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Guest Column: How CMS Paved a Path for Remote Patient Monitoring for Home Care Agencies in 2019

Thursday, April 18, 2019   (0 Comments)

By Sanjay Chadha, SafetyLabs

Remote Patient Monitoring (RPM) is the next big thing in medical care; however, patients and health care providers are generally unaware of these changes. This article provides an overview of RPM and the brief journey of Current Procedural Terminology (CPT) codes related to RPM and how home care agencies benefit from the latest changes starting January 1, 2019.

RPM is a technology that enables the monitoring of patients outside of their conventional setting for example in the home or a senior living, which increases access to care and decrease health care delivery costs.

Among the many changes the Centers for Medicare & Medicaid Services (CMS) has made to bring efficiencies in health care delivery, one is moving towards value-based care, setting a goal of tying 50 percent of all Medicare payments to value-based models.

This move towards value-based care has led to the creation of several Alternate Payment Methods (APMs) such as Accountable Care Organizations (ACOs), which involves hospitals and physician groups partnering with providers across the care spectrum to coordinate services in an effort to improve outcomes and lower costs for their patient population. 

ACOs see home health agencies as their partners for low cost care, opening new opportunities for industry providers. For agencies to attract new opportunities from ACOs, they need to demonstrate their ability to:

  • Provide value-based care;
  • Reduce hospital readmissions and ER visits; and,
  • Provide seamless transfer of patient information between the hospital and the home health agency.

Technology such as RPM is necessary for agencies to provide value-based care reducing readmissions and ER visits. Incorporating RPM in chronic care management significantly improves an individual's quality of life, allowing them to maintain independence, prevent complications, and minimize personal costs. RPM reduces readmissions and rehospitalizations by enabling delivery of right care at the right time to the home. 

CMS on RPM

CMS has shown commitment to RPM in the Patient-Driven Groupings Model (PDGM) final rule, in which CMS acknowledged the benefit to augment the home health plan of care. CMS believes RPM could enable the agencies to more quickly identify any changes in the patient’s clinical condition, prompting faster action by clinical staff or physician to review potential changes to the patient’s care plan. RPM could augment home health visits, for example, in the home health scenario where a patient is admitted for observation and assessment of the patient’s condition due to a possible potential for complications or possible potential for an acute episode.

CMS also appears to support the position that RPM could improve monitoring for fluctuating or abnormal vital signs between visits, thus enabling quicker interventions and updates to the treatment plan. CMS believes that RPM improves patients’ ability to maintain independence, improving their quality of life, which is especially true for patients with Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF). Research indicates that RPM has been successful in reducing readmissions and long-term acute care utilization.

Brief History of CPT Codes, Remote Care, and RPM

Before 2018, CMS mandated that certain remote care services could not be billed for the same patient during the same service period in conjunction with many of the treatments that utilize RPM services — specifically:

  • CPT codes 99487, 99489, and 99490, which cover chronic care management (CCM), including CCM for diabetes, hypertension, cardiovascular disease, and COPD;
  • CPT codes 99495 and 99496, which cover Transitional Care Management (TCM), or services involving the period of care in which a patient is discharged from a hospital, rehab, nursing, or similar facility to a home or to a senior living setting; and,
  • CPT codes 99492, 99493, 99494, and 99484, which cover General Behavioral Health Integration (BHI) services and a psychiatric collaborative care model (CoCM), including psychosocial assessment and preventive care recommendations and oversight of patient self-management and medications.

Last year started with big opportunities for health care providers using telemedicine and digital health. One of the most notable developments was CMS’ decision to reimburse providers for RPM. Effective January 1, 2018, the Medicare program started to pay providers for RPM services billed under CPT code 99091. The service is defined as the “collection and interpretation of physiologic data (e.g., ECG, blood pressure, oxygen, glucose monitoring, and weight), which are digitally stored and/or transmitted by the patient and/or caregiver to the provider organization for a physician or qualified health care professional, requiring a minimum of 30 minutes of time.”

RPM in 2019

CPT 99091 was created in 2002 covering the collection and interpretation of physiological data for 30 minutes or more. The challenge with 99091 was that it was conceived based on a model in which a patient collects the vital signs, which are then sent to their physician via email. This process is obsolete in today’s cloud-technology with provider-supplied devices offering a much higher level of personal health information security. Although, in early 2018 Medicare “unbundled” CPT 99091 and designated it as a separately-payable service paying approximately $59 per month with the new challenge being that it the obsolete technology remained in place.

