The Rise of Remote Care
Telehealth received a major boost in adoption ever since CMS began introducing reimbursement codes for it. In particular, two notable years were 2015 and 2017.
Center for Disease and Control (CDC) says that 60% of Americans live with at least one chronic disease and that it contributes to 90% of the USA’s annual healthcare expenditure. Punching a few numbers, the figure comes to an astronomical 3.1 trillion dollars!
So to add value to people’s lives who were suffering, the chronic care codes were introduced. In 2015, the Chronic Care Management codes were introduced that recognized that patients undergoing chronic care needed services that went beyond the scope of regular office hours.
In 2017, remote patient monitoring codes were introduced that acknowledged the need for remotely collecting a patient’s physiological data in order to manage their care plans.
In 2020, because of the pandemic, there were many restrictions temporarily lifted off telehealth for the first time. The originating site prerequisite was removed where the patient had to be in a certain location. The mandatory established relationship between the physician and the patient was also done away with for the time being.
So whether it is to manage prevalent diseases, systemize patient data collection, or to respond to emergencies, the healthcare system in the USA has been forced to adopt remote care over the past years.
More so than ever before in its history, the idea of remote care has gained mass cultural acceptance. Compared to the previous year, 2020 saw telehealth usage grow by almost 30 folds.
All in the Name of Remote Care
We want to make it clear, when we say remote care, we are simply referring to the care provider and care recipient not being in the same place.
Usually telecommunications play a role in two-way audio and video, hence why the word telehealth is used. But not always. It could be that the physiological data is being transferred, where the term remote patient monitoring is commonly used. When mobile phones come into the picture, the term mHealth is used.
To bring all jargon under one umbrella, we say remote care to capture all scenarios depicted above.
As remote care is such an extensive field, we’ll cover chronic care management and telehealth in future articles. For the purpose of this piece, we’ll stick to remote patient monitoring.
Where do we stand in 2021 on Remote Patient Monitoring reimbursement? That is precisely the question we will answer in this article. We’ll use the 2021 Physician Fee Schedule (PFS).
Why is it Important to be well versed on the Physician Fee Schedule?
Relevance is a precious commodity in healthcare. What is true in one year, may not be so in the next. It’s why everyone looks towards the Physician Fee Schedule (PFS) every year.
The 2021 PFS is a complete listing of fees annually released by Medicare to pay doctors and other healthcare providers/suppliers. Its full nomenclature is the 2021 PFS Final Rule.
Fees Reign Supreme
While alternative models of payment are becoming popular in healthcare now, the fee for service (FFS) model is still very important because it forms the basis of constructing other value-based payment systems.
Even if payment is tied to value, where physicians have a percentage differential applied to their earnings based on certain standards like performance or reporting, their base earnings are still derived from the FFS model.
Even when they enter into risk-based payment models where they can share savings or losses, the total expenditure is calculated primarily based on the FFS model.
Sometimes, the FFS model is not so where every fee is mapped to one service, but rather a bundle of services. But still, its fees applied to a bunch of services stringed together or an episode of care. The Chronic Care Management program earlier discussed, come to mind.
The only case where it can be said that the FFS model does not truly apply is the population-based payment model where you have capitation for a certain number of people, regardless of the care they receive.
But with other value or volume-based payment systems, the fee is very important, and it’s the PFS that contains all the codes for such fees.
Rules are Only Added After Much Consideration and Have Staying Power
The other reason why the PFS is so important is that it tends to be sticky. Once something is introduced, its validity increases in the eyes of all stakeholders. There may be minor changes from year to year, but once something new is instituted like the chronic care program codes in 2015, and the remote patient monitoring codes in 2017, they become officially recognized as part of USA’s medical system.
It’s not only applicable to governmental healthcare spending by Medicare and Medicaid, but private insurances also update their policies or introduce programs to pay for similar services.
Medicare and Medicaid constituted 37% of the national healthcare expenditure according to The Center for Medicare & Medicaid Services (CMS), while private health constituted 31% of the national healthcare expenditure. So to know the PFS, is to know how to service these systems.
