2019 Medicare Physician Fee Schedule and Quality Payment Program CMS Proposed Rule CPT Codes 99453, 99454, and 99457 – Everything You Need to Know
Please see below for CMS Final Rule Update*
CMS has proposed three new codes for RPM services, retitled “Chronic Care Remote Physiologic Monitoring,” which do a far better job reflecting how providers can more effectively and efficiently use RPM technology to monitor and manage patient care needs, including chronic care management. If finalized, these three codes would go live January 1, 2019.
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.”
Medicare’s Current Remote Patient Monitoring Code
Medicare already offers separate reimbursement for RPM services billed under CPT code 99091. That service is defined as the “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.” It went live for the first time earlier this year (effective January, 2018).
Why the New Codes?
While industry advocates generally applauded CMS for activating RPM reimbursement, they simultaneously recognized CPT 99091 fails to optimally describe how RPM services are furnished using current technology and staffing models. This failure may be due to the fact that CPT 99091 is 16 years old and had never before been a separately payable service. (It is an older code CMS “unbundled” and designated as a separately-payable service.) Indeed, the AMA’s CPT Editorial Panel developed and finalized a set of three new RPM codes in late 2017. These codes (CPT 99453, 99454, and 99457) are what CMS recently proposed activating effective in 2019. The new codes do a far better job accurately reflecting contemporary RPM services.
What Are the New RPM Codes?
The new Chronic Care Remote Physiologic Monitoring codes are:
- CPT code 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.” The proposed Medicare payment for these services is $21.
- CPT code 99454: “Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.” The proposed Medicare payment for these services is $69.
- CPT code 99457: “Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.” The proposed Medicare payment for these services is $54.
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):
The three biggest takeaways from the new RPM codes that differ from the current CPT 99091 are as follows:
- Less treatment time required to qualify for reimbursement. CPT 99091 requires at least 30 minutes per 30-day period, whereas CPT 99457 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.
- 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.
- 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.
Chronic Care Remote Physiologic Monitoring is Not a Telehealth Service
Providers frustrated with the labyrinthine and narrow Medicare coverage of telehealth services can take comfort in the fact that RPM is not considered a Medicare telehealth service. Instead, like a physician interpretation of an electrocardiogram or radiological image that has been transmitted electronically, RPM services involve the interpretation of medical information without a direct interaction between the practitioner and beneficiary. As such, Medicare pays for RPM services under the same conditions as in-person physicians’ services with no additional requirements regarding permissible originating sites or use of the telehealth place of service (POS) 02 code. This means Chronic Care Remote Physiologic Monitoring does not require the use of interactive audio-video, nor must the patient be located in a rural area or a qualified originating site. Patients can even receive RPM services in their homes.
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.
*CMS Final Rule Update:
Through several recently published rules, the Centers for Medicare & Medicaid Services (CMS) is making it possible for Medicare beneficiaries to have greater access to health care services provided remotely through telehealth or “telehealth-like” methods and to implement telehealth provisions included in the Bipartisan Budget Act of 2018 (BBA). The recently posted Medicare physician fee schedule (PFS) and home health prospective payment system (HH PPS) final rules and the Medicare Advantage and Prescription Drug Benefit proposed rule all included provisions that establish or would establish new rules concerning telehealth or related services. Viewed together, this demonstrates CMS’ belief that telehealth and related communication technology-based services can provide expanded access to high-quality and cost-effective health services and that CMS will be providing more flexibility to encourage the use of these services. These changes recognize growing beneficiary and health care professional comfort with the use of communication technology in the provision of health services. The changes also implicitly acknowledge the growing demand for the convenience of telehealth services. It remains to be seen whether these Medicare program developments will result in expanded coverage of telehealth services under any state Medicaid programs.
Medicare physician fee schedule final rule
On November 1, CMS posted the Medicare physician fee schedule final rule. Because the Medicare statute limits payment for telehealth services to beneficiaries in certain geographic areas (primarily rural) and limits the “originating sites” where beneficiaries can get access to telehealth services, CMS has used its rule-making authority to bypass these restrictions by identifying and paying for certain telehealth-like services described below as “communication technology-based services” outside the telehealth benefit. CMS also is paying for new remote monitoring services, as described below. Medicare will begin paying separately for all of these new services in January 2019. CMS has expressed interest in recognizing innovations in the use of new communication technologies. CMS also noted that several of these new services are aimed at avoiding the scheduling of office visits that may not be necessary by providing a lower level payment for a separate service. The rates for these new services are provided in a chart below.
