Telehealth for Home Dialysis

This blog post was made by Beth Witten, MSW, ACSW, LSCSW on December 20, 2018.
Telehealth for Home Dialysis

Guess what? Patient complaints about having to go to a clinic monthly to see the doctor and dialysis staff have been heard! On February 9, 2018, President Donald Trump signed into law the Bipartisan Budget Act of 2018. A provision in this law may help more people have access to home dialysis by allowing home dialysis patients to choose to have some visits with their physician by “telehealth.”

What is telehealth?

According to CMS, telehealth is an interactive two-way audio and video telecommunications system that permits real-time communication. In the past, physicians could only see dialysis patients using telehealth if they were at certain ”originating sites,” such as skilled nursing facilities, hospitals, doctor’s offices, and only at hospital-based dialysis clinics and in-center dialysis clinics were excluded. This law changes all of that.

What does the law allow?

A home dialysis patient may choose to use his/her home as an “originating site” for telehealth. Starting on or after January 1, 2019, Original Medicare and Medicare Advantage plans will pay physicians whose home dialysis patients choose to see them by telehealth. It doesn’t matter whether a patient’s home is in an urban, suburban or rural area. However, a physician and home dialysis patient cannot use telehealth if they’re in the same location.

The law requires physicians to assess new home dialysis patients during face-to-face visits for the first three months of home dialysis. After that, the physician must see home patients at least quarterly. If patients choose to use telehealth for visits with their physician, they still need to get labs and should have access to other members of the interdisciplinary team.

How is telehealth reimbursed?

Medicare pays the same for telehealth or face-to-face visits. Dialysis clinics get no extra payment either way since they’re paid under Medicare’s bundled rate. For hospitals or others, there is no added facility charge for telehealth when the originating site is the home dialysis patient’s home. CPT codes are the same for face-to-face and telehealth visits:

  • 90963: End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients younger than 2 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

  • 90964: End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 2-11 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

  • 90965: End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 12-19 years of age to include monitoring for the adequacy of nutrition, assessment of growth and development, and counseling of parents

  • 90966: End-Stage Renal Disease (ESRD)-related services for home dialysis per full month, for patients 20 years of age and older

  • 90967: End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients younger than 2 years of age (effective for services furnished on and after January 1, 2017)

  • 90968: End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 2-11 years of age (effective for services furnished on and after January 1, 2017)

  • 90969: End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 12-19 years of age (effective for services furnished on and after January 1, 2017)

  • 90970: End-Stage Renal Disease (ESRD)-related services for dialysis less than a full month of service, per day; for patients 20 years of age and older (effective for services furnished on and after January 1, 2017)

Potential Telehealth Advantages for Patients Potential Telehealth Advantages for Physicians
Working patients don’t have to take off work as often. They don’t have to drive to multiple clinics to see home patients, saving time and gas.
Students or school children don’t have to miss school as often. They may be able to spend more quality time interacting with home patients.
Fewer trips to the dialysis clinic can save gas and wear and tear on a car. They can “see” a patient’s home set up for equipment and supplies.
Patients without cars do not have to find a ride or pay to get to the clinic as often. They may be more able to advise a patient on how to adjust his/her home dialysis to improve health and quality of life.
Patients can stay home in bad weather.
With a patient’s permission, families can be involved in a patient’s care plan and care.
Potential Disadvantages for Patients Potential Disadvantages for Physicians
Patients may fail to mention symptoms during a telehealth visit that a physician might identify in a face-to-face visit. Unless using more costly equipment, they can’t fully examine a patient’s access.
Patients may have technical issues with Internet connectivity or speed (even if they have Internet at home) They can’t touch a patient’s ankles to see if s/he has edema.
Patients who prefer face-to-face visits may feel pressured to use telehealth if their physician is not available otherwise. There is a cost to obtaining telehealth equipment and providing it to patients.
Telehealth visits could limit relationship building between patients and physicians.
They may feel pressured by clinics to use telehealth to save home dialysis staff time.

