As of January 1, 2018, the Centers for Medicare and Medicaid Services (CMS) unbundled the 99091 CPT code making it possible for some eligible practitioners to be reimbursed “for time spent on collection and interpretation of health data that is generated by a patient remotely,” digitally stored and transmitted. In this instance, “remotely” refers to the patient being in their home or other natural environment.1
Remote patient monitoring (RPM) then, is currently considered to be one of the more promising services in the immediate future. Approximately 20 states reimburse for RPM services at the time of this writing. Summarizing current legislation, Crowell & Moring’s C&M Health Law blog offers these guidelines for clinicians seeking to qualify for using the new 99091 CPT Code:
- Providers must obtain advance beneficiary consent for the service and document this consent in the patient’s medical record
- For new patients or those not seen within one year before the provision of remote monitoring services, providers must initiate these services in a face-to-face visit, such as an annual wellness visit or physical
- Providers can use 99091 no more than once in a 30-day period per patient
- The code includes time spent accessing the data, reviewing or interpreting the data, and any necessary modifications to the care plan that result, including communication with the patient and/or her caregiver and any associated documentation
- This code will not be subject to any of the restrictions on originating sites (patient location) or technology that telehealth services are subject to by statute
How to Get Paid for RPM (see restrictions below)
- Clinicians should use digital tools in such a way that allows them to provide ongoing guidance and assessments for patients outside of the in-office visit. This includes the collection and use of patient-generated health data.
- Clinicians must use health technology platforms and devices that collect patient data as part of an “active feedback loop” which CMS defines as “providing PGHD in real or near-real time to the care team, or generating clinically endorsed real or real-time automated feedback to the patient.”
- Platforms and devices used for this improvement activity must be, at a minimum, “endorsed and offered clinically by care teams to patients to automatically send ongoing guidance (one way).”
- CMS makes a distinction between technologies covered by this activity, versus “passive platforms or devices” that collect but do not transmit PGHD in real-time. The latter is not eligible technology under this activity.
Being new, there are a host of restrictions on RPM by CMS, including those in place at the time of this writing:
- RPM is limited to home health agencies
- Which conditions can be monitored at home
- The devices used and information gathered
- State variance with definitions of who or what they will reimburse for RPM.
For example, Hawaii, New York, and New Jersey all require Medicaid to reimburse for the service, but there’s nothing currently in the regulations in these states to indicate which technology is to be used or which reimbursements are to be made. Kentucky has also mandated an RPM pilot, although the details are not available at the time of this writing.
Where Does This Growth Pattern Leave You?
The zigzag growth pattern across states and disciplines is common for U.S.-based telehealth. As mentioned in a prior lesson, the U.S. is a country organized as 50 independent fiefdoms, each with their own decision makers and regulations. As with interjurisdictional practice, state rulings can seem outdated even as they start and be directly opposed to other states in their rulings. If you are from another country than the U.S., you may want to check with your local authorities to find movement in this regard. Many other countries are ahead of the U.S. with reimbursement for a variety of different telehealth services.
The important news to take away from this page is that RPM is here and will create more reimbursement opportunities for you if you keep your eyes open.
How to keep your eyes open for RPM reimbursement opportunities:2
- Subscribe for the TBHI NEWS, a free newsletter that collects the top 10-12 articles every week and drops them into your email inbox. To subscribe, click here.
- If you are a Google fan, create Google Alerts for yourself to be notified daily or weekly for issues that you identify.
- Start an email discussion group for reimbursement topics in your state, discipline or specialty area.
- If you are in the U.S., consider partnering with an innovative home health agency
Want to Maximize Telehealth Reimbursement?
For more information about other telebehavioral health and telemental health reimbursement, see the Telebehavioral Health Institute’s “Telemental Health and Telebehavioral Health Reimbursement Strategies: Increasing Authorization & Payment.” This professional online training with 3 CME/CE Hours will review relevant telehealth, telemedicine, telemental health, and telebehavioral health reimbursement law and proper procedures for practitioners and consultants.
1 This change in reimbursement policy is based in the 2018 Quality Payment Program Final Rule, which provides policy updates to the Quality Payment Program (QPP). These initiatives were established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Repercussions are becoming visible throughout the U.S. healthcare environment.
2 If you find information or opportunities that could benefit your colleagues through TBHI, please share it with us through our contact desk. We are delighted to have such contributions from our graduates and always appreciate hearing from you.