COVID-19 has changed how, when, and where healthcare is administered and received. We have seen a drastic shift away from traditional settings of care and towards telemedicine and remote patient monitoring (RPM). The numbers are staggering. Before the pandemic, the average weekly number of Medicare beneficiaries who received telemedicine was around 13,000. In the last week of April alone, there were 1.7 million such beneficiaries.
“We believe that RPM services support the CDC’s goal of reducing human exposure to the novel coronavirus while also increasing access to care and improving patient outcomes.”
Specifically in terms of RPM, many centers are implementing programs to monitor COVID-19 patients post-discharge – often earlier than otherwise possible – in order to free up hospital resources and catch relapses quickly. Preliminary results of such programs are beginning to be published, with more data sure to follow. Outside of COVID-19 monitoring, centers are using RPM solutions like patientMpower to keep their vulnerable respiratory patients away from the hospital while maintaining high quality care. Such programs may also reduce hospital costs. A recent study by USC suggests that their lung transplant RPM program saved the hospital $132,000 in a single year.
In part, this shift has been made possible by the Centers for Medicare and Medicaid Services (CMS) recognizing the need for these services and adjusting their reimbursement policies accordingly. On August 3rd, as part of their proposed changes to the Medicare Fee Physician Schedule for 2021, CMS announced which of the changes that were made in response to the public health emergency (PHE) would remain in place and asked for additional input from industry professionals. But before discussing more recent changes, it may be helpful to look at the brief history of RPM codes.
In January 2018, CMS introduced the first RPM-specific CPT code: 99091. Under this code, physicians could be reimbursed for the “Collection and interpretation of physiologic data… digitally stored and/or transmitted by the patient… to the physician…”. This was an important step for the future of RPM, but 99091 was not enough on its own to incentivize the shift from in-person to remote care, in part because it failed to account for many of the associated costs of operating an RPM program.
In response, three new RPM codes were introduced in 2019 by CMS – CPT codes 99453, 99454, 99457. These codes aimed to address the shortfalls of 99091.
- 99453 addresses the cost of setting a patient up with RPM
- “Initial; set-up and patient education on use of equipment.”
- 99454 addresses the monthly costs associated with operating an RPM program
- “Initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.”
- 99457 addresses the cost of time spent communicating with the patient
- “20 minutes or more of clinical staff/physicians/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.”
The introduction of these new codes meant that it was now practical for hospitals to focus more resources on RPM without sacrificing revenue.
In January 2020, just before the COVID-19 crisis, CMS released 3 additional codes for RPM. One such new code, 99458, was an add-on to 99457, and allowed hospitals to bill for each additional 20 minutes of interactive communication, up to 60 minutes total. (The other 2 codes were related specifically to blood pressure monitoring.)
- “Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes”
The second major change for RPM in the 2020 CMS final rule was that 99457-458 were now considered “designated care management services”. These services could now be furnished under general supervision, or in other words, personnel besides the physician or qualified HCP could now provide these services without sacrificing reimbursement. This was another step towards making RPM reimbursement more hospital-friendly, acknowledging the fact that RPM services may result in a variety of hospital staffing structures.
All of these changes and additions set the stage for RPM reimbursement in the COVID-19 era, with a few adjustments yet to be made. On March 30th of this year, with the COVID-19 PHE in its early stages, CMS released an interim final rule (IFC) that made many changes to telehealth reimbursement, including adjustments to RPM. CMS made it clear that they believe in the importance of RPM in the COVID-19 era, writing, “We believe that RPM services support the CDC’s goal of reducing human exposure to the novel coronavirus while also increasing access to care and improving patient outcomes.” Two main clarifications for RPM were addressed:
Who can RPM be used for?
- RPM services can now be provided to new patients in addition to established patients
- RPM services can now be provided for patients with both acute and/or chronic conditions
How often must patients consent to RPM services?
- Patient consent must obtained once annually
This new ruling was particularly beneficial to users of the new patientMpower COVID-19 monitoring platform. Originally developed for use in a national monitoring program in Ireland, the pMp COVID-19 solution was rolled out in the US shortly thereafter. COVID-19, an acute condition, now fell under the scope of RPM reimbursement. In the IFC, CMS writes, “For example, RPM services allow a patient with an acute respiratory virus to monitor pulse and oxygen saturation levels using pulse oximetry. Nurses, working with physicians, can check-in with the patient and then, using patient data, determine whether home treatment is safe, all the while reducing exposure risk and eliminating potentially unnecessary emergency department and hospital visits.”
With all of the pieces in place for RPM reimbursement opportunities to catalyze the shift to RPM, the only question remaining is what changes the future holds once the PHE is behind us. On August 3rd, CMS released their proposed changes to the Medicare Fee Physician Schedule for 2021. In this proposal, CMS clarified how they interpret certain aspects of the RPM code descriptors. Here are some highlights from the proposal:
- To bill for 99454, patient data must be collected for at least 16 days out of the 30 day period. In addition, 99453-454 may not be reported more than once during a 30 day period.
- Devices used for RPM do not have to be FDA cleared, they simply must meet the FDA’s definition of a medical device. This is an important distinction, opening up possibilities for the use of many novel RPM devices.
- Going forward, RPM can be used for patients with acute as well as chronic conditions, a change originating due to the PHE. This is a reassuring continuation of the PHE policy that allowed for the reimbursement for COVID-19 monitoring programs.
- 99457-458 will remain as care management services, meaning that they can be furnished by auxiliary clinical staff under general supervision.
- “Interactive communication”, as referred to in 99457-458, involves “a real-time synchronous, two-way audio interaction that is capable of being enhanced with video or other kinds of data transmission.” They also specify that there must be 20 minutes of interactive communication itself in addition to any other time spent performing RPM services.
- Consent can be obtained at the time RPM services are furnished.
What does all of this mean for the future of RPM and for users of RPM services like patientMpower? For one, it’s clear that CMS is making an effort to make RPM more widely available and attractive for hospitals and health care providers. CMS are interested in both increasing access to care and reducing exposure to COVID-19, and RPM is an important cog in that wheel. Second, CMS is open to change and is hearing input from those within the telehealth industry. For example, in the 2021 proposal they ask specifically for physician input on appropriate RPM monitoring periods and whether it is worth considering codes for shorter-duration RPM services. Changes such as these would increase the breadth of conditions that can be monitored remotely and propel CMS’s mission to increase access to care via digital health technologies.