2019 Medicare Physician Fee Schedule and Quality Payment Program - CMS Proposed Rule - CPT Codes 990X0, 990X1, and 994X9 - 2018-07-12

CMS’ explanation for its bold, new proposal: “We now recognize that advances in communication technology have changed patients’ and practitioners’ expectations regarding the quantity and quality of information that can be conveyed via communication technology. From the ubiquity of synchronous, audio/video applications to the increased use of patient-facing health portals, a broader range of services can be furnished by health care professionals via communication technology as compared to 20 years ago.”

The biggest takeaways from the proposed 2019 Medicare Physician Fee Schedule and Quality Payment Program with regard to remote patient monitoring (Chronic Care Remote Physiologic Monitoring):

CMS introduced three new RPM codes, retitled “Chronic Care Remote Physiologic Monitoring,” which largely adopt the new codes created by the American Medical Association in 2017.  The codes (CPT 990X0, 990X1, and 994X9) are intended to better reflect how RPM services can be delivered to patients.

Even before these new codes were proposed, separate billing Medicare for RPM has been allowed using CPT 99091, defined 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 (where applicable) requiring a minimum of 30 minutes of time.”

The three biggest takeaways from the new RPM codes that differ from the current CPT 99091 are as follows:

  1. Less treatment time required to qualify for reimbursement. CPT 99091 requires at least 30 minutes per 30-day period, whereas CPT 994X9 requires only 20 minutes per calendar month.  The new code is much easier to track on a monthly basis, and requires 33 percent less time.
  1. Separate payment for initial set-up and patient education. CPT 99091 does not offer additional reimbursement for the time spent setting up the RPM equipment or educating the patient on its use.  The new codes offer separate reimbursement for the work associated with onboarding a new patient, setting up the RPM equipment and training the patient on same. This is a very helpful move to further incentivize providers to start using these technologies with their patients. In addition, this separate payment is different from how Medicare reimburses Durable Medical Equipment (DME) suppliers (e.g., CPAP, oxygen, etc.). CMS requires the DME supplier to set up the equipment at the patient’s home and educate the patient on how to use the equipment, but does not offer separate payment for that work.
  2. Clinical staff allowed. CPT 99091 is limited only to “physicians and qualified health care professionals” and does not expressly allow the RPM service to be delivered by clinical staff (e.g., RNs, medical assistants, etc.). This means the physician or qualified health care professional must perform the full 30 minutes per 30-day period, which is a lot of time for these highly trained professionals. For some providers, this is too resource-intensive to justify the $58.68 per month reimbursement rate.  The new code allows RPM services to be performed by clinical staff.

The only manner in which a Medicare provider could potentially use clinical staff for CPT 99091 is by complying with all the requirements for “incident to” billing, which – among other things – requires that auxiliary personnel be under the direct supervision of the physician. Under Medicare rules, direct supervision means the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the auxiliary personnel is performing services.

Most RPM services are best provided via general supervision, which does not require the physician and auxiliary personnel to be in the same building at the same time, and the physician could instead exert general supervision via telemedicine. This is a huge difference in operations and business models, but in order for CMS to make these new RPM codes work in the real world, it is near-essential that CMS allow RPM to be delivered “incident to” under general supervision.

Healthcare providers should begin launching RPM programs:

Healthcare providers service Medicare patients should consult with companies, such as mTelehealth, to deliver RPM services to patients, similar to what we have seen with Chronic Care Management (CCM) companies. This is because the new codes expressly allow the use of “clinical staff” to help fulfill part of the 20 minutes per month. Current CMS guidance on CCM services expressly contemplates and allows third-party companies to contract with Medicare providers to help deliver CCM services. In order to further enable that, CMS created an exception allowing a Medicare provider to bill CCM services as “incident to” under general supervision. Normally, most services billed incident to must be provided under the direct supervision of the provider.  

Healthcare providers should prepare for these new opportunities:

The first thing is to take the time to truly understand, with precision, the billing and supervision rules fundamental to a compliant RPM service model. Providers should not focus too much on the technology and business development until they are confident the model they are “selling” or delivering does, in fact, comply with Medicare billing requirements.

Second, providers should take time to develop a model business-to-business RPM contract with mTelehealth, whether this is technology-only, support services-only or a combination of both.


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