If you are well versed on the PFS final rule any one year, you have an idea of which way the wind is blowing. There may be incremental or drastic changes in the upcoming years, but what has been set into motion via the PFS Final Rule is here to stay.
With each rendition of the PFS, the existing laws become clearer as more physician practices and organizations apply them, and lawyers interpret them.
Decoding Remote Patient Monitoring Codes from the 2021 Physician Fee Schedule Final Rule
A disclaimer first.
If you require clarifications on any codes, we would strongly advise you to check out the Calendar Year 2021 PFS Final rule.
All pages on reimbursement codes that you see on the web are taken from there. So to be completely sure of something, it’s always good to get it straight from the horse’s mouth. It’s the approach we have taken in this article.
Why Start with Remote Patient Monitoring?
We wanted to tackle remote patient monitoring (RPM) first because of its distinct but essential nature.
It’s distinct because it is not just telehealth. A device and software just won’t cut it. There is the added component of including hardware that will capture the remote data. This increases complexity in the type of software that is used because while you can still make something as ubiquitous as Zoom HIPAA compliant, it’s much harder to integrate devices into the software.
It’s essential because other codes can usually be billed alongside RPM services in the same billing period. It usually goes hand in hand with chronic care for example, because the remote monitoring aspect of a chronic care plan is needed. It’s not considered double counting.
Purpose of Remote Patient Monitoring Codes
Remote patient monitoring (RPM), is also known as remote physiological monitoring as the patient’s physiological data is monitored.
It involves the set-up, collection, transmission and analysis of the patient’s physiological data. Such physiological parameters are used to develop and subsequently manage a patient’s treatment plan throughout the course of their care.
Remote Patient Monitoring is not specific to either chronic or acute care. In both scenarios, it can be equally applicable. This was not clear before, but the 2021 PFS Final Rule states that RPM services can be ordered for patients with acute conditions.
Certainly in chronic programs, a patient’s physiological data like heart rate or blood glucose level is monitored so their condition is stabilized and so proper action can be taken if there are any signs of regression.
In the Chronic Care Management program, where the patient suffers from two or more chronic diseases, multiple patient physiologic signals may need to be reported. In the case of a Principal Care Management program where one chronic condition is sufficient to enrol a patient, remote physiological monitoring may be deployed to measure just one patient signal.
Similarly for acute episodes of care such as post-surgery or a sudden illness, a patient’s health is monitored from afar once they are home, to ensure a smooth recovery.
Whatever the situation is that mandates the need to remotely monitor the patient, the reimbursement codes as outlined the 2021 PFS Fee schedule cover the expenses needed to do this.
We break them down into Practice Expense (PE) Only Codes, Analysis and Interpretation Reimbursement Codes, and Development and Management Codes.
The Practice Expense (PE) Only Reimbursement Codes
These two codes involve using medical devices which are considered equipment. They do not need any physician time according to CMS. For this reason, they have designated as PE only codes.
CPT Code 99453 captures the remote monitoring of physiologic parameter(s), e.g., weight, blood pressure, pulse oximetry, respiratory flow rate, etc. It is the initial set-up and patient education on the use of equipment. It is valued to reflect clinical staff time that includes instructing a patient and/or caregiver about using one or more medical devices.
It can be billed once per episode of care. The CPT Codebook defines an episode of care as “beginning when the remote physiologic monitoring service is initiated and ends with attainment of targeted treatment goals”. It cannot be billed more than once per 30 days.
CPT Code 99454 captures the remote monitoring of physiologic parameter(s), e.g., weight, blood pressure, pulse oximetry, respiratory flow rate). It is the initial device(s) supply with daily recording(s) or programmed alert(s) transmission over a 30 day period. It is valued to include the medical device or devices supplied to the patient and the programming of the medical device for repeated monitoring.
It can be billed once per 30 days. The confusion arises when people think about reporting twice when there are multiple monitoring devices involved. But the final rule makes it clear that the code can only be used once per 30 days per patient.
Important Points to Consider
In order to bill using the two codes, monitoring must occur over at least 16 days of a 30 day period.
