The new year continues to offer big opportunities for telemedicine and digital health companies, and one of the most notable developments is CMS’ decision to reimburse providers for remote patient monitoring (RPM).  Effective the Medicare program will  January 1, 2018, the Medicare program will pay providers for RPM services billed under CPT code 99091.   The service is currently defined as the “collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.”

It is great to see CMS agree with health innovation advocates that RPM services can be a significant part of ongoing medical care and that the Medicare program should recognize these services for separate payment as soon as practicable.  Providers and telehealth companies should act now to embrace this landmark shift by Medicare to directly pay for RPM services on a monthly recurring basis.

RPM is Not a Telehealth Service

RPM services are technically not considered a Medicare telehealth service.  Instead, like a physician interpretation of an electrocardiogram or radiological image that has been transmitted electronically, RPM services involve the interpretation of medical information without a direct interaction between the practitioner and beneficiary. As such, Medicare pays for RPM services under the same conditions as in-person physicians’ services with no additional requirements regarding permissible originating sites or use of the telehealth place of service (POS) 02 code.  RPM services do not require the use of interactive audio-video, nor must the patient be located in a rural area. The patient can even receive RPM services in their home.

CPT 99091 is not a newly-created code. Instead, Medicare “unbundled” it and designated it as a separately-payable service. Regardless of how CMS accomplished it, the final result is clear: Medicare will now pay providers a monthly fee for delivering RPM services.

Industry response was positive and telehealth advocates supported CMS’ action as another step in recognizing the increasing importance of RPM services.

Not All RPM Codes Made the Cut

When assessing whether or not Medicare should pay for RPM services, CMS also evaluated CPT 99090 as a potential covered service. That service is defined as the “analysis of clinical data stored in computers (e.g., ECGs, blood pressures, hematologic data).”  Unlike CPT code 99091, CPT code 99090 does not state that the RPM information must be interpreted by a physician or other qualified health care professional, nor does it specify a 30 minute minimum. After considering the differences, CMS elected to keep CPT 99090 “bundled” and not allow its use for separate payment.

What Does CMS Require for CPT 99091?

It is true that CPT 99091 fails to optimally describe how RPM services are furnished using current technology.  This may be due to the fact that the code description is years old and has never before been a separately payable service. The AMA’s CPT Editorial Panel is currently working on new codes intended to more accurately describe remote monitoring. But providers, patients, and CMS itself did not want to wait until those new codes were developed.  Until new codes are published and approved by CMS, providers should use the current CPT 99091 for billing RPM services. Here are some of the core requirements to bill Medicare for RPM services under CPT 99010:

• The practitioner must get the patient’s consent for RPM services and document it in the patient’s medical record.

• For new patients or patients not seen by the practitioner within one year prior to billing RPM, the practitioner must first conduct a face-to-face visit with the patient (e.g., an annual wellness visit or physical). E/M services levels 2 through 5 (CPT codes 99212 through 99215) should qualify for this face-to-face visit. Transitional care management (TCM) services should also qualify. However, services that do not involve a face-to-face visit by the billing practitioner or which are not separately payable under Medicare (e.g., online services, telephone and other E/M services) would not qualify as an initiating visit.

• CPT 99091 should be reported no more than once in a 30-day period per patient.

• The service must include the physician or other qualified health care professional time involved with data accession, review and interpretation, modification of care plan as necessary (including communication to patient and/or caregiver), and associated documentation.

• CPT 99091 can be billed once per patient during the same service period as chronic care management (CCM) services (CPT codes 99487, 99489, and 99490), TCM services (CPT codes 99495 and 99496), and behavioral health integration services (CPT codes 99492, 99493, 99494, and 99484). This is allowed because CMS recognizes the kind of analysis involved in furnishing RPM services is complementary to CCM and other care management services. However, time spent furnishing these services cannot be counted towards the required time for both RPM and CCM codes for a single month (i.e., no double counting).

• Because RPM services are not considered telehealth services under Medicare, the patient can be at his/her home, and need not be in a rural area or qualifying originating site.

Entrepreneurs and companies offering RPM technologies should take steps now to understand the new billing opportunities under Medicare. With the forthcoming new CPT codes for more RPM services, this looks to be an area of significant upside potential over the coming years.  Hospitals and providers using telehealth and non-face-to-face technologies to develop patient population health and care coordination services should take a serious look at RPM services billing opportunities, and keep abreast of developments that can drive recurring revenue and improve the patient care experience.