Virtual check-in (HCPCS code G2012)
Under Healthcare Common Procedure Coding System (HCPCS) code G2012, Medicare will pay separately for “brief communication technology-based services,” also referred to as a “virtual check-in,” provided certain conditions are met. This five to 10-minute non-face-to-face telephone or computer-based interaction can be provided only to established patients in order to assess whether the patient’s condition warrants an office visit. If the visit is in follow-up to a related evaluation and management (E/M) service provided within the past seven days, or if it results in an office visit within the next 24 hours or the soonest available appointment, then CMS will consider it to be bundled into those visits and it will not be separately reimbursed. The payment will be lower than the rate for the lowest level E/M in-person service, and because these “visits” will be subject to Medicare coinsurance, the patient’s verbal consent (oral consent, as opposed to written or electronic consent) must be obtained and noted in the medical record. CMS has said it will monitor utilization of this code to determine whether frequency limits are warranted.
Remote evaluation of prerecorded patient information (HCPCS code G2010)
Similar to the virtual check-in, Medicare also will pay separately for professional evaluation of prerecorded images or video transmitted by established patients for the purpose of determining whether an office visit is warranted. After reviewing the images or video sent by patients, the clinician must follow up with the patient within 24 business hours by phone, email, text message, or other mode of communication. As with the virtual check-in, if this remote evaluation originates from a related E/M service within the past seven days or results in an office visit within the next 24 hours or the next available appointment, the service will be considered bundled and not separately payable. Beneficiary consent (oral, written, or electronic) to the service must be documented because the service would be subject to coinsurance.
Interprofessional internet consultation (CPT®1 codes 99446-49 and 99451-52)
CMS also finalized its proposal to pay separately for four existing and two new Current Procedural Terminology (CPT®) codes describing consultations between physicians or other qualified health professionals when they are for the benefit of a specific patient. These consultations occur when a treating physician seeks the opinion and/or treatment advice of a consulting physician or other health professional with specific expertise, and CMS noted that the current lack of reimbursement for these interactions often leads to the scheduling of an office visit for the patient even though the patient’s presence is not necessary and a telephone or internet consultation between health care professionals would be sufficient. CMS views its recognition of these services as part of the movement away from a strictly fee-for-service-based system and toward a more care management-based approach to providing quality care to beneficiaries with multiple complex conditions. CMS is requiring documentation of beneficiary consent to receive these services because they will be subject to coinsurance, and it will monitor use of the consultations and consider refinements in documentation and billing policies if warranted.
Remote patient monitoring (HCPCS codes 99453, 99454, and 99457)
Having already established payment for chronic care management services in 2016, which are non-face-to-face, in 2019 CMS will establish payment for three codes to report “Chronic Care Remote Physiologic Monitoring.” These include a code for the initial setup and patient education regarding use of remote monitoring of physiologic parameters such as weight, blood pressure, pulse oximetry, and respiratory flow rate, and another code that can be billed monthly for the costs associated with the supplies and transmission of data. A separate code can be reported for 20 minutes or more of a physician or other health care professional’s time on treatment management during the month, but this service cannot be provided by auxiliary personnel and billed “incident to” a professional’s service. CMS will be issuing further guidance on the specific kinds of technology and scope of services covered under these codes.
Medicare telehealth services (HCPCS codes G0513 and G0514)
In addition to the new types of services described above, CMS annually updates the list of approved Medicare telehealth services, and this year added two codes for reporting “prolonged preventive services.” These codes, which are similar to existing E/M codes, are for reporting preventive services that require direct patient contact beyond the typical service time.
1 CPT Copyright 2018 American Medical Association. All rights reserved. CPT® is a registered trademark of the American Medical Association.
