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WASHINGTON — Leaders in Congress have reached a sweeping deal to ease Medicare pay cuts to doctors, make major changes to post-pandemic Medicaid policy, and to help prepare for future pandemics.

Lawmakers are aiming to pass a health care policy package along with legislation to fund the federal government by Friday. The details of the omnibus spending package were confirmed by two lobbyists and two congressional aides.

The bill’s text is not yet finalized, and the deal is still subject to changes.

Medicare policy

Doctors were facing down 4.5% Medicare pay cuts at the end of the year and had pleaded with Congress to cancel the cuts altogether. Lawmakers met them halfway: In 2023, physicians will face a 2% cut, and in 2024, the amount will increase to 3.5%, two lobbyists said.

Lawmakers are also expected to waive a rule that would have resulted in further cuts to Medicare. The Medicare hospital at home program is also supposed to be extended for two years.

Some of the package will be paid for by extending future Medicare pay cuts until 2032. Leftover Medicare funds from the gun safety bill that Congress passed earlier this year were also used to pay for some of the policy.

Some behavioral health policy could also be included, as well as two-year extensions of programs that support safety-net and rural hospitals.

Medicaid policy

Lawmakers also agreed to allow states to begin kicking ineligible people off their Medicaid rolls in April, regardless of when the Covid-19 public health emergency ends. Previously, states had to agree to hold off on re-evaluating people’s eligibility in exchange for more federal Medicaid money, and the end date was contingent on the end of the public health emergency.

In addition, lawmakers are expected to extend the Children’s Health Insurance Program until 2029. Children on Medicaid are expected to get one year of continuous eligibility, which means they won’t lose insurance even if their circumstances change. But while Democrats fought to require every state Medicaid program cover postpartum care for a year, the final legislation has fallen short and instead would only make permanent 33 states’ extended coverage.

Advocates have long argued that expanded coverage could help reverse staggering maternal and infant mortality rates, among the worst for high-income countries. Thirty-three states had already extended care for a year after Congress passed the option in last year’s American Rescue Plan, but among the 17 holdouts are some of the states with the highest maternal mortality rates in the country — figures that have only surged during the pandemic.

More robust federal Medicaid funding for Puerto Rico and other territories will be extended for five years, which offers some certainty for territorial governments and providers, according to one congressional aide and one lobbyist.

Telehealth

Pandemic-era telehealth flexibilities are expected to be extended for two years, which was a major ask from the health care industry.

Pandemic preparedness

The pandemic preparedness package negotiated by Senate health committee leaders Patty Murray (D-Wash.) and Richard Burr (R-N.C.) also made it in the deal, though it was narrowed somewhat, according to one lobbyist and one congressional aide. It is unclear precisely which policies made the final cut.

The package included a policy that would require Senate confirmation for the director of the Centers for Disease Control and Prevention.

No diagnostics reform

A provision that would have given the Food and Drug Administration more authority to regulate in-house tests developed in clinical labs like academic medical centers and hospitals was squeezed out of the agreement. While the device industry and federal regulators backed the measure, arguing it would close an oversight gap that helped Theranos thrive with unproven tests, labs argued it would hobble their ability to quickly diagnose patients.

Ultimately, those labs found sympathy with some Republicans, namely Rep. Cathy McMorris Rodgers (Wash.), who stands to lead the powerful House Energy and Commerce committee next year, two sources familiar with the deliberation said. Besides being hesitant to give the FDA more authority, Rodgers argued that the bill, called the VALID Act, had not gone through any House hearings or markup, those two people said. FDA Commissioner Robert Califf has said that if the legislation fails to make it into the omnibus, the agency will begin rulemaking itself to bring these labs under its regulatory umbrella.

VALID’s omission from the bill is “disappointing” because many lawmakers in both parties supported the measure, Scott Whitaker, CEO of device lobby AdvaMed, said. “The last thing we need is more Theranos-type tests in the health care system.”

The package is also expected to include some FDA reforms connected to extending several regulatory flexibilities that Congress punted to this month to bring negotiators back to the table after they failed to reach a deal in September. At least reforms to the FDA’s accelerated approval process, FDA’s authority to regulate cosmetics, and policy on encouraging diversity in clinical trials are expected to make the cut, two lobbyists said.

Nursing school repayments

Nursing schools are also expected to get some relief from fees they were supposed to have to pay back to the government following a mistake by the government.

