Remote Patient Monitoring: Benefits, Barriers, and Billing
Center for Connected Health Policy
Remote patient monitoring (RPM) policy considerations and how RPM can improve chronic condition care and prevention.
Last month, the California Health Care Foundation (CHCF) released a new report, Remote Patient Monitoring in the Safety Net: What Payers and Providers Need to Know, which looks at remote patient monitoring (RPM) policy considerations and how RPM can improve chronic condition care and prevention. The CHCF report focuses on RPM’s use specific to safety-net providers given system constraints particularly limiting chronic illness management to those patient populations. They note that in California, avoidable hospitalizations are highest for Medicaid beneficiaries and that almost 700 hospitalizations per 100,000 people could be prevented through better access to care and more effective chronic care management. In addition, they discuss that providers have seen how telehealth can improve treatment of diabetes, hypertension, and heart disease, as well as mortality and quality of life. RPM specifically has shown benefits for older patients and those facing barriers such as lack of transportation to care. Nevertheless, as discussed in the report, technological issues and strict reimbursement policies remain barriers to RPM utilization. The report also offers potential best practices for providers considering RPM adoption.
RPM Basics and Benefits
As noted on CCHP’s state and federal RPM policy tracking page, RPM is considered to be the collection of a wide range of health data from the point of care, such as vital signs, weight, and blood pressure measurements. The data is then transmitted to health professionals in facilities such as monitoring centers in primary care settings, hospitals and intensive care units, as well as skilled nursing facilities. The CHCF report gets into various RPM benefits found within the authors’ research across all settings, including how RPM maximizes use of the entire care team and enhances quality of care and outcomes, as well as how it can improve costs of care. Focus group information gathered for the report also showed that patients feel empowered when able to track trends related to their health information through RPM, becoming more engaged and also more willing to change treatment plans when related to the monitoring information. Other research cited found benefits specific to vulnerable populations, including high adherence and successful self-management education to high-risk and low-income populations. Examples were also provided showing that RPM can give patients, especially those that are Spanish-speaking, an overall sense of support.
Despite the evidence on its benefits, as mentioned previously, RPM is not widely used as a modality of care in the safety net, largely related to a number of technological and reimbursement policy barriers. For instance, ensuring that devices can integrate into electronic health records (EHRs) and that data is seamlessly shared and uploaded is crucial, but often costly. Some technological options also don’t offer an ability to be alerted to new and concerning information in a timely manner. Instead, the report discusses how often lower cost options include devices that are not directly connected to EHR systems and involve patients manually reporting measurements through a patient portal or by text message. The study also cites how many patient groups within the safety net population struggle with lack of broadband connectivity as well as digital literacy issues, which also highlights the need to cover phone and text communication modalities. As the authors note, without additional certainty around RPM reimbursement, providers are limited in properly assessing associated costs and savings to be able to provide RPM related services, especially within the safety net.
State Medicaid RPM Reimbursement
CCHP’s recent state telehealth policy tracking shows that twenty-seven states now have some form of reimbursement for RPM in their Medicaid programs. Many of the states that offer RPM reimbursement also have a multitude of restrictions associated with its use. The most common of these restrictions include only offering reimbursement to home health agencies, restricting the clinical conditions for which symptoms can be monitored, and limiting the type of monitoring device and information that can be collected. One state (Ohio) has reimbursement only for specific remote physiologic monitoring codes modeled after Medicare reimbursement. In California under newly enacted legislation AB 133, the Department of Health Care Services (DHCS) may authorize the use of RPM as an allowable telehealth modality under its Medicaid program. However, the language states that DHCS will establish a new undetermined fee schedule for it and likely limit covered services and providers eligible for RPM reimbursement. More details on AB 133 can be found in CCHP’s newly released fact sheet on California health budget agreement and all of its telehealth components.
Medicare Remote Physiological Monitoring (and proposed RTP) Reimbursement
As far as Medicare RPM reimbursement in the Centers for Medicare & Medicaid Services (CMS) proposed 2022 PFS they are suggesting the addition of five new CPT codes for remote therapeutic monitoring (RTM):
*989X1: Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment
*989X2: Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days
*989X3: Remote therapeutic monitoring (e.g., respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (e.g., daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days
*989X4: Remote therapeutic monitoring treatment management services, physician/ other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; first 20 minutes
*989X5: Remote therapeutic monitoring treatment management services, physician/other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient/caregiver during the calendar month; each additional 20 minutes
According to CMS, the RTM codes are similar to the seven Remote Physiological Monitoring (RPM) codes they have included over the past few years with a couple of differences which are primarily related to the particular equipment being used and data collected, and which providers can directly bill for these codes. For instance, RTM codes are proposed to monitor health conditions and allow non-physiologic data to be collected, including self-reported and digitally uploaded information, though devices for both RTM and RPM must meet the same Federal Drug Administration (FDA) definition of medical device. CMS is soliciting comments on the types and costs of devices that may be used for RTM services under the proposal. In addition, RPM services have been considered to be evaluation and management (E/M) codes which cannot be billed by certain providers, while RTM codes are considered to be general medicine codes. Additional details are still to be determined and questions remain related to billing and code construction that stakeholder comments can hopefully lead them to clarify after the comment period on the proposed PFS closes on September 13, 2021. Details on the other items in the proposed 2022 PFS can be found in CCHP’s fact sheet, explainer video, and slide deck.
RPM Adoption Guidance
Barriers in mind, the CHCF report suggests providers look to incorporate RPM into programs and workflows prior to considering the use of a specific technology, highlighting a number of considerations and ways providers can assess how to utilize RPM and adopt it consistent with best practices and existing policies. The guidance recommends to those considering starting an RPM program includes:
Use RPM as a tool within a wider program, such as on top of an existing chronic disease management or diabetes educational program
Invest in organization-wide adoption and management to ensure deployed at scale
Identify key performance indicators to prioritize specific populations and results, such as no-show rates and clinical outcomes
Estimate enrollment and overall costs, potential partnerships with other health centers
Incorporate cultural responsiveness and solutions designed for patients with physical limitations
As best practices continue to emerge and interest and understanding increases around use of telehealth modalities, including RPM, hopefully coverage consistency, and clarity, can increase as we move forward. Given existing variance amongst the states and the use of two different terms by the federal government for just this one type of modality – which they consider separate from telehealth – it will remain important moving forward to continue to highlight the benefits of telehealth and how they can outweigh any concerns necessitating the need for such strict and confusing policies that vary by each telehealth modality.
For more details on the report’s RPM findings, please download it here - https://www.chcf.org/wp-content/uploads/2021/07/RemotePatientMonitoringSafetyNetNeedKnow.pdf.
To track the ever-evolving telehealth landscape, please utilize CCHP’s policy finder - https://www.cchpca.org/new-mexico/