Conclusion:

Home dialysis patients will be able to choose to see their physician by telehealth starting on January 1, 2019. There may be advantages and disadvantages to the use of telehealth for patients and their physicians. Medicare doesn’t pay more for telehealth visits, so patients have no extra cost. However, providing telehealth equipment can be costly to physicians and lack of additional Medicare payment for telehealth visits may limit how many physicians offer home dialysis patients the option to choose to see their physician by telehealth.

References:

  • Bieber SD, Weiner DE. Telehealth and home dialysis: A new option for patients in the United States. Clin J Am Soc Nephrol 13: 1288–1290, 2018.

Comments

  • Robert L. Goins

    Oct 14, 2024 9:53 PM

    Been a dialysis patient for 20 years since the age of 21. For the past 13 years (1 year off due to a completely botched transplant). I am a stable patient but when I bring this up the doctor and nurse say it was for Covid only. Running into a ton of patient rights issues like being denied access to my patient care plan also. Anybody know someone that can be contacted to resolve this issues? Thank you.
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    • Beth Witten

      Oct 15, 2024 8:50 PM

      Although CMS provided waivers allowing many providers to use telehealth to see patients during COVID, home dialysis patients were allowed by a law (PL 115-123) that took effect in 2019. This law allows stable home dialysis patients to choose telehealth for 2 of 3 quarterly clinic visits after training and their first 3 months of face-to-face clinic visits. The law linked below is 250 pages long. This provision is in Sec. 50302. Print pages 127-129 for your clinic and nephrologist. They may be fearful of being cited by a Medicare surveyor, but this is justification if you as a stable patient request telehealth for clinic visits. https://www.congress.gov/115/statute/STATUTE-132/STATUTE-132-Pg64.pdf
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  • Tracey Barkes

    Nov 29, 2022 5:34 PM

    would we use patient home or the physician's office for location code for telehealth 90966 with modifier 95?
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    • Beth Witten

      Nov 30, 2022 10:06 PM

      I would suggest you contact your Medicare Administrative Contractor about what location code to use and whether to add the modifier 95 to 90966. As you've probably found yourself, the information provided by Medicare is unclear.
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  • nathan levin

    Sep 27, 2019 8:11 PM

    I am interested in a list of issues and data that people are using for TELE HEALTH
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    • Beth Witten

      Sep 29, 2019 2:14 PM

      Some nephrologists may be using telehealth to consult with stable home dialysis patients after having seen them in-person for the first 3 months of their home dialysis. I hope nephrologists will respond to your question, but in the meantime, I found some clinical trials that are underway or recently completed.

      The University of Alabama-Birmingham is conducting a clinical trial entitled "Interactive Videoconferencing in the Provision of Remote Peritoneal Dialysis (Telemedicine)." According to the Clinical Trials website, the study started in April 2015 and is expected to be completed in May 2020. You can read about it at https://clinicaltrials.gov/ct2/show/NCT02428803.

      French researchers just completed a clinical trial in June 2019 that started in November 2015 entitled "Medico-economic Evaluation of a Telemedicine System for the Management of Chronic Renal Failure (eNephro)." The results haven't been published yet. A publication is linked on the Clinical Trials site describing the study at https://clinicaltrials.gov/ct2/show/NCT02082093.
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  • DB

    May 24, 2019 11:03 PM

    I understand that the rural geographic requirement is being lifted for renal dialysis facilities and the home's of patients on home dialysis. Question: Are telehealth services available to in-center hemodialysis patients at any dialysis facility or is the rural geographic requirement only lifted for home dialysis patients at a dialysis facility?
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    • Beth Witten

      May 26, 2019 4:24 PM

      The physician fee schedule changes in telehealth are just for home dialysis patients not in-center ones in outpatient dialysis clinics at this time. Under the Medicare monthly capitation payment (MCP) rules, a physician must see in-center dialysis patients face-to-face once a month. The physician can have a nurse practitioner, clinical nurse specialist or physician assistant see patients face-to-face other weeks of the month to bill the maximum Medicare MCP. "Independent dialysis facilities" (most outpatient dialysis clinics fit this description) are specifically excluded as "originating sites" (places where a patient is getting care). Physicians can communicate with in-center patients using telehealth without being paid extra for it. Here's a CMS publication for providers that describes the telehealth benefit. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/TelehealthSrvcsfctsht.pdf
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  • Stephanie Fischer

    May 06, 2019 8:29 PM

    Hi! Does this apply for both home dialysis modalities- Home Hemo and PD? Please and thank you!

