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RPM During COVID-19
Why is RPM receiving increased attention during the pandemic?
A HIMSS article provides a great answer to this question: "RPM can be an especially safe and useful method of care as our healthcare system works to combat COVID-19. … This connected care technology is uniquely helpful for treatment and care during a pandemic such as COVID-19 since it allows clinicians to monitor temperature and pulmonary function, blood pressure, and other appropriate physiology for changes in a patient's disease and symptom progression…
"Clinicians and clinical staff can communicate modifications in medication and other self-care to the patient and provide answers to patient questions. If symptoms and the disease progress to the point that hospital services are needed, providers will be able to arrange for care and transport that will ensure safety of the patient and health personnel…
"For patients who test positive for COVID-19, home-based monitoring for symptom escalation can help reduce the risk of transmission and can target the provision of hospital-based care on a timely basis, should the need arise. As we face a growing hospital bed shortage, allowing for this type of remote monitoring can free up valuable and critical hospital resources to treat the most critical cases."
How has COVID-19 affected coverage of RPM?
In late March, CMS issued specific guidance concerning RPM in its "Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency" interim final rule.
As the previously cited HIMSS article notes, CMS made several changes to how it covers RPM. These are changes for the duration of the pandemic and some permanent fixes. They include the following:
- Going forward, RPM can be used for Medicare patients with acute and/or chronic conditions. This expands coverage from patients with only chronic conditions.
- For the duration of the public health emergency, CMS clarified that RPM could be provided to new and established Medicare patients.
Many commercial payers are following the new Medicare guidelines for RPM during the pandemic. Some states have also included RPM into their telehealth parity laws.
Does the FCC's COVID-19 Telehealth Program include RPM?
Yes. The COVID-19 Telehealth Program was established by the Federal Communications Commission (FCC) in response to the COVID-19 pandemic. Through the program, the FCC is distributing $200 million Congress appropriated under the Coronavirus Aid, Relief, and Economic Security (CARES) Act to help providers deliver telehealth services to patients at their homes or mobile locations. RPM platforms and services are eligible for COVID-19 Telehealth Program funding. Eligible healthcare providers may apply to receive funding support through the COVID-19 Telehealth Program for eligible services and devices purchased on or after March 13, 2020.
How did the guidance issued by the FDA in March affect RPM?
The U.S. Food and Drug Administration (FDA) issued guidance to expand the availability and capability of non-invasive RPM devices to facilitate patient monitoring while reducing patient and healthcare provider contact and exposure during the pandemic. Several devices are included in the guidance, such as FDA-cleared non-invasive blood pressure devices, pulse oximeters, cardiac monitors, and electrocardiograph (ECG) devices.
The FDA's policy, which is limited to the duration of the public health emergency, details how the FDA does not intend to object to companies making modifications in product indications, claims, functionality, or limited modifications to hardware and software.
What is RPM?
RPM is the use of digital technologies to monitor and capture medical and other health data from patients and electronically transmit this information to healthcare providers for assessment and, when necessary, recommendations and instructions. RPM allows providers to continue tracking healthcare data for patients once they are discharged. It also encourages patients to take more control of their health.
What are common patient data types collected via RPM?
Providers can use RPM to collect a range of patient health data, including blood pressure, vital signs, weight, heart rate, blood sugar levels, and physical activity.
What are common examples of RPM devices?
RPM can employ wired or wireless measurement devices. The most common RPM devices are blood pressure monitors, weight scales, cardiac implants, and blood glucose meters. Pulse oximeters will likely become more common due to the COVID-19 pandemic.
Who can deliver RPM services?
Physicians and other qualified healthcare professionals (QHCPs) can provide and bill for RPM. Clinical staff can furnish and manage RPM under the general supervision of the billing provider.
Who can receive RPM services?
Any patient. With that said, a provider should only order/prescribe RPM if captured data is directly relevant to managing a patient's condition(s) (i.e., medical necessity), with such justification documented in the medical record.
What are the benefits of using RPM?
RPM provides a wide range of benefits, including the following:
- Keeping people healthy
- Reducing the number of hospitalizations
- Reducing readmissions
- Reducing hospital lengths of stay
- Reducing patient, provider, and overall healthcare costs
- Permitting older and disabled individuals to remain at home longer and delay or avoid moving into skilled nursing facilities
What do providers need to deliver RPM services?
Since each RPM program is different, the steps to set up programs will vary. The amount of work that providers must complete will differ by RPM program, but these are the general steps for providers who choose to deliver RPM services with minimal external support:
- Speak with private payers to determine coverage (if considering non-Medicare patients)
- Consider who you will take as RPM patients (i.e., establish your patient base)
- Identify the condition(s) you will manage
- Select the device(s) you will use to provide RPM
- Set up an intake procedure to address matters such as initiating the patient care process, training patients on using the RPM device, installing the equipment in patients' homes (if necessary), maintaining the devices, and responding to equipment problems
- Establish policies and procedures
- Train staff
- Market program
While this may seem like a lengthy list, a good RPM program vendor will perform many of these steps, thereby reducing the effort and management required from the provider and staff.
What do patients need to receive RPM services?
This will largely depend upon the RPM device and how data is transmitted from patient to provider. Some devices require patients to access one or more of the following: Wi-Fi; smartphone (in some instances, newer models); and personal computer. Other devices may only require the device itself. Such devices use cellular data to transmit information.
Depending upon the design and/or complexity of the device, patients may need in-person or virtual assistance to set up and use the technology.
Where is data captured via RPM stored?
Where RPM data is stored will depend upon the device. Typically, data is captured and transmitted via a Wi-Fi or cellular network to a central data repository. Types of repositories include an electronic health record (EHR) system or personal health record.
