Remote Patient Monitoring (Updated 11/18/19)
By Dr. Gordon Wilhoit
Beginning with the Affordable Care Act came the era of transition from the volume based FFS payment model, rewarding providers for their volume of productivity, to the quality/cost conscious/convenience FFV model, rewarding those that provide care designed to add value to the patient’s health care experience. Thus was coined the phrase “The Triple Aim,” which later expanded to The Quadruple Aim with its added goal of improving provider satisfaction and work stress through use of an expansive team based care delivery. CMS has doubled down in 2019 with its emphasis on the transition to value by introducing new reimbursable codes in telehealth and Remote Patient Monitoring to follow Chronic Care Management. Saving telehealth for a future blog and having discussed CCM previously, let’s focus on RPM, how it works, and, more importantly, what it can do for your patients.
3 new codes for RPM are set to become available as of 1/1/19 and will replace the infrequently used, and infrequently reimbursed, CPT code 99091. They require the use of a computerized device that records patient-entered data used to create a monitoring report electronically transmitted to the provider for review and assistance in medical decision making. To date, 5 “vital signs” have been approved to qualify for monitoring:
1) Daily weight with Smart Scales in patients with CHF,
2) Repetitive or continuous BP monitoring of patients with unstable HTN, post MI and /or CABG, and those with recurrent hypotensive events,
3) Pulse Ox,
4) Respiratory rate for those with fragile COPD and sleep apnea, and
4) Blood sugar in unstable diabetics or new insulin starts.
The new codes are:
1) CPT code 99453 – this allows for a one time reimbursement for the initial enrollment, set up, and patient education on the equipment and its purpose. It can be accomplished by a physician, midlevel, or any certified clinical staff. The proposed CMS payment varies by specific MAC between $19.46 and $21.00.
2) CPT code 99454 -- this code reimburses for the use of the device(s) equipped with daily recording(s) and predetermined alert(s) transmission. The code can be billed each 30 day period of use. The proposed CMS payment varies by specific MAC between $64.15 and $69.00.
3) CPT code 99457 – this code involves a time requirement of 20 minutes or greater and includes review, interpretation of results, and interactive communication with the patient and/or their caregiver of findings suggesting alteration of the care plan, if any. It can be performed by physician, midlevel, or any certified clinical staff. The proposed CMS payment varies by specific MAC between $51.54 and $54.
For those familiar with CCM coding, you can see CMS followed similar coding requirements with one very significant exception. RPM code 99457 does NOT qualify for “incident to” billing and as such describes only physician time not midlevel or certified clinical staff if you expect reimbursement! This in in conflict with the wording of the code requirement and needs clarification. It is the opinion of Value Health Partners that this service should be performed but not billed as coded unless performed by the physician.
RPM is NOT considered a telehealth service, and thus is paid regardless of geographic locality or communication choice. RPM can be provided and billed coincident with CCM services as long as time spent on both are mutually exclusive - no double counting (20 min. for CCM and 20 min. for RPM). Finally, RPM requires a verbal consent documented in the EMR and is subject to the 20% cost sharing copay regulations.
With regard to the value added to patient care, RPM has been extensively studied and found to potentially create significant savings to the total cost of care. The ability to closely monitor outside the office patient’s chronic complex diseases allows for early detection and intervention immediately with onset of instability and/or disturbing trends in their ongoing day to day status. RPM of blood glucose in diabetics has repeatedly yielded reductions of HgB A1C of up to 1%. This translates into as much as $109 PMPM total savings by reduction in co-morbidities, ER visits, and hospitalizations. The other monitoring listed above has consistently proven similar benefits.
Not just ACO’s, but physician groups and health systems in general, interested in delivery of low cost, convenient non face-to-face services, while expanding the reach of care in a value based population health manner, need to familiarize themselves with the many emerging remote care coordination technologies.
We at VHP have thoroughly researched the many new value add innovations and their regulatory drawbacks, and vetted many of the vendors. We would be happy to assist you in the development of your strategic plan.
Updated 11/18/19 -
After a tremendous feedback response from physicians, CMS has issued an important clarification of the rules and regulations guiding billing of service code 99547. The new rules confirm the similarity to billing for Medicare’s CCM model with regard to following incident-to guidelines. Starting 1/1/20 physicians may provide the 99547 service through certified clinical staff incident-to under their general supervision. This allows for a leveraging of the physician’s skills across the clinical team. Those utilizing remote patient monitoring devices should strongly consider taking advantage of the rule clarification and provide and receive reimbursement for this element of the complete service.