The federal government miscalculated funding for hospital-based nursing schools for nearly two decades, and now the Biden administration was forcing them to pay up during the worst health care workforce crisis in decades.

Coverage of emergency use authorization products

The government has been buying Covid-19 vaccines and providing them for free to everyone, but that arrangement will likely end once the stockpile of government-bought vaccines runs out. When it became clear that the Biden administration was going to have a difficult time getting Republicans to agree to more pandemic preparedness funding, White House officials began preparing the public for commercial coverage.

To help with that transition, the bill would allow Medicare Part D plans to cover coronavirus products through 2024 that have been authorized for emergency use but not approved.

Doctor training on opioid use

The end-of-year package is expected to include a bipartisan bill that would mandate doctors be trained on treating people with opioid use disorder, despite opposition by the American Medical Association.

A related piece of legislation, called the MAT Act, that would lower barriers to prescribing opioid use disorder medication like buprenorphine, is also in the final package.

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WASHINGTON (AP) — The Biden administration said Thursday that the COVID-19 public health emergency will continue through Jan. 11 as officials brace for a spike in cases this winter.

The decision comes as the pandemic has faded from the forefront of many people’s minds. Daily deaths and infections are dropping and people — many of them maskless — are returning to schools, work and grocery stores as normal.

The public health emergency, first declared in January 2020 and renewed every 90 days since, has dramatically changed how health services are delivered.

The declaration enabled the emergency authorization of COVID vaccines, testing and treatments for free. It expanded Medicaid coverage to millions of people, many of whom who will risk losing that coverage once the emergency ends. It temporarily opened up telehealth access for Medicare recipients, enabling doctors to collect the same rates for those visits and encouraging health networks to adopt telehealth technology.

WATCH: Health experts worry effort to vaccinate against COVID variants moving too slowly

Since the beginning of this year, Republicans have pressed the administration to end the public health emergency. President Joe Biden, meanwhile, has urged Congress to provide billions more in aid to pay for COVID-19 vaccines and testing. The federal government ceased sending free COVID-19 tests in the mail last month, saying it had run out of money.

Public health officials are urging people age 5 and older to get an updated COVID-19 booster alongside a flu vaccine this fall before a predicted winter coronavirus surge and a nasty flu season. As of last weekend, about 13 million people had gotten the updated booster, which targets the omicron variant, according to White House COVID-19 coordinator Dr. Ashish Jha.

The administration has said it would provide 60 days notice before it ends the public health emergency.

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As the Center for Connected Health Policy has continued to update our Telehealth Policy Finder over the course of 2022, a few new elements are beginning to emerge in newly passed legislation and in adopted Medicaid policies.  While these may not yet be trends, they have potential to develop into trends, as it is common for states to research and copy telehealth policy language from other states. Policy elements CCHP has noted as potentially emerging trends are listed below:

In-Person Exam Requirement – Congress started this with the passage of the SUPPORT for Patients and Communities Act which requires an in-person visit occur within 6 months prior to an initial telehealth mental health visit and every 12 months afterward in the Medicare program.  A few states have picked up on this policy, but not always as it relates to reimbursement.  For example, a new Alabama law now requires in its Code regulating health professionals that if a physician or group provides telehealth medical services more than four times in a 12-month period to the same patient for the same medical condition without resolution, the physician must see the patient in person or refer the patient to a physician who can provide the in-person care.  Tennessee’s private payer law specifies that evidence of an in-person encounter between the health care provider and the patient within sixteen months prior to the interactive event is required (although there is an exception during a state of emergency).

Allowance for Out-Of-State Providers:  Prior to COVID, it was rare to find an explicit allowance for a provider from another state to practice within their state, even if delivering services to a patient that they have a prior relationship with and is a permanent resident of the state they are licensed in (as is often the case for college students and out-of-town vacationers).  CCHP has noted a few states that have recently passed legislation to make this allowance for specific professions and in certain circumstances, including Alabama, Virginia, and Illinois.

Prescribing Requirements and Payer Restrictions in Private Payer Law:  While in the past prescribing requirements were confined to telehealth practice standards within professional codes and regulation (often for pharmacists, physicians and APRNs), two states are now also including mentions of them in their private payer law.  For example, Maine is requiring that a clinical evaluation be conducted either in person or via telehealth before a written prescription is ordered, and the law also prohibits insurers from placing any restrictions on prescriptions through telehealth that is within their scope of practice.  Oklahoma also now has a similar law which prohibits insurers from placing restrictions on prescribing medications through telemedicine that are more restrictive than what is typically required in federal or state law.