Older devices often stored the information on the device itself, which then required patients to convey the information to their providers. This type of workflow is no longer considered RPM by Medicare and the vast majority of other payers.
How is remote patient monitoring different from telehealth?
RPM is considered a specific subset of telehealth. One can use the phrase ‘telehealth’ to refer to RPM, but telehealth can also refer to many other types of remote healthcare services.
RPM is the use of a device for interaction between providers and patients outside of the provider’s organization. Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical care, patient and professional health-related education, public health, and health administration.
Must patients provide consent to receive RPM services?
Yes, and providers must obtain and document consents in patients' medical records. Medicare allows for informed verbal consent, but other payers may require written.
What rules and regulations do I need to follow when creating an RPM program?
Like any healthcare program, providers should follow HIPAA security and privacy regulations. Providers should also ensure that their RPM devices and technology are compliant with FDA standards. Technology that meets FDA standards can help ensure quality control and assurance, data accuracy, and compliance.
How do I ensure my RPM program is HIPAA compliant?
This essentially boils down to carefully vetting RPM vendors and their devices. Vendors should build their devices so that patient data is encrypted when it is in transit — from patient to provider and vice versa — and when the device that stores the data is not in use.
What are the common types of RPM programs available to providers?
There are a variety of programs and vendors providers can choose from. Generally speaking, they can be broken down into two types: full-service programs and those requiring a self-managed approach. The following summarizes the essential differences between these programs:
- For a full-service program, a practice contracts with an RPM company to supply patients with devices. The practice can either hold a stock of the devices to distribute to patients or have the vendor ship devices directly to patients as the office enrolls them. Many full-service programs allow practices to lease the devices, eliminating upfront costs for each new patient. Devices are often cellular, which is simpler for patients to use. All they need to do is insert batteries into the devices and power them on. Some full-service programs offer technical support to patients. Monthly costs are a higher percentage of reimbursement, but the initial cost for each device is eliminated and staff time to manage the program is greatly reduced.
- For programs requiring a self-managed approach, practices maintain the supply of devices (typically Bluetooth) and contracts with an RPM software vendor to manage the data from those devices. This approach requires the practice to perform what amounts to providing ongoing technical support for patients, although this time does count towards the management codes and is therefore not billable. Taking a self-managed approach can prove cheaper in the long run, but practices will need to incur significant initial costs and allocate more office resources and staff time to the program.
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What payers cover RPM and how is it reimbursed?
RPM is payable by Medicare, 22 state Medicaid programs (as of April 2020), and an increasing number of private payers. In 2020, the CPT codes for RPM were overhauled, making it one of the most lucrative Medicare care management programs.
There is a small payment for initial patient enrollment, and a monthly base payment for management of the device and patient readings. There is an optional service for each 20 minutes of care management — which can be provided by clinical staff — up to 60 minutes total.
Is setting up the RPM device and related patient education considered covered services?
Yes, via CPT code 99453. See the FAQ "What CPT codes cover RPM and how much are they reimbursed by Medicare?" below for more details.
Are there rules governing where patients need to be to receive RPM services?
Essentially, no. As long as patients are not in a shared space with the provider delivering the RPM services, they can receive these services. This means patients can be in their homes, on vacation, in a skilled nursing facility, at work, or any other location where the service can be provided.
What CPT codes cover RPM and how much are they reimbursed by Medicare*?
As of April 2020, they are as follows:
- 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) — Medicare pays $21 for initial setup of an RPM device and patient education.
- 99454 (Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days) — Medicare pays $64 per month for monitoring patient data as it streams in from a device.
- 99457 (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; initial 20 minutes) — Medicare pays $55 per month for spending 20 minutes a month tracking and monitoring data and managing resulting care.
- 99458 (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; additional 20 minutes) — Medicare pays $44 per month for each additional minute spent past 99457's initial 20 minutes up to 60 minutes total.
* Amounts identified are approximate. Reimbursement varies among Medicare administrative contractors (MACs).
Note: CPT code 99091 was the original way to bill for remote patient monitoring, but its limitations and requirements have made it rarely reported due to the availability of the newer codes listed above.
Who can perform RPM under CPT code 99457?
99457 reimburses for time spent by the billing physician, QHCP, or clinical staff, in accordance with laws.
Are RPM services only reimbursable for patients with multiple chronic conditions?
No. Providers may recommend RPM services for any patient who may benefit from the service.
Is CPT code 99454 reimbursed per device or per patient?
99454 can only be billed once per patient every 30 days. This is regardless of whether the patient is using a single device or multiple devices.
Can RPM be billed in conjunction with chronic care management (CCM)?
Yes, a provider can bill both the RPM CPT code 99457 and CCM CPT code 99490. CMS recognizes the analysis involved in furnishing RPM services is complementary to CCM and other care management services. With that said, the time spent by providers in furnishing these services cannot be counted towards the required time for RPM and CCM codes for a single month. In other words, no “double counting.” Billing 99457 and 99490 together requires a provider to deliver at least 40 minutes of services: 20 minutes of RPM, 20 minutes of CCM.
Is there a copayment associated with RPM services?
For Medicare beneficiaries: Yes. RPM services, like other Medicare Part B services, are subject to a 20% beneficiary copay. This copay is generally not waivable, but it may be covered if a patient has supplemental coverage or Medicaid.
Private payers establish their own copay policies and may choose not to require a copay.
What are the documentation requirements to bill for RPM?
Providers should initially obtain informed beneficiary consent to receive RPM services.
To document CPT 99453, include the following:
- practitioner order for device deployment;
- condition(s) for which the patient is being monitored;
- device identification;
- date of delivery of the device to the patient; and
- date(s) on which training is provided to the patient.
For time-based codes (CPT 99457 and 99458), document the time spent on each.