audio and visual observation of the patient must be in place to bill for the session.
Does physician supervision need to be constant during the session?
Yes, similar to on site rehab, the physician must be immediately available during the entire time of the session. This can be met through audio-visual technology. Real time, live observation of the patient can be done by the rehab staff.
Would it be acceptable to use audio-visual technology for physician supervision for our onsite program?
Yes, physician supervision may be met through audio-visual technology during the PHE.
What monitoring does Medicare require for the virtual synchronous sessions during the PHE?
Medicare requires 31 minutes of observation of the patient through live synchronous audio-visual technology, physician supervision and SOME exercise. Most are billing 93797, which is non-continuous ECG monitoring. No other physiological monitoring is required. If continuous ECG monitoring is involved, 93798 would be the billable code. Medicare does not dictate whether the patient needs continuous ECG monitoring.
Which billable codes are acceptable for pulmonary rehab virtual synchronous sessions?
Most are billing 94625, which is non-continuous pulse oximetry monitoring. No other physiological monitoring is required. If continuous ECG monitoring is involved, 94626 would be the billable code. Medicare does not dictate whether the patient needs continuous pulse oximetry monitoring.
Can a patient have virtual cardiac rehab and home health?
It depends on the diagnosis of “medical necessity” of home health. It would need to be case by case.
Is Zoom HIPPA compliant?
Zoom encryption fully complies with HIPPA Security Standard to ensure the security and privacy of PHI
How do you suggest logging these sessions for reimbursement?
Sessions should be logged the same way you are currently logging sessions. This includes any program management software system (ScottCare, LSI, Chanl Health) or your EMR.
How do patients monitor their blood pressure?
If a patient has high blood pressure, as with traditional center-based programs, staff will educate patients to purchase and monitor a home blood pressure cuff. If they are in a hybrid virtual program, they would be asked to monitor and input the data in the Chanl Care App.
Does the patient have to monitor their heart rate?
Many programs will provide the patient with a target heart rate to be used during exercise. When in center-based rehab the patient may or may not have continuous ECG monitoring. When exercising at home the patient may be taking a palpable pulse or using some type of monitor such as a FitBit or Apple Watch. Some patients exercise using the RPE scale and signs and symptoms to determine intensity.
Does your roadmap include virtual ECG monitoring?
Medicare does not require continuous ECG monitoring for all patients all the time in site-based programs and consistent with virtual rehab being recommended for low to moderate risk patients, it would not be necessary for virtual ECG monitoring. It may be something considered in the future.
If you do not include virtual ECG monitoring, how can a high-risk patient participate in VCR?
High risk patients can participate in a number of ways using the Chanl Care App. They can receive their education, input vitals and communicate with the staff. Additionally, they are likely being given a home exercise prescription based on an assessment from the CR staff which is exercise without ECG monitoring. They may still be able to also participate in virtual real-time audio-visual session performing low level exercise tasks.
What can we do if the patient does not have a smartphone, tablet or computer?
Some organizations offer those patients an option by providing/loaning a device to be used during rehab. We can help manage this, but it is a cost to the department.
What is the liability to the program or hospital if a patient has an incident while exercising at home?
If the patient experiences an issue performing an asynchronous task, the liability is no different than when site-based programs ask their patients to exercise on off days. Due diligence is critical that programs educate and instruct patients on what to do if they experience symptoms while exercising their own.
If the patient is in an observed real-time audio-visual rehab session, the program should have an emergency response plan and the supervising physician must be immediately available. A consent with described risks to participate in cardiac rehab is similar to onsite sessions. Some programs have the patient consent to virtual sessions.
How can we ask patients to exercise on their own without our supervision?
We have been always been asking patients to exercise on their own on off days without our supervision. These are “asynchronous tasks” and are considered safe. Similar to site-based rehab, the clinician is responsible for assessing the patient and prescribing home exercise.
How much revenue of the billable sessions do you take from the program?
Chanl Health’s model is a site license model and does not take any revenue received by the programs.
What is needed for IT Security?
The Chanl Care App and Chanl Dashboard are a cloud-based service. We provide a high-level overview as well as a detailed security questionnaire for review by the organization’s IT department. Often times Chanl Health will be asked to complete a lengthier internal IT security review. To date, Chanl Health has had over 50 reviews without issues to move forward.
Why can’t we use RPM codes?
Remote Physiological Monitoring CPT codes are typically used for remote monitoring of weight, blood pressure, pulse oximetry, and respiratory flow rate. They are limited in quantity (usually used monthly) and who is eligible to provide the service. RPM codes can be billed by physicians, Advanced Practice Providers (APP’s) and other Qualified Health Professionals (QHP’s). Cardiac and pulmonary rehab staff are not categorized as QHPS and RPM codes are not consistent with CRPR.
Can we interface with EMRs?
The Chanl software platform can interface with hospital EMR’s which would require a separate project scope. Most programs are documenting in their program management system such as VersaCare that may or may not interface to the hospitals EMR. Programs using both VersaCare and Chanl Health would document in the appropriate system based on whether the patient was on site or virtual. Programs without an interface would print out end of program reports and scan into the EMR.
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