Professional Telehealth Practice Standards in Medicaid Policy:  Typically, standards related to forming a provider-patient relationship are contained within states’ Professions and Occupations Code. However, Arkansas recently updated their Medicaid provider manual regulations to incorporate such standards within its policy.  As many Arkansas boards also have their own telehealth practice standards (See: CCHP AR Professional Board Standards), this can create complexity for providers navigating both policies. To keep up to date on each states’ policies, search in CCHP’s Telehealth Policy Finder; and for recent legislation, visit CCHP’s Pending Legislation webpage.

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The declared Public Health Emergency (PHE) under the Public Health Service Act will apparently be renewed at least one further time beyond its current July 15, 2022 expiration, as the Department of Health and Human Services (HHS) has repeatedly committed to provide a 60-day notice prior to the termination or expiration of the PHE, and mid-May has passed without any such notice. Assuming that HHS issues the maximum 90-day renewal in line with the length of past renewals, such a renewal would extend the PHE through October 13, 2022.

Baker Donelson has launched a series of articles examining transition matters as the emergency declarations are anticipated to expire, including that providers will need to brace for expanded uninsured populations as Medicaid rolls are trimmed by state Medicaid agencies upon the reinstatement of eligibility redeterminations. Notably, each extension raises the magnitude of the looming Medicaid enrollment drop-off due to natural shifts in income and the like that occur over time.

Certain telehealth waivers implemented in connection with the PHE have already been legislatively extended for 151 days following the end of the PHE, with permanent changes possible given a flurry of recent telehealth legislative activity. The apparent additional extension of the PHE would thus lengthen the waiver of certain telehealth coverage requirements, providing a temporary reprieve to the large constituencies of providers and patients who have been advocating for such temporary waivers to become permanent.

Additionally, Public Assistance funding through the Federal Emergency Management Agency (FEMA) has not yet shut down, but FEMA has issued a year-end deadline for public entities and eligible non-profits to submit funding requests for eligible pandemic response costs incurred through July 1, 2022.

On the other hand, other governmental flexibilities spurred by the pandemic are already winding down, as the Department of Homeland Security has ended the temporary policy allowing employers to accept expired List B documents for I-9 purposes.

We will continue to monitor developments related to the end of the PHE and other pandemic-related governmental programs and waivers.

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APRIL 13, 2022•STATEMENTS AND RELEASES

Vice President Harris to Host First-Ever Meeting with Cabinet Officials on Maternal Health

On Wednesday, April 13, 2022, during Black Maternal Health Week, Vice President Kamala Harris will convene a meeting with Cabinet Secretaries and agency leaders to discuss the Administration’s whole-of-government approach to addressing maternal mortality and morbidity. The Vice President will convene leaders across the federal government – including agencies that may not have historically taken a leading role addressing the maternal health crisis.
 
In December 2021, Vice President Harris convened the first-ever federal Maternal Health Day of Action, where she announced a historic Call to Action to improve health outcomes for parents and infants in the United States. This resulted in the Administration’s announcement of private sector and public sector investments. Ahead of the meeting with Cabinet officials, the Administration is following up with additional actions to address maternal health, and to combat the systemic inequities that lead to worse maternal outcomes for Black, Native American, and rural women.
 
New Announcements:

• 11 Additional States and D.C. Ask to Extend Medicaid and CHIP Coverage to a Full Year After Pregnancy under American Rescue Plan: The American Rescue Plan is working to make Medicaid and CHIP coverage for 12 months after pregnancy a reality for people across the country. The Vice President called on states to expand their postpartum coverage during her Call to Action in December.
  • The Centers for Medicare & Medicaid Services (CMS) has approved Louisiana, Virginia, New Jersey, and Illinois’ extension of Medicaid and CHIP coverage for 12 months after pregnancy on or before April 1, 2022. CMS is also working with another eleven states and the District of Columbia to extend postpartum coverage for a full year after pregnancy, including: California, Indiana, Kentucky, Maine, Michigan, Minnesota, Oregon, New Mexico, South Carolina, Tennessee, and West Virginia.  In addition, a number of other states have announced that they are working to extend Medicaid and CHIP coverage to 12 months after pregnancy, and CMS looks forward to working with those states.
  • In order to receive federal funds and to ensure consistency with federal standards, including those set by the American Rescue Plan, states must go through a formal process run by CMS. Medicaid covers more than 40 percent of births in the United States, and extending this coverage will bring the peace of mind of health coverage to parents and children during the vulnerable post-partum period. 
  • Based on HHS estimates, approximately 720,000 people would benefit if all states were to adopt the American Rescue Plan’s new option to extend post-partum Medicaid and CHIP coverage for a full 12 months.
• “Birthing-Friendly” Hospital Designation: CMS is proposing the “Birthing-Friendly” hospital designation to drive improvements in maternal health outcomes and maternal health equity. The “Birthing-Friendly” hospital designation would assist consumers in choosing hospitals that have demonstrated a commitment to maternal health. The Administration announced this new designation during the White House Maternal Health Day of Action Summit.
  • Initially, the designation would be awarded to hospitals based on attestation that the hospital has participated in maternity care quality improvement collaboratives and implemented best practices that advance health care quality, safety, and equity for pregnant and post-partum patients.
  • Data will be submitted by hospitals for the first time in May 2022, and CMS will post data for October to December 2021 in fall 2022. Criteria for the designation may be expanded in the future.
• Engaging the Health Care Industry to Improve Health Outcomes: In Summer 2022, CMS will convene health care industry stakeholders – including health care facilities, insurance companies, state officials and providers – to focus on industry commitments to improve health outcomes experienced by pregnant and postpartum people. CMS and experts will share best practices and commitments and request that health care industry leaders make commitments to advance maternal health.
• Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Programs: The Department of Health and Human Services (HHS), through the Health Resources and Services Administration (HRSA), announced approximately $16 million to strengthen Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Programs through seven awards supporting eight states.
  • These awards will advance data and technology innovations to support positive maternal and child health outcomes in states and communities, and focus on addressing health disparities.
• State Maternal Health Innovation and Implementation (State MHI) Program: State MHI supports state-level development and implementation of proven strategies to improve maternal health and address maternal health disparities. The new funding, $9 million, will continue to build state capacity to deliver high-quality maternity care services and provide training for maternal care clinicians. It also adds a component to enhance the quality of state-level maternal health data through better collection, reporting and analysis. The program will fund up to nine cooperative agreements, and each will receive up to $1 million over five years.
• Maternal Health Best Practices: HHS, through the Health Resources and Services Administration (HRSA), is also, on telehealth.hhs.gov, posting a new Maternal Health Best Practice Guide for providers to incorporate telehealth for prenatal and postpartum care, and monitoring within high-risk pregnancy. Through remote patient monitoring, screening and treatment for postpartum depression, and lactation consulting, maternal telehealth can help reduce barriers to access to critical care for mothers before, during and after a pregnancy.

Previous Actions Announced since the Vice President’s Call to Action in December

• Investing in Doulas: HHS announced the availability of $4.5 million for hiring, training, certifying, and compensating community-based doulas in areas with high rates of adverse maternal and infant health outcomes, doubling the number of Healthy Start doula programs nationwide.
• Title X: HHS restored access to Title X family planning services nationwide to fill service gaps caused by more than a quarter of Title X providers withdrawing from the program over the past two and a half years in response to the previous administration’s Title X rule. HHS awarded $256.6 million in grant funding to support 76 grantees to deliver equitable, affordable, client-centered, and high-quality family planning services.
• FY23 Budget Request: The President’s budget includes $470  million to: reduce maternal mortality and morbidity rates; expand maternal health initiatives in rural communities; implement implicit bias training for healthcare providers; create pregnancy medical home demonstration projects; and address the highest rates of perinatal health disparities, including by supporting the perinatal health workforce.