The medical device used must meet the FDA’s definition of a medical device, but it’s unclear if they have to be FDA approved. The Final Rule states that no language in the CPT codebook was found that indicates that a medical device must be first cleared with FDA.
It’s clarified however that the medical device must be capable of automatically collecting the patient’s physiological data. Furthermore, the devices must be reasonable and necessary for the diagnosis or treatment of the patient’s illness or injury. They must be used to collect and transmit data that allows the understanding of a patient’s health status so a treatment plan can be developed and managed.
Development and Management Reimbursement Codes
After the collection and transmission of the patient’s physiological data, the physician or qualified non physician practitioner must analyze and interpret the data so a care plan can be constructed
After the interpretation and charting work is done, it’s time for the physician or non-physician provider (NPP) to design a care plan on the basis of the prior learnings. After such a patient-centered care plan is put together, it is implemented and managed until the targeted goals of the plan are met.
CPT Code 99457 captures the remote physiologic monitoring treatment management services. It consists of the clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/ caregiver during the month; for the first 20 minutes.
CPT Code 99458 captures the remote physiologic monitoring treatment management services. It consists of the clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/ caregiver during the month; each additional 20 minutes.
Both these codes can be furnished by clinical staff under the general supervision of a physician or qualified healthcare professional. General supervision is different from direct supervision. Under general supervision, the clinical staff and physician or NPP may not be in the same building and be immediately available to each other. As long as the services are furnished under the supervisory practitioner’s direction and control, it is deemed fine.
The Final Rule interprets interactive communication as real-time interaction between the patient and the care provider or staff. At a minimum, it is to be understood as synchronous two-way audio interaction that can be accompanied by video or other forms of data.
On January 11th, CMS further clarified that the 20 minutes of the physician, practitioner, or staff’s time could also go towards non-face-to-face care management in addition to interactive communication.
Expected Temporary Changes
At the time we publish this article, the public health emergency is still in effect. In light of the prolonged emergency, the Final rule has finalized some policies on an interim basis for the remainder of the PHE.
- No prior patient-physician relationship is needed to enroll new patients into an RPM program. Consent can be acquired at the time of furnishing the services either by the physician or NPP, or by individuals providing the service who are under contract with them.
- The minimum number of days of remote data collection in a 30-day period has been lowered to 2 days from 16 days.
These waivers are for the emergency period, but the final rule states that after the public health emergency (PHE) ends, this requirement will be restored.
Who is Allowed to Bill?
It’s important to note that only physicians and qualified healthcare professionals can bill for RPM as of 2021. Clinical staff are not allowed to bill these codes
It’s worth defining qualified healthcare professionals and providing examples, because every year, there is always confusion about who exactly is a qualified healthcare professional.
Both the physician and the qualified healthcare professional, as per the CPT according to Foley & Lardner should be “qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.”
They are not clinical staff. Rather, they supervise clinical staff. Clinical staff work under them. They are allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service. However, they cannot individually report that service.
It’s tricky because the regulations and scope of practice laws vary from state to state. But generally, popular qualified healthcare professionals are
- Registered Nurses
- Physician Assistants
- Nurse Practitioners
- Certified Nurse Specialist
- Certified Nurse Midwife
- Certified Registered Nurse Anaesthetists
- Licensed Clinical Social Worker
- Physical Therapists
- Speech Therapists
- Occupational Therapists
To conclude, we hope you are now updated on the remote patient monitoring reimbursement codes for this year. It’s as good a time as any to get a refresher because once you understand each code’s use and place in managing a remote care sequence, you can start using them at your healthcare organization or private practice. They will serve you well not just for this year, but for years to come because small addendums or alterations will be made to the existing codes. So if you master these codes first, you will have an understanding of what to expect.
Going forward, the use cases of remote care can be aplenty. Joining the ranks of chronic care and acute care, there have been talks of measuring objective data such as weight and sleep patterns to monitor behavioral health as well.
But it all starts with understanding the basics first, which is why we thought it would be useful to provide commentary on the existing laws on the books. Next up, we’ll cover the current chronic care management reimbursement codes.