Chronic care management (CCM), initiated in 2015, by the Centers for Medicare and Medicaid Services (CMS)to open opportunities in telehealth services is nearing the end of its third year. Yet,many Providers have opted not to provide CCM services - the reporting requirements and eligibility has been a significant barrier. Coupled with the fact that the median number of CCM patients per physician is 10, remote patient monitoring (RPM) is emerging as more attractive opportunity for Providers due to the staff requirements, reimbursement rate, patient eligibility and service flexibility. RPM has the potential to gain rapid traction where CCM could not.
Remote Patient Monitoring
CPT 99091 was introduced in 2002 to describe remote patient monitoring, however the code had to be attached with other services codes to indicate RPM services provided. CPT 99091 eventually evolved to include reimbursement of $58. CPT 99091 is defined as "Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time."
Remote Patient Monitoring – New Ruling and Requirements
CMS released a new rule in November 2018 for RPM services.CMS unbundled CPT 99091 into three separate codes under the Chronic Care Remote Physiologic Monitoring grouping. The three new codes, to be implemented as of January 1 2019, offer greater flexibility in monitoring and reimbursement:
- CPT Code 99453: Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment
- CPT Code 99454: Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
- CPT Code 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month
The new codes allow Providers to earn reimbursement for initial setup of RPM services and subsequently bill $58 for 20 minutes of monitoring each month. CMS allowed Providers to practice greater flexibility by allowing clinical staff to monitor patient-reported data, thus reducing the monitoring cost. Unlike CCM, there aren’t any restrictions as far as the type of patients that are eligible to be enrolled. The new codes open opportunities for Providers and digital health companies to leverage RPM & Telehealth technologies to provide monitoring capabilities focused on low-cost and efficient care.
Chronic Care Management – Existing Requirements
The new RPM codes differ from the CCM codes introduced in 2015. CCM appears to have some similarities to RPM services but varies significantly in terms of patient eligibility as well as reporting requirements. CMS introduced CPT 99490 to allow Providers to better manage Medicare patients with complex chronic diseases:
Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:
- Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
- Chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline
- Comprehensive care plan established, implemented, revised, or monitored
Twenty minutes or more of non-face-to-face time spent monitoring the patients qualifies for $42 of monthly billing. Additionally, the Provider must ensure that patients have 24/7 access to physicians, qualified health professionals, and or clinical staff. Eligible staff includes: Physicians, Certified Nurse Midwives, Clinical Nurse Specialists, Nurse Practitioners, and Physician Assistants. Chronic condition eligibility includes (Not limited to):
- Alzheimer’s disease and related dementia
- Arthritis (osteoarthritis and rheumatoid)
- Atrial fibrillation
- Autism spectrum disorders
- Cardiovascular Disease
- Chronic Obstructive Pulmonary Disease
- Infectious diseases such as HIV/AIDS
Further requirements include a comprehensive care plan must be created for the patients that encompasses:
- Expected outcome and prognosis
- Measurable treatment goals
- Symptom management
- Planned interventions and identification of the individuals responsible for each intervention
- Medication management
- Community/social services ordered
- A description of how services of agencies and specialists outside the practice will be directed/coordinated
- Schedule for periodic review and, when applicable, revision of the care plan
CMS added further CCM codes, CPT 99487 and CPT 99489. CPT 99487 is billed for 60 minutes spent each month for complex chronic condition management and CPT 99489is billed for each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.
Considering that CCM has complex requirements and has had mixed results after three years of deployment, RPM opens new opportunities for Providers to expand their services by adopting telehealth and remote patient monitoring technologies. RPM and telehealth adoption has not been ubiquitous across the board; however, as CMS expands the services they reimburse for, they are paving a path for Providers to embrace new technology and services.
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