Additional Background

• As Vice President, Kamala Harris has worked closely with President Biden and other leaders in the Administration to improve outcomes for Black women and their families.
  • The White House released a Presidential Proclamation to mark Black Maternal Health Week in 2021 and 2022.
  • In December 2021, the Vice President led a Maternal Health Day of Action Summit, noting the urgent need to address this crisis.
    • At the Summit, the Vice President announced guidance to help states provide 12 months of continuous postpartum coverage through their Medicaid programs, up from 60 days; a new HHS report showing the impact of state extensions of Medicaid postpartum coverage to 12 months; and CMS’s plan to propose the establishment of a “Birthing-Friendly” hospital designation. She also announced that more than 20 companies and nonprofits have pledged to invest over $150 million and take other critical actions to address the maternal health crisis.
  • In April 2021, the Vice President hosted a roundtable on Black Maternal Health with Domestic Policy Advisor Ambassador Susan Rice. She was joined by women who shared their experiences with complications from pregnancy, childbirth, and postpartum as well as their work in advocacy and research, highlighting the disparities that Black women face in maternal health.

• The Omnibus spending bill passed in March and signed by the President includes both the Maternal Health Quality Improvement Act and an expansion of the Rural Maternal and Obstetric Modernization of Services (Rural MOMS) program. 
  • These foundational bills authorize and improve programs to address the maternal mortality crisis in this country and build on current funding at the Centers for Disease Control & Prevention (CDC) and Health Resources and Services Administration (HRSA) to reduce maternal morbidity and mortality.
• Last fall, the Administration released the first-ever National Strategy on Gender Equity and Equality, which includes its vision to strengthen health care and  women’ health, including through addressing the maternal mortality crisis in the United States and abroad.
• As a Senator, Vice President Harris was a champion on the issue of maternal health. She brought racial disparities in maternal mortality, particularly for Black women, to the forefront legislatively, increasing awareness among her colleagues and leading to a broader discussion of racial disparities across other health issues.
  • She convened roundtables, lifted up local organizations that are focused on the issue, and ensured that initiatives on maternal health included references to racial disparities and relevant solutions.

She introduced several bills in the Senate specifically targeted to addressing racial disparities in maternal mortality, including the Maternal CARE Act and the Black Maternal Health Momnibus Act.

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Three US senators have introduced legislation to increase access to virtual mental health services for children and underserved populations.

By Mark Melchionna

April 12, 2022 – To expand access to virtual mental health services, US Sens. Sherrod Brown (D-OH), John Thune (R-SD), and Ben Cardin (D-MD) have introduced the Medicaid Ensuring Necessary Telehealth is Available Long-term (MENTAL) Health for Kids and Underserved Act.

Historically, and especially during the COVID-19 pandemic, many people found it challenging to access necessary mental health services.

Data from the Centers for Disease Control and Prevention also showed that pediatric mental health services decreased by 43 percent in March 2020, due to the beginning of COVID-19 restrictions. This also led to a disruption in education for children.

Brown, Thune, and Cardin, members of the Senate Finance Committee, believe that the MENTAL Health for Kids and Underserved Act can help boost education and mental health services through telehealth.

The Senate Finance Committee has jurisdiction over Medicaid and the Children’s Health Insurance Program (CHIP). The new bill directs the Centers for Medicare and Medicaid Services (CMS) to assist states in learning how to widen access to services while under the two programs that cover low-income populations and children.

The MENTAL Health for Kids and Underserved Act would also require CMS to provide guidance on how to integrate behavioral services best and how to implement them in school-based settings, including full-service community schools.

“As a result of the pandemic, kids across the country – especially those in underserved communities – have faced major disruptions to their educational and behavioral development, and schools have not had the resources they need,” said Brown in the press release. “We need to expand behavioral telehealth options for students, and this is one commonsense, bipartisan step to do that.”

Since the start of the COVID-19 pandemic, there have been various efforts to increase access to pediatric healthcare.

To assist schools in providing medical and mental health services, Sen. Brown introduced the bicameral Full-Service Community School Expansion Act in February 2021. This bill intends to help create youth development programs and maintain education courses serving various populations.

In November 2021, TD Bank awarded a grant to support Nemours Children Health initiative, hoping to enhance pediatric care. Researchers noted that the COVID-19 pandemic increased the need for pediatric mental health services but also limited access to them. Using the grant, Nemours plans to create an integrated model of care to meet the needs of children in Florida.

Another recent study provided data on how the integration of pediatric behavioral healthcare into primary care.s. Developed by researchers from Boston Medical Center and Boston University School of Public Health, the program sought to assist marginalized children in receiving robust and more accessible behavioral healthcare.

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By Robert King Apr 13, 2022 03:11pm

The Department of Health and Human Services (HHS) has extended the COVID-19 public health emergency for another 90 days and potentially for the final time. 

