Getting paid for remote and virtual care services: CPT codes to know and understand

Remote patient monitoring, home care and telehealth have been gaining traction as a healthcare offering due in no small part to an aging population, which increasingly views these kinds of options as a means of avoiding certain age-related hardships, such as transportation and receiving regular check-ups.

Until recently, though, reimbursement for remote patient monitoring services was something of a gray area for providers. It was only in November, after all, that the Centers for Medicare and Medicaid Services issued its final 2019 Physician fee Schedule and Quality Payment Program, which opened the door to reimbursement for services that enable providers to manage and coordinate care at home.

There were a number of changes, one being the implementation of new CPT codes, according to a fact sheet released by CMS.

CPT code 99453 sets parameters on remote monitoring in regards to measuring weight, blood pressure, pulse oximetry and respiratory flow rate, as well as guidelines on patient education surrounding such equipment.

CPT code 99454 is similar, but focuses on the devices themselves and sets guidelines around daily recordings and programmed alerts.

For providers, though, perhaps the most impactful new CPT code is 99457. That's where the reimbursement picture becomes a little more clear.

THE CODE: 99457

CPT code 99547 went live in January. According to Health Care Law Today, it offers Medicare reimbursement for "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."

When CMS' final rule was published in November, CMS said code 99457 described professional time -- meaning it "cannot be furnished by auxiliary personnel incident to a practitioner's professional services."

But in a technical correction inspired by industry feedback, CMS removed that sentence entirely and confirmed that these services may be furnished by auxiliary personnel incident to a practitioner's professional service." Telehealth providers applauded the revision.

The change means that remote patient services are now more closely aligned with chronic care management services, the difference being that the default rule for incident to billing under Medicare requires direct, not general, supervision.

Direct supervision essentially means that the physician and all auxiliary personnel have to be in the same building at the same time, though not necessarily in the same room. General supervision, on the other hand, doesn't require all parties to be in the same building simultaneously. Instead, the physician could use telemedicine to facilitate general supervision over the auxiliary personnel.

WHAT DOES IT MEAN?

The kind of technology covered under the codes remains a bit ambiguous, with CMS falling short on specifics. But according to the National Law Review, the agency plans to issue some guidance to help inform practitioners and stakeholders.

What's clearer is who can actually deliver these remote patient monitoring services. Physicians, qualified health professionals or clinical staff are all covered; clinical staff can encompass registered nurses and medical assistants depending on the scope of state law and requirements.

Under the new codes, Medicare pays for setting up the remote patient monitoring devices, as well as any patient education. Specifically, 99453 offers separate reimbursement for the initial work associated with onboarding a new patient, setting up the equipment, and patient education on use of the equipment.

Conveniently, a patient doesn't needs to be in a rural setting for the provider to quality for remote patient monitoring reimbursement. Remote patient monitoring is not considered a Medicare telehealth service. It involves the interpretation of of medical information without a direct interaction between the provider and the patient, and in this way it's similar to a physician interpretation of a radiological image or electrocardiogram. Medicare pays for remote patient monitoring services under the same conditions as in-person physicians' services -- there are no additional requirements.

Also, remote patient monitoring services are not expressly required to use interactive audio and video. CMS has not been prescriptive as to which technologies can be used to perform consultations; it could be anything from real-time video to a message delivered through a patient portal.

WHAT TO WATCH OUT FOR

There's one catch, though: New patients, or patients who haven't been seen for one year, have to undergo a face-to-face visit with their provider, such as in an annual wellness visit or physical. Evaluation and management services levels 2 through 5, as well as transitional care management services, should qualify as a face-to-face visit. Online services, phone calls and other E/M services would not qualify.

Any practitioner is required to get the patient's consent for remote patient monitoring services, and document it in the patient's medical record. As a Medicare Part B service, the patient is responsible for  a 20 percent copayment for such services. Providers are advised to bill the patient, or their secondary insurer, as waivers of patient copayments puts the provider under fraud and abuse risk under the federal Civil Monetary Penalties Law and the Anti-Kickback Statute.

Twitter: @JELagasse

Email the writer: jeff.lagasse@himssmedia.com