In 2019, Medicare began to pay for clinics to monitor their patients remotely, under its Chronic Care Remote Physiologic Monitoring (RPM) program. Recently finalized rules for 2020 expand the opportunity, while refining, if only slightly, what kind of care is expected.
Offered in the wake of the Chronic Care Management (CCM) that is several years old now, RPM set sail in 2019. Clinics could use FDA-approved devices to monitor the health of patients at home and get paid for their services, even without the traditional face-to-face encounter traditionally required to submit a claim to Medicare. Three CPT® codes could be used by the clinics:
- 99453 - Remote monitoring of physiologic parameter[s] [e.g., weight, blood pressure, pulse oximetry, respiratory flow rate], initial set-up and patient education on use of equipment.
- 99454 - Device[s] supply with daily recording[s] or programmed alert[s] transmission, each 30 days.
- 99457 - Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.
In the details, several requirements were pertinent.
First, for the 99453/99454 device charge, the patient had to use the device to record data or receive alerts at least 16 days out of the 30 day billing period.
Next, for the 99457 professional service charge the clinic had to engage in interactive communication with the patient at least one time in the calendar month billing period.
Finally, while staff time could be counted toward the 20 minute minimum service requirement, staff were required to work on “direct supervision” rules, which meant staff had to be “in the office” with the billing provider for their work to count towards the required time.
What’s changing in 2020?
For 2020, the Centers for Medicare and Medicaid Services (CMS) have made several changes.
First, they have added a CPT® code 99458, to account for extended time spent in RPM. CPT® 99457 is billed for the first 20 minutes spent in RPM, and a claim using 99458 can be billed for each additional 20 minute period of service provided.
A second change is more in the tone of the commentary than in any specific code or requirement. In the published final rule, you see the idea of a “treatment plan” come to the fore. “Care plans” were a central part of the preceding CCM program; a comprehensive, electronic care plan that was available to the patient and care team is required for CCM.
The emergence of a call for a treatment plan echoes CCM in a way, suggesting two things. First, the remote monitoring should have a treatment goal. That is, RPM isn’t monitoring for monitoring’s sake. While not specifically addressing many comments seeking clarification of what types of monitoring CMS will reimburse, the need for a treatment plan does provide some, if minimal, constraint on this front. Second, it would behoove physicians and staff documenting their RPM work to include their treatment plan and its progress in their supporting notes.
Shifts in supervision
The final noteworthy change shifts the staff work requirement from “direct supervision” to “general supervision.” Under “general supervision” rules, the staff working for the billing provider to conduct the work of RPM do not have to be physically in the same office while working the provider’s behalf. This change in supervision will be a boon to centralized or itinerant disease management teams in a large group or health system setting. Thus, a heart failure program could monitor patients at home, using now-common remotely-connected devices, sharing their monitoring work with PCPs or specialists across their system, and have it all count towards RPM billing. Alternatively, the diabetes educators who travel between the PCP offices can now follow all their patients’ blood sugars with remotely connected devices wherever they happen to be that day, yet have their work with the devices and patients count for any of the PCPs they support, across all locations.
This change also creates opportunity for the small, independent clinic. Third-party services can now contract with smaller clinics, to be that off-site disease management team found in large health systems. These services can manage devices, monitor data and contact patients on behalf of the providers, and have all that work count towards billing for RPM under Medicare.
Challenges still remain, as small offices may struggle to stay on top of RPM billing requirements, the evolving commercial payor coverage of RPM and the subsequent cycle of denial and appeal. Some offerings, such as Voluntis Practice Solutions, include robust billing support, even denials and appeals processing, to help the small practice get started, despite these obstacles.
In conclusion, CMS’s changes to the RPM rules for 2020 take some definite steps forward in the pragmatic work of implementing the bright-and-shiny remote device tools we’ve been hearing about for a while now, within programs that can deliver value at any scale of care. We need further guidance on the range of clinical conditions we can address, but there is plenty of opportunity to get started.