ESRD-Related Telehealth Services Documentation Found Lacking During PHE

While telehealth services related to end-stage renal disease (ESRD) skyrocketed during the pandemic, providers documented few details of the services with most leaving out the type of telecommunications system used, according to a federal report.

Released by the United States Department of Health and Human Services Office of the Inspector General, the report details an audit of ESRD-related telehealth services provided during the COVID-19 public health emergency (PHE), including an examination of what information was documented in medical records and whether claims met certain Medicare requirements.

ESRD occurs when kidney damage is permanent, requiring a regular course of long-term dialysis or a kidney transplant. ESRD, also called end-stage kidney disease (ESKD), is prevalent in the US, with 808,000 people living with the disease in 2020, according to the Centers for Disease Control and Prevention. Of those with ESRD, 69 percent were on dialysis, and 31 percent had a kidney transplant.

For the report, the OIG considered ESRD-related services as outpatient dialysis-related physician services for treatments delivered at home or in a center.

During the COVID-19 PHE, the Centers for Medicare and Medicaid Services (CMS) implemented several waivers for ESRD services to expand access to care. These included waiving the requirement that the clinical examination of the dialysis access site be furnished in person, instead allowing it to occur via telehealth.

As a result, telehealth use for ESRD spiked during the pandemic. The report shows that between March and December 2020, Medicare claims payments for ESRD-related telehealth services increased almost 10,000 percent from 2019. While CMS did not issue any specific telehealth documentation requirements, it did expect providers to perform the same level of documentation as when the services were furnished in person.

The OIG audit covered $37 million in Medicare Part B payments for 179,952 ESRD-related telehealth services provided from March 1, 2020, through December 31, 2020. The auditors selected a stratified random sample that included two groups: one with 75 claim lines for telehealth services provided to in-center dialysis patients and the other with 25 claim lines for telehealth services provided to at-home dialysis patients.

The OIG found that of the 100 sampled claim lines, 88 noted that the ESRD-related services were provided via telehealth, while ten were incorrectly billed as telehealth.

But only medical records for 25 claim lines identified the type of telecommunications system used to deliver telehealth, while medical records for 64 claim lines did not note that information for any of the telehealth visits.

"Therefore, we could not determine whether telehealth services were provided using an interactive telecommunications system using audiovisual technology that was non-public-facing," the OIG stated.

The OIG noted that the Office for Civil Rights (OCR) defines a non-public-facing remote communication product as one that allows only the intended parties to participate as a default.

But the OIG also found that the ESRD-related telehealth claim lines generally met certain Medicare requirements and identified the ESRD-related service provided. For example, all medical records for the 88 sampled claim lines noted dialysis planning and prescription assessments.

The OIG did not make any recommendations in its report but stated that it could be beneficial to document the type of telecommunications system used for ESRD-related telehealth visits.

"This information may be beneficial to CMS and OCR when considering future oversight mechanisms or changes regarding remote communication products," the agency said.

As telehealth becomes increasingly integrated into healthcare delivery in the US, the OIG is conducting audits to identify fraud, waste, and abuse of the care modality.

Earlier this year, the agency announced errors in Medicare reimbursement for some psychotherapy services, including those provided via telehealth, that occurred during the COVID-19 PHE. After an audit, the OIG found that $580 million of the $1 billion that Medicare paid for psychotherapy was improper and did not coincide with Medicare requirements. Of this $580 million, $348 million was for telehealth-enabled psychotherapy services.