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New Reimbursement for CPT Code 99091 under the 2018 Medicare Physician Fee Schedule

The Centers for Medicare & Medicaid Services gave physicians and other healthcare providers ringing in the New Year another reason to celebrate. Two final rules issued by CMS in November 2017 opened up entirely new avenues for reimbursement of Remote Patient Monitoring services in 2018, creating the potential for better patient outcomes and a boost to a practice's bottom line.

Background: What is Remote Patient Monitoring?

CPT Code 99091 was created in 2002 to describe "Remote Patient Monitoring" -- an interaction whereby a patient purchased a home monitoring device to collect her health information and transmit that information to her doctor. Since that time, CMS has considered the work of the physician in reviewing and interpreting that data to be covered by the management services codes already billed by the practice - meaning, CPT Code 99091 was "bundled" in with other management services codes and was not separately reimbursable. In 2018, the reimbursement landscape for Remote Patient Monitoring changes dramatically, as CPT Code 99091 is "unbundled" and separate payment for RPM services by practitioners is available. As of January 1, 2018, CMS will pay $59 per patient per service period for Remote Patient Monitoring services (subject to geographic variations). Whether commercial payers will follow suit remains to be seen, but payers in general are trending towards reimbursing for services shown to improve patient care and reduce costs. 

Remote Patient Monitoring under the 2018 Physician Fee Schedule

The 2018 Medicare Physician Fee Schedule Final Rule describes CPT Code 99091 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." Although CMS has imposed a number of requirements with respect to CPT Code 99091, it is important to note that Remote Patient Monitoring is NOT subject to the same restrictions that currently govern reimbursement of general telehealth services under Medicare. Specifically, reimbursement for RPM services is not limited by geography to rural or medically underserved areas, nor is there any "originating site" restriction for RPM services. In fact, RPM services can be provided anywhere the patient is located, including at the patient's home.

Key Requirements for Billing CPT Code 99091

In order for Remote Patient Monitoring services to be reimbursed under Medicare, CMS requires the following:

  • Advance Beneficiary Consent. Practitioner should obtain beneficiary consent prior to initiating RPM services and document this consent in the beneficiary's medical record.

  • Face-to-Face Visit. For new patients or patients who have not seen the billing practitioner within one year, RPM services must be initiated during an initial face-to-face visit with the billing practitioner, such as a Preventive Physical Exam or an exam included in Transitional Care Management.

  • 30-Day Period, 30 Minutes of Time. RPM services may be billed under CPT Code 99091 once per patient per contiguous thirty days. The services should be billed at such time when a practitioner in the practice has accrued thirty minutes of time reviewing, interpreting, and responding to the RPM data. This may include, for example, communicating with the patient/caregivers, modifying the patient's care plan, and documenting recommended interventions. (Note: Interpretation of data from hospital or clinical lab computers is NOT to be included as time attributable to CPT Code 99091.)

  • Physician or other Qualified Health Professional. CPT Code 99091 encompasses time spent by a physician or other qualified health professional on RPM services as described above. Note that this is distinguishable from time spent by Chronic Care Management staff furnishing care management services.

  • Use with other care/monitoring services/codes. CPT code 99091 can be billed once per patient during the same service period as Chronic Care Management (CPT codes 99487, 99489, and 99490), Transitional Care Management (CPT codes 99495 and 99496), and Behavioral Health Integration (BHI) (CPT codes 99492, 99493, 99494, and 99484).

CMS has indicated that reimbursement under CPT code 99091 is an interim measure until new additional codes for a variety of specific types of Remote Patient Monitoring are approved, hopefully for 2019. Contact us to learn more about reimbursement for RPM services in your practice. 

MACRA's Quality Payment Program (QPP) & Remote Patient Monitoring

There is more good news in the 2018 Quality Payment Program Final Rule for practices using Remote Patient Monitoring. The Rule, which sets forth parameters for Year 2 of MACRA's QPP, includes changes to the Clinical Practice Improvement Activities performance category and the Advancing Care Information performance category that can benefit practitioners providing RPM services.

Clinical Practice Improvement Activities performance category

Physicians and other eligible practitioners participating in the Merit-Based Incentive Payment System ("MIPS") track of the QPP under MACRA must attest to participation in up to four Clinical Practice Improvement Activities -- 2 "high-weighted" activities, 4 "medium-weighted" activities, or a combination thereof to obtain the maximum performance score in this category. In 2018, CMS is emphasizing the use of technologies that facilitate Patient Generated Health Data ("PGHD") as a means of engaging patients by providing real-time feedback to patients/families and informing the care team about changes to a patient's health that may require intervention.  In accordance with this new emphasis, the Improvement Activity called “Engage Patients and Families to Guide Improvement in the System of Care” is now classified as a "high-weighted" activity -- thereby incentivizing the use of Remote Patient Monitoring technologies that provide real-time feedback to patients and their care team. Another Improvement Activity called “Use of CEHRT to Capture Patient Reported Outcomes” remains from Year 1 as a "medium-weighted" activity and involves use of digital tools to capture health data from patients. 

Advancing Care Information performance category

Under MIPS, participating physicians must also report on their use of Certified Electronic Health Record Technology ("CEHRT") for the secure exchange of health information to support patient engagement and improve quality of care. In Year 2 of the QPP, physicians are eligible for a 10% bonus on their performance score in this category if they use CEHRT to complete at least one of several specified Clinical Practice Improvement Activities. Both of the Improvement Activities discussed above qualify for this bonus. So, practitioners who use Remote Patient Monitoring technologies that collect real-time Patient Generated Health Data and allow patients to access and/or transmit their data, or practitioners who use digital health technologies to incorporate PGHD into their CEHRT, can increase their performance scores in the Advancing Care Information category as well as benefiting in the Improvement Activities category. 

As is always the case in the healthcare industry, the devil is in the details. First, it's important that arrangements between technology vendors and practitioners for Remote Patient Monitoring services should be evaluated by an attorney for any potential Anti-Kickback and/or Stark Law implications. Further, the way in which you implement Remote Patient Monitoring technology for patients in your practice and the method by which you bill for and report these services matters when it comes to 1) being reimbursed for specific services, and 2) the potential for enhanced performance scores under MIPS. Please contact us for guidance in establishing a compliant RPM program for your practice. 

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