To circumvent this issue that CPT 99091 was based on old technologies, CMS last November published a final rule on its new RPM codes, three of which went into effect on January 1, 2019. These codes incentivize providers such as home health agencies by reimbursing costs associated with RPM technology and monitoring to manage patient care needs. The new codes were added after activating CPT 99091 in 2018 because CMS recognized that code fails to optimally describe how RPM services are furnished using current technology and staffing models.

The American Medical Association's CPT editorial panel developed and finalized the three new RPM codes in late 2017 (990X0, 990X1, and 994X9), but were finalized by CMS as 99453, 99454, and 99457. The new codes accurately reflect contemporary health care scenarios, hence are a much better fit to today's health care environment and are outlined below:

CPT July 2018 CPT November 2018 Description Frequency of Payment Approximate Payment
990X0 99453  RPM initial; setup and patient education on use of equipment. This reimbursement is for the initial work associated with onboarding a new patient, setting up the equipment, and patient education on use of the equipment. 
One time  $21
990X1 99454 RPM initial; device(s) supply with daily recording(s) or programmed alert(s) transmission 30 days $69 per month
994X9 99457  RPM minimum 20 minutes of qualified health care professional requiring interactive communication with the patient/caregiver
Calendar month  $54 per month

Frequently Asked Questions

  1. Where can service be delivered? Since RPM is not considered a Medicare telehealth service by CMS (i.e., the patient need not be located in a rural area or any specific originating site). Medicare pays for RPM services using the same conditions as an in-person physicians’ service without any additional requirement regarding permissible originating sites or rural geographies. The patients can receive RPM services in their homes, a boon for home health agencies.
  2. Who can deliver RPM? CPT 99457 included the monitoring service to be delivered by the “clinical staff”, which is the key significant differentiator from CPT 99091 which is limited only to “physicians and qualified health care professionals.” All practitioners must also practice in accordance with applicable state laws. The new RPM services can be performed by the physician, qualified health care professional, or clinical staff where clinical staff includes, registered nurses and medical assistants. Inclusion of nurses and medical assistants is a boon for home health agencies and senior living facilities who may have these providers on staff. Note that the provision of RPM for these health care professionals is still subject to state laws regarding scope of practice and supervision requirements.
  3. What does the reimbursement include? Reimbursements covers the three important aspects of RPM including initial setup work (e.g., onboarding a new patient, setting up the equipment, and patient education on use of the equipment) using code 99453, monthly device costs using code 99454, and monthly RPM services using code 99457).
  4. Must the patient provide consent? Does the patient have a co-pay? The health care provider must obtain the patient’s consent for RPM services and document it in the medical record. Although CMS did not address this in the final rule for the new codes, the patient’s consent is required for CPT 99091 and likely would be expected as a requirement for the new CPT codes 99453, 99454, and 99457. It is recommended to obtain the patient’s consent at onboarding and also informed that the patient is responsible for a 20 percent co-pay for the RPM services under Medicare Part B.
  5. What is the relation of RPM-specific CPT codes and other CPT codes such as CCM? A provider can bill both CPT 99457 (RPM) and CPT 99490 (CCM) in the same month. CMS recognizes that the analysis involved in furnishing RPM services is complementary to CCM and other care management services. Note that the time spent providing CCM services cannot be counted towards the required time for both RPM and CCM codes for a single month (i.e., no double counting).  To bill both 99457 (RPM) and 99490 (CCM) requires at least 20 minutes of CCM and 20 minutes of RPM time. 
  6. What are the types of technologies allowed for RPM? RPM are inherently non-face-to-face, therefore furnishing these services does not require the use of interactive audio-video. CMS did not provide any specifics in the final rule on what technology qualifies, but does plan to issue forthcoming guidance to inform health care providers and stakeholders on these issues. This is expected to be in the form of a CMS Medicare Learning Network article or FAQ document in the near future.
  7. Can RPM (CPT 99457) be billed “incident to”? What supervision level is required? CMS stated that CPT code 99457 describes professional time and therefore services for 99457 cannot be furnished by auxiliary personnel incident to a practitioner’s professional services.
  8. Where can I find more information? This PDGM final rule and the November 2018 final rule documents can be referred to for more information. If you have questions or would like to be informed when CMS comes out with any new ruling regarding use of technology, please send us an email at rpm@safetylabs.org.

Sanjay Chadha is founder and CEO ofSafety Labs. Safety Labs’ novel approach enables delivery of RPM services through a patient’s television. For more information, visit SafetyLabs.org.


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