CMS has issued its final update to the 2019 Physician Fee Schedule and Quality Payment Program, including three new CPT codes for reimbursement of remote patient monitoring. The changes mark an important step in the government’s acceptance of mHealth and telehealth technology.

By Eric Wicklund

– The Centers for Medicare & Medicaid Services has finalized plans to reimburse healthcare providers for certain remote patient monitoring and telehealth services.

CMS this week issued its final 2019 Physician Fee Schedule and Quality Payment Program, opening the door to reimbursement for connected care services that enable providers to manage and coordinate care at home. The changes are focused on three new CPT codes that separate RPM services from telehealth, which is more restricted.

“This provides opportunities for patients around communicating with providers remotely,” CMS Administrator Seema Verma said during a Thursday afternoon conference call with reporters. “We’ve never had this in the program at large. There has been a telehealth benefit mostly for rural providers, but access to care is not just a rural issue, it’s something that patients struggle with across the country.”

“This is an historic change in terms of increasing access and it’s also a great example of some of the efforts that we’re trying to make around supporting innovation,” she added. “This has been happening in the private market and I think the opportunities and the impact could be tremendous. We’re excited to be able to harness this innovation for Medicare beneficiaries.”

Alongside the 2,378-page rule, CMS also issued a fact sheet breaking down the changes.

When the changes were proposed this past July, Nathaniel Lacktman, a partner and healthcare lawyer with Foley & Lardner who chairs the firm’s Telemedicine Industry Team and co-chairs its Digital Health Work Group, said they represent a “landmark change” in government efforts to embrace telehealth and mHealth.

He made that point again in a blog released today.

“With the new CPT codes for Chronic Care Remote Physiologic Monitoring, RPM will become an area of significant upside potential over the coming years,” Lacktman said. “Hospitals and providers using RPM and non-face-to-face technologies to develop patient population health and care coordination services should take a serious look at these new codes, and keep abreast of developments that can drive recurring revenue and improve the patient care experience.”

The new CPT codes are:

  • CPT code 99453: “Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.”
  • 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.”
  • 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.”

Among the significant changes highlighted by Lacktman, CPT 99457 allows RPM services to be performed not only by the physician or qualified healthcare professional, but also by “clinical staff,” such as RNs and medical assistants. This could make it easier for healthcare providers to figure RPM programs into their workflow.

Lacktman also noted the new guidelines aren’t specific about the technology that would qualify for reimbursement.

“Many advocates asked CMS to clarify the kinds of technology covered under CPT codes 99453, 99454, and 99457,” he wrote in his blog. “Some groups gave examples of the kinds of technology they believe these codes should cover, such as software applications that could be integrated into a beneficiary’s smartphone, Holter-Monitors, Fitbits, or artificial intelligence messaging. Other examples included behavioral health data and data from wellness applications, or results of patients’ self-care tasks. Unfortunately, CMS did not offer any specifics in the final rule on what technology qualifies, but CMS does plan to issue forthcoming guidance to help inform practitioners and stakeholders on these issues.  This may likely be in the form of a CMS MLN article or Q&A.”

Aside from the new CPT codes, CMS has issued an interim final rule to eliminate geographic restrictions for telehealth services furnished for purposes of treatment of a substance use disorder or a co-occurring mental health disorder for services furnished on or after July 1, 2019. That ruling – a provision from the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act – would also make the home an originating site, enabling consumers to receive treatment through telehealth at home.

Also this week, CMS released final calendar year 2019 and 2020 payment and policy changes for Home Health Agencies and Home Infusion Therapy Suppliers. Among the changes listed, CMS will no longer require the home health agency to prove medical necessity for a home visit in place of an office visit, giving HHAs more leeway to use RPM and telehealth.

“CMS is finalizing its proposal to define remote patient monitoring in regulation for the Medicare home health benefit and to include the cost of remote patient monitoring as an allowable cost on the HHA cost report,” the agency said. “Studies note that remote patient monitoring has a positive impact on patients as it allows patients to share more live-time data with their providers and caregivers, which will lead to more tailored care and better health outcomes. CMS believes that defining remote patient monitoring and including such costs as allowable costs on the HHA cost report could encourage more HHAs to adopt the technology.”

These announcements follow by one week a CMS proposal to expand the use of telehealth and telemedicine in Medicare Advantage plans.

As part of a 362-page proposal issued on October 26, the Centers for Medicare & Medicaid Services (CMS) is proposing to eliminate geographical restrictions on telehealth access in MA plans by 2020, enabling those in urban areas to use connected health technology. The proposal would also give members more locations to access care, including their own home.

“The Original Medicare telehealth benefit is narrowly defined and includes restrictions on where beneficiaries receiving care via telehealth can be located,” the agency wrote in an accompanying fact sheet. “CMS believes that the additional telehealth benefits in MA will increase access to patient-centered care by giving enrollees more control to determine when, where, and how they access benefits.”

“The proposed rule would give MA plans more flexibility to offer telehealth benefits to all their enrollees, whether they live in rural or urban areas,” the agency stated. “It would also allow greater ability for Medicare Advantage enrollees to receive telehealth from places including their homes, rather than requiring them to go to a health care facility to receive telehealth services. Plans would also have greater flexibility to offer clinically-appropriate telehealth benefits that are not otherwise available to Medicare beneficiaries.”

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