The PHE, which gives key flexibilities to providers and states, will not expire in July. The PHE was originally expected to expire April 16. 

It remains unclear whether HHS will extend the emergency for a second time this summer, but providers will likely know the answer in a month. HHS Secretary Xavier Becerra has promised a 60-day heads-up to providers and states that the PHE will end. 

The PHE went into effect in 2020 at the onset of the pandemic and granted major flexibilities to providers and states. It gave more flexibility to providers to waive key reporting requirements and removed barriers to telehealth reimbursement under Medicare. 

In addition, states may not drop anyone off Medicaid rolls for the duration of the PHE. States are readying to examine thousands of Medicaid enrollees to redetermine whether they are eligible.

Some members of Congress and provider groups have wanted HHS to give even greater lead time, but Becerra has indicated he will not go beyond the 60 days. He has also previously said any decision will be based on the science and the status of COVID-19 in the country. 

COVID-19 cases have spiked in recent weeks due to a new subtype of the omicron variant.

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By: Collin Couey on March 25, 2022

Imagine spending precious time and money setting up a remote patient monitoring program at your practice only to realize it’s too costly to maintain. If you’re on the fence about setting up such a program, you can avoid that worst-case scenario. We’ll break down the ins and outs of remote patient monitoring reimbursement so you can feel confident that it makes financial sense for you.

 What is remote patient monitoring?

Remote patient monitoring is a healthcare delivery model that uses tech to monitor patients’ health outside of your clinic or practice. Put simply, remote patient monitoring uses electronically transmitted patient health data to assess and monitor patient vitals remotely.

Practices that can master the reimbursement component shouldn’t hesitate to reap the many benefits of a remote patient monitoring program. For you, it’s a chance to get a more complete look at your patient’s overall condition while boosting your marketing and patient retention efforts. For patients, remote monitoring helps them establish a chronic care management routine and gives them more control over their health.

Understand how remote patient monitoring coverage works

Remote patient monitoring reimbursement is pretty simple from a coverage perspective because it’s covered by Medicare as well 27 state Medicaid services. Additionally, many commercial insurance providers cover remote monitoring using their telehealth coverage policies. In fact, the number of commercial insurance providers who offer remote patient monitoring coverage has increased due to the COVID-19 pandemic.

When planning a remote patient monitoring program, it’s important to take stock of your practice’s patient population to determine whether your practice is a good candidate to make a continual profit. For instance, if you have a lot of Medicaid and Medicare patients with chronic conditions (heart disease, high blood pressure, diabetes, etc.), you probably have enough patients to set up a remote patient monitoring program right away.

On the other hand, if you’re a smaller independent physician who mostly sees privately insured patients who don’t experience chronic conditions, you might not be well set-up to start a remote patient monitoring program today.

Additionally, remote patient monitoring should be one of your first thoughts for patients with chronic conditions who prefer telehealth, telemedicine, or at-home treatment who are insured or qualify for Medicare or (in some cases) Medicaid services because they are covered and your reimbursement process will be simple.

 Key considerations: If you want to start a remote patient monitoring program, it’s important to have a firm grasp on your patient population. Running patient surveys to gauge interest is a great place to start once you know if your patient population can support a robust and profitable remote patient monitoring program.

Know which CPT codes are crucial for remote patient monitoring reimbursement

If you want to be reimbursed, you need to know which Current Procedural Terminology (CPT) codes are important for remote patient monitoring services.

The five primary Medicare RPM codes are CPT codes: 99453, 99454, 99457, 99458, and 99091. Remote patient monitoring codes are considered evaluation and management (E/M) services and can be ordered and billed only by a healthcare provider or non-physician provider who are eligible to bill Medicare E/M services.

Most remote patient monitoring services will be billed under four codes that are split into two categories: service codes and timed remote patient monitoring management codes.

Remote patient monitoring service codes

CPT code 99453 and 99454 are practice expense only codes specifically related to device set-up and education and are valued to cover clinical staff time, supplies, and equipment, including the medical device for remote monitoring.