    Stephanie Fischer, LSCW
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    • Beth Witten

      May 06, 2019 11:07 PM

      Yes. Any home dialysis patient (PD or HHD) is eligible to use telehealth for 2 out of 3 visits after the first 3 months of home dialysis if his/her doctor is OK with it and if the equipment is available to communicate that way.
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  • chironhealth

    Apr 30, 2019 9:14 AM

    thank you for the information and posts
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  • Peggy Bushey

    Jan 03, 2019 10:14 PM

    I am grateful that CMS has come around to the idea of approving telehealth visits for our home dialysis patients. While this may not be the best option for complicated patients, I do see advantages for our stable patients. Living in a rural state, we have patients who have 2-hour drives to come in for a monthly visit, just to hear that everything is fine. With bad weather in the winter, they may decide not to come at all that month, which could lead to missed issues. I agree that patients should not feel pressured into using this option and that they should be educated around the questions/issues that will be discussed during the visit, so they can be prepared and make the best use of the time and technology.
    We have been utilizing telehealth with our in-center patients and find that it is well accepted. Patients are not at all shy about having a discussion with the doctor during that time. We are currently employing Nx2Me for our home hemodialysis patients, so every patient already has an iPad. One of the first things our patients asked when they received their iPads was if they could use it for the monthly clinic visit from home. So… I think the home-dialysis patient world is ready for this!
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    • Beth Witten

      Jan 03, 2019 10:28 PM

      Thank you for your comment. I'm glad to hear that patients are open to using technology when they have it to be able to talk with their doctor and other team members. I think using telehealth also opens the door to having family members involved more in the patient's care, if the patient agrees to that. Family members can be great allies to the team in helping their loved one do well on dialysis.
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  • Michael Kraus

    Dec 22, 2018 12:06 AM

    Thank you and this blog, it is a nice summary. I believe telehealth/telemedicine is extremely important to empowering the patient and increasing access to care. We have much work to do and need to continue to improve.

    The Bipartisan Balance Budget Act of 2018 promotes increased access to home dialysis and realizes the impact of telemedicine as part of the solution. Telehealth needs are not well defined and the technology needed is also not defined. CMS should intentionally minimize technology requirements and complexity to encourage adoption while technology and access to technology improves.

    It is important to note, that the use of telemedicine is a patient preference and a patient has the ability to opt out of telemedicine - it is the patient's decision to participate. Also, to participate in telehealth visits the patient is required to have monthly face to face visits for 3 months and then 1 face to face every 3 months ( slightly different than quarterly which could be a visit at month 1 and month 6).

    I do like your chart on benefits and disadvantages, but would like to point out the patient disadvantages mentioned could all be avoided or minimized. Patients may feel more comfortable in their home setting without the rush sometimes experienced in the clinic and hence, more prone to discussing all issues; If we minimize technology requirements we could even remove the need for high speed internet connections as a percentage of rural patients have limited access; and again the patient can elect not to participate in telemedicine. It is wrong to pressure participation and unlikely to be successful.


    The physical exam limitations of telemedicine today can be improved with proper education of patient self-exams of access and signs of volume overload, supplemented by the ability to forward photos as indicated.

    Again thank you for this important blog, we have much to learn but the future is exciting.
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    • Beth Witten

      Dec 23, 2018 1:59 PM

      Thank you for your comment, especially for pointing out the once every 3 months visit vs. quarterly. I hadn't considered how that might be misinterpreted. Also, that you for pointing out how what some might consider negatives might not be negatives for others or can be overcome.
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