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The final rule for the 2020 Physician Fee Schedule gives hospitals and health systems more opportunities to use remote patient monitoring and paves the way for new telehealth and mHealth programs.

By Eric Wicklund

November 05, 2019 – Hospitals and health systems will see Medicare reimbursement for more remote patient monitoring services, according to finalized guidelines recently released by the Centers for Medicare & Medicaid Services.

In its final rule on Chronic Care Remote Physiologic Monitoring, CMS has expanded the reimbursement plateau for RPM services delivered “incident to” general supervision, and has added a new code – 99458 – for patients receiving an additional 20 minutes of mHealth services in a given month.

The two changes were part of a package of mHealth and telehealth amendments proposed in August for the 2020 Physician Fee Schedule, designed to expand opportunities to use connected health services for came management and coordination.

“These new changes to RPM services advance the ability to improve the patient care experience and allow more cost-effective business models,” Nathaniel Lacktman, a partner in the Foley & Lardner law firm and chair of its national Telemedicine & Digital Health Industry Team, and Emily Wein, a healthcare lawyer with the firm, said in a blog post.

The amendments follow the introduction of three CPT codes in last year’s physician fee schedule for certain – and limited – connected health services. Healthcare providers and telehealth experts hailed the new codes as a step in the right direction for digital health adoption, though many also said they were too cumbersome and small to move the needle.

The “incident to” revision aims to expand RPM reimbursement by allowing more providers and business models to use the technology.

An “incident to” service is defined by CMS as a service performed under the supervision of a qualified healthcare professional and billed to Medicare in the name of that professional, subject to certain requirements. CMS originally mandated that RPM services could not be delivered incident to the physician’s service, but later issued a correction allowing some incident to reimbursement by certain members of the care team under direct supervision of the physician.

That, however, created a new dilemma. Direct supervision requires both physician and care team member to be in the same building at the same time, a challenge for many telehealth companies and health systems who see RPM as a means of connecting care providers in one place with patients in another location, such as the home. With that in mind, telehealth advocates urged CMS to allow RPM use under general supervision, which, according to Medicare, doesn’t require both parties to be in the same building and can be accomplished through telemedicine.

With this final rule, CMS has agreed.

“Because care management services include establishing, implementing, revising, or monitoring treatment plans, as well as providing support services, and because RPM services include establishing, implementing, revising, and monitoring a specific treatment plan for a patient related to one or more chronic conditions that are monitored remotely, CMS will now include CPT codes 99457 and 99458 as designated care management services,” Lacktman and Wein wrote in their analysis. “As designated care management services, RPM can be furnished under general supervision. The regulation, at 42 CFR § 410.26(b)(5), states that designated care management services can be furnished under the general supervision of the ‘physician or other qualified health care professional (who is qualified by education, training, licensure/regulation and facility privileging)’ when these services or supplies are provided ‘incident to’ the services of a physician or other qualified healthcare professional.”

“Starting January 1, 2020, RPM services reported with CPT codes 99457 and 99458 may be billed ‘incident to’ under general supervision,” they concluded. “The physician or other qualified healthcare professional supervising the auxiliary personnel need not be the same individual treating the patient more broadly. However, only the supervising physician or other qualified healthcare professional may bill Medicare for ‘incident to’ services.”

The new CPT code, meanwhile, gives care providers more reimbursable time each month to spend in virtual care with their patients.

Under the new guidelines, CPT code 99457 covers the first 20 minutes per month of RPM services, defined as “remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.” CPT code 99458 would then be used for an additional 20 minutes.

In a setback, CMS is preventing federally qualified health centers (FQHCs) and rural health centers (RHCs) from billing for RPM services.

“CMS made clear that RPM services are not separately billable under Medicare for rural health centers (RHCs) or federally qualified health centers (FQHCs),” Lacktman and Wein wrote. “RHCs are paid an all-inclusive rate when a medically necessary, face-to-face visit is furnished by an RHC practitioner. FQHCs are paid the lesser of their charges or the FQHC Prospective Payment System rate when a medically-necessary, face-to-face visit is furnished by an FQHC practitioner.”

“Both the RHC all-inclusive rate and the FQHC Prospective Payment System rate include all services and supplies furnished ‘incident to’ the visit,” they added. “Services such as RPM are not separately billable because they are already included in the RHC all-inclusive rate or FQHC Prospective Payment System payment, CMS explained.”

In their post, Lacktman and Wein also noted several questions asked during the comment period that were not addressed by CMS. They include requests to better define “physiologic parameters,” “digitally transmitted data,” “medical device” and “interactive communication,” as well as questions on whether RPM can be used outside of the chronic care spectrum, what types of providers can bill for services and whether an established provider-patient relationship is needed before RPM is put into play.

“While CMS did not answer these questions, it understands the frustration commenters express with the current code descriptors and plans to consider these questions in future rulemaking,” they wrote.

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