Remote patient monitoring management codes

• CPT code 99457 reimburses medical professionals and healthcare organizations for their time spent performing duties related to interpreting remote monitoring physiologic data such as medical decision-making to assess patient stability, communication with patients either in person or via telehealth service, and oversight of the management and coordination of service.
• CPT code 99458 is an add-on code to 99457 for each additional 20 minutes of remote physiologic monitoring treatment management service provided in a 30-day calendar month.
• CPT code 99091 is for the collection and interpretation of physiologic data digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional. It can also be billed monthly but has more requirements than CPT codes 99457 and 99458.

 Key considerations: Practices risk financial losses if they fail to code care correctly with the Center for Medicaid and Medicare Services (CMS), so if your care organization is thinking about adopting a RPM service, you need to know what CPT codes to worry about and how they affect your practice.

For a much more detailed breakdown of how CMS and remote patient monitoring work together, check out A Guide to Remote Patient Monitoring and CMS.

Calculate how much Medicare pays per CPT code assigned to remote patient monitoring

It’s important to understand how much you can expect to get paid per patient for your remote monitoring services.

Here’s how remote patient monitoring reimbursement breaks down using average Medicare reimbursement:

• Using CPT code 99453, Medicare pays a one-time payment of $18.48 for initial patient enrollment into the program. This includes the setup of the remote patient monitoring device, the delivery of the device, patient education, and receiving initial remote patient monitoring services.
• Using CPT code 99454, Medicare provides a base monthly payment of $55.77 for continuously monitoring patient data transmitted from the device (like blood pressure or blood sugar levels) as well as ongoing management of the device.
• Using CPT code 99457, Medicare provides a monthly payment of $50.18 for 20 minutes of communication between the patient and caregiver or practitioner specifically pertaining to the data transmitted by the device.
• Using CPT code 99458, Medicare provides an additional $40.84 if the time spent exceeds 20 minutes but is less than 40 minutes. If you spend more than 40 minutes per month, Medicare will provide an additional $40.84 dollars. There is no additional reimbursement after 40 minutes.
• Using CPT code 99091, Medicare provides a monthly payment of $56.41 for collecting and interpreting the transmitted and stored physiologic data provided by the remote patient monitoring device. The amount of time spent interpreting and analyzing must be at least 30 minutes to qualify for reimbursement.

A single remote patient monitoring patient will earn your healthcare organization $2,928.48 per year, assuming you get reimbursed the maximum reimbursement per month.

If your practice enrolls 50 patients into a remote monitoring program, and, assuming you get reimbursed for the maximum amount you can each month for each payment, you’d earn $147,348 in annual Medicare remote patient monitoring reimbursement. Even after you factor in the cost of remote patient monitoring software, you’d still be yielding a significant and consistent amount of revenue.

 Key considerations: Realistically, your care organization will likely only meet the initial 20 minutes for reimbursement, and you also might not consistently meet CPT code 99091 each month, so it’s important to factor in how much time you can feasibly devote to each patient enrolled in the program when calculating potential revenue.

Understand which CMS guidelines pertain to remote patient monitoring reimbursement

You must understand the CMS guidelines for remote patient monitoring to reduce the likelihood that your claims get denied.

In order to even qualify for reimbursement, CMS expects your practice to follow these remote patient monitoring requirements:

• Charge Medicare Part B patients a 20% copayment.
• Receive verbal or written consent from a patient to receive remote patient monitoring services.
• Ensure the remote patient monitoring services are ordered by a physician or other “qualified healthcare professional” (nurse practitioner, certified nurse specialist, or physician assistant).
• Monitor patients for at least 16 days per billing period.
• Verify physiologic data can be wirelessly synced for evaluation.
• Confirm each remote patient monitoring device meets the U.S. Food and Drug Administration’s definition of a medical device.
• Ensure the remote patient monitoring device can digitally and automatically upload patient physiologic data which cannot be self-recorded or self-reported by the patient.

Key considerations: Meeting these requirements should be relatively easy for any healthcare organization, but it’s important to have a complete understanding of them in order to avoid claims denials and scrutiny.

Remote patient monitoring allows practices to provide an important service while also being reimbursed

Remote patient monitoring is swiftly becoming more important than ever for patient care because of the shifting necessity and popularity of telehealth, telemedicine, and virtual care. It’s also an aspect of value-based care, which is a pricing model that incentivizes your practice based on the quality of services you provide to patients.

Adopting a remote patient monitoring program will help your healthcare organization get a more complete look at your patient’s overall condition, give your patients more control over their health, and will make your practice more marketable while helping retain patients.

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