In recent years, the Centers for Medicare and Medicaid Services (CMS) have expanded reimbursement opportunities for remote patient monitoring (RPM) in an effort to affect the affordability and accessibility of healthcare services. In 2018, CMS unbundled CPT code 99091, meaning physicians are able to be reimbursed separately for time spent on the collection and interpretation of patient-generated health data (PGHD). 2019’s Physician Fee Schedule (PFS) Rule expanded these reimbursements: new CPT codes 99453, 99454, and 99457 more clearly offered reimbursement for the initial set-up and patient education, procurement of devices and transmission of data, and the time spent reviewing data or communicating with the patient. Earlier this year, the 2019 Rule was corrected to allow code 99457 to be billed “incident to,” meaning qualified medical professionals as well as physicians could bill for the service.

With the most recent PFS, CMS set out to further expand reimbursement for remote monitoring services. In the 2020 Physician Fee Schedule Proposed Rule, CMS amended code 99457 to allow for “general supervision” rather than “direct supervision” and also proposed a new code, 99458, to reimburse for each additional 20 minute interval spent monitoring data and communicating with a patient.

This proposed code comes at a time when more providers are working to scale remote monitoring across populations as a way to deliver proactive care to a growing number of patients managing multiple chronic conditions. These amendments allow providers to build a stronger financial model for RPM services, to incentivize physicians to participate, and to receive greater reimbursement for their time.

General Supervision for RPM Services

Under the former requirement of “direct supervision” for code 99457, auxiliary personnel – any individual who is acting under the oversight of a physician – delivering RPM services were required to be in the same building at the same time as the billing physician. This limited care teams’ ability to deliver RPM services that meet the requirements for reimbursement. Under “general supervision,” auxiliary personnel are now able to furnish RPM services without being in the same building or working at the same time as the billing physician. In fact, physicians could even use telemedicine to communicate with other personnel and deliver “general supervision” in this way. This opens doors for qualified medical professionals to deliver RPM services without the physical presence of the physician – enabling physicians to operate at the top of their licenses and improve patient triage, so resources can be allocated to care for the most high-risk patients.

The allowance of general supervision can enable care teams to more regularly and autonomously deliver remote monitoring services to patients, which is particularly beneficial for those providing care to high-risk patients in need of more regular monitoring and touchpoints. With this change, auxiliary personnel can spend time – without onsite presence of the physician  – monitoring data, communicating with patients, making recommendations to the care team, and intervening when needed. 

In addition, this opens new RPM opportunities for care teams in which the physician and auxiliary personnel are staffed across multiple locations or in the case of broad national or regional RPM deployments. This also enables RPM services to be outsourced to remote clinical staff, driving further efficiencies in care.

This change could greatly impact how RPM programs and the supporting business models are built, as care teams have more autonomy to deliver the necessary services and interventions and call for treatment proactively – without the physical presence of the billing physician. The reimbursement allows for health systems to broadly deploy and scale these programs to include thousands of physicians and hundreds of thousands of patients. That allows for new revenue streams for health systems, operational changes, process updates, and new value to be created.

Expanding Reimbursement for Time Spent Monitoring

Notably, CMS also proposed a new CPT code (currently titled 994X0), which would allow providers to bill for each additional 20 minute interval spent monitoring data and communicating with patients – outside the initial 20 minutes covered by CPT code 99457. This could enable a care provider to review a patient’s data weekly, for example, and get reimbursed for their time spent. The Rule did not address whether there is a limit to how many times the code could be billed per month.

For a patient managing diabetes, this could mean continuous, passive monitoring using home health devices and virtual touchpoints. With access to her ongoing health data and alerts to bring attention to readings outside a set threshold, her care team can more closely track her condition. For the patient, very little changes in her routine; she still takes her blood glucose everyday, tracks her meals, and steps on the scale regularly. 

Frequent in-person visits are no longer required, her data is being incorporated into a program of care, and she is receiving more personalized support. The access to physiologic home health data helps the care manager better understand how a negative behavioral or biometric trend is impacting the progression of the patient’s condition. The technology to identify trends quickly ensures the care team is not responsible for data discovery and entry, instead their time is focused on lifestyle or treatment adjustments. 

This program structure helps drive better accountability for the patient, greater impact and efficiency for the provider, and the broadscale prevention of negative health events for the health system. Empowered with greater reimbursement opportunities, health systems can scale these programs to manage larger populations of patients – regardless of condition. These programs can be deployed to the masses, focusing not only on the highest risk patients, but also patients who are trending towards developing more complex conditions or comorbidities.

Providers continue to implement new technology as a way to deliver proactive patient care and to more cost-effectively manage chronic conditions. These new reimbursement opportunities enable providers to use available technology and data to intervene before risks and trends become critical episodic events or hospitalizations and to better encourage positive lifestyle and behavior change. These interactions in care can lead to a better quality of life for all patients. To learn more, read the proposed rule available on the federal register.

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