Use of telehealth in treatment of substance use disorders
The physician fee schedule final rule also implements provisions in the recently passed Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act, which is focused on addressing the opioid crisis, expanding the use of telehealth for treatment of substance use. Effective July 1, 2019, the geographic restrictions applicable to most telehealth services will not apply to use of telehealth for the treatment of diagnosed substance use disorders or co-occurring mental health disorders. The patient’s home will also be an acceptable originating site, although no facility fee will be paid. Implementation of this SUPPORT for Patients and Communities Act provision was issued as an interim final rule with a 60-day comment period, and CMS solicits comments on this provision.
Medicare home health prospective payment system final rule
On October 31, CMS posted the HH PPS final rule, which will allow home health agencies to include the costs of remote patient monitoring as an allowable administrative cost (e.g., operating expense) on their cost report if the remote monitoring is used to assist in the care planning process. This will allow such expenses to be factored into the costs per visit. Commenters on the proposed rule suggested that CMS should take an even broader approach to telehealth and include payment for virtual visits. CMS declined to do so, but described the inclusion on the cost report of costs associated with remote patient monitoring as a necessary first step in determining whether the use of such technology improves outcomes for home health patients. This suggests CMS may further expand payment for the use of telehealth in home health in the future.
Expanded coverage of telehealth by Medicare Advantage plans
In implementing the Bipartisan Budget Act of 2018, CMS also is proposing to allow Medicare Advantage (MA) plans to offer expanded coverage for “clinically appropriate additional telehealth benefits” beginning in plan year 2020. CMS would allow the plans to treat them as “basic benefits” for purposes of bid submission and payment, making it more likely that plans will offer them. Under the proposal, MA plans could offer Part B covered services as “additional telehealth benefits” outside the scope of services currently allowed under the Medicare telehealth benefit and not subject to the location restrictions applicable to telehealth services. To preserve beneficiary choice, any Part B service covered by plans as an “additional telehealth benefit” must also be available through an in-person visit and not only via telehealth. In addition, CMS is proposing to continue allowing plans to offer supplemental benefits (e.g., benefits not covered by original Medicare) via remote technologies or telemonitoring services that do not qualify as “additional telehealth benefits.”
CMS is not proposing to define which services are “clinically appropriate” to be offered as “additional telehealth benefits,” but would instead allow MA plans the flexibility to make that determination for themselves each year, consistent with professionally recognized standards of care. The MA plan would have to use contracted providers to provide these additional telehealth benefits and other MA regulations, including those regarding provider credentialing and selection would apply. Plans would be responsible for ensuring that the telehealth provider was in compliance with applicable licensing requirements and other state laws for the state in which the enrollee is located. CMS has solicited comments on its proposed approach and on the impact such telehealth providers should have on determinations of MA network adequacy.
Taken together, these recent changes by Congress and CMS indicate significant interest in making more health services available to Medicare beneficiaries via telehealth and similar technologies and to continue testing whether and when such services can be used to expand access to high-quality, cost-effective care, and to improve care coordination.
Appendix: Remote monitoring services payment rates
|Calendar year 2019 PFS national average payment rates (final rule)
|Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous seven days, nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment
|Facility: US$9.37, Non-Facility: US$12.61
|Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous seven days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; five to 10 minutes of medical discussion
|Facility: US$13.33, Non-facility: US$14.78
|Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; five to 10 minutes of medical consultative discussion and review
|Facility: US$18.38, Non-facility: NA
|Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review
|Facility: US$36.40, Non-facility: NA
|Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review
|Facility: US$54.78, Non-facility: NA
|Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review
|Facility: US$72.80, Non-facility: NA
|Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified health care professional, five or more minutes of medical consultative time
|Facility: US$37.48, Non-facility: US$37.48
|Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes
|Facility: US$37.48, Non-facility: US$37.48
|Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; setup and patient education on use of equipment
|Facility: NA, Non-facility: US$19.46
|Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
|Facility: NA, Non-facility: US$64.15
|Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month
|Facility: US$32.44, Non-facility: US$51.54
|Prolonged preventive service(s)(beyond the typical service time of the primary procedure), in the office or other outpatient setting requiring direct patient contact beyond the usual service; first 30 minutes (list separately in addition to code for preventive service)
|Facility: US$62.35, Non-facility: US$65.95
|Prolonged preventive service(s) (beyond the typical service of the primary procedure) in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (listed separately in addition to code for preventive service)
|Facility: US$62.35, Non-facility: US$65.95