Telehealth in USA During COVID-19. What has Changed and What was Always There.

Telehealth in USA During COVID-19. What has Changed and What was Always There.

 Telehealth in USA

A lot of federal funds and financial stimulus packs have been released in the wake of COVID-19. Two such measures have been game changers for the telehealth sector, namely the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act. Together, these measures have enabled CMS to make telehealth more accessible than ever before during this period of public health emergency. They are temporary however, designed to be an response to this pandemic. We review the changes in this post, but also go over the whole gamut of telehealth options for physicians which had existed prior to the enactment of the new measures.

What Has Changed?

During this period, coverage for telehealth reimbursement is extended where physicians can be contacted by patients from any location, waiving the originating site requirementTo understand how big of a deal this is, see the following originating sites where a patient had to be to receive care via telehealth prior to COVID-19: 

  • Physician and practitioner offices  
  • Hospitals  
  • Critical Access Hospitals (CAHs)  
  • Rural Health Clinics  
  • Federally Qualified Health Centers  
  • Hospital-based or CAH-based Renal Dialysis Centers (including satellites)  
  • Skilled Nursing Facilities (SNFs)  
  • Community Mental Health Centers (CMHCs)  
  • Renal Dialysis Facilities  
  • Mobile Stroke Units 

Only instances where the patient was allowed to be in home while receiving care was for End Stage Renal Dialysis (ESDR), substance use disorder or a co-occurring mental health disorder.

Apart from the patient being in one of the above sites, the patient would have had to reside in a county outside of a Metropolitan Statistical Area (MSA) or in a rural health professional shortage are (HPSA).

The Changes

Beginning from March 6th, a patient does not have to be outside of MSA, in a rural HPSA or in any of the originating sites above. They can avail the care they need right from the safety and privacy of their own homes. Not only for ESDR, substance abuse or co-occurring mental disorder, but for any care service. 

Furthermore, there will be payment parity for these services. Providers will be able to bill for telehealth services at the same rate as in-person visits. 

A patient must initiate services, but physicians will be allowed to inform their patients on the availability of telehealth services.  HHS (Health and Human Services) has said that it will not conduct audits to confirm prior patient-physician relationships for claims submission. 

What Was Always There

So we see that more than any other time in history, telehealth is being treated like real health. As everyone practices social distancing and self-isolation, the line between the two has been greatly blurred, where any form of care starts out as virtual care to minimize unnecessary visits outside. Therefore, it has garnered a lot of attention from physicians who want to use the system, encouraged by the waiving of originating sites and payment parity. But from a financial or coding perspective, how do you begin to account for patient visits? 

The movement to switch to telehealth for initial contact or at least encourage more use of it, had started years back. Codes had been enacted with their own reimbursement rates which could be billed by physicians irrespective of the patient’s location.  Only early adopters of the relevant codes would know. But worry not, this post makes sure you catch up to speed. The reimbursement rates for the codes are also included. 

Virtual Check-In 

HCPCS G2012Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion. 

Notice  the before and after time stipulations in the code. CMS is big on non-duplication, where you cannot code twice for treating the same condition within a certain time spanSo the purpose of the virtual check-in code, is just that, it is just a quick consultation. If it is related to an E/M service from the last week, or if it will lead to an E/M service or procedure anytime soon, then you would be better off not coding it. The purpose of this code is to clearly keep the patient out of the facility for the time being, and for them to bring forth new concerns that requires the physician’s attention.  The virtual check in is for established patients.

National non-facility payment: $14.80.     National facility payment: $13.35 

Note: There are  no frequency limitations. 

Requirements: Need advance consent from a patient who is established. Physician must be on the call. Cannot only be clinical staff. 

Allowed Technology: Real time audio only synchronous two-way audio interactions that are enhanced with video, or just telephonic communication.  

Remote Evaluation of Pre-recorded Patient Information 

HCPCS G2010- Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment 

National non-facility payment: $12.61.     National facility payment: $13.35 

Requirements: Need advance consent from a patient who is established. 

Allowed technology: May involve prerecorded use of patient generated still or video images. Follow up with patient can be done over a phone call, audio/visual communication, secure text messaging, email, or patient portal communication. 

Interprofessional Internet Consultation 

The purpose of these codes to enhance care coordination. 

For Consultative Physician

CPT  99446- Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/ requesting physician or other qualified health care professional; 5-10 minutes of medical consultative discussion and review  

Amount Reimbursed: $18.38 

CPT 99447- Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/ requesting physician or other qualified health care professional; 11-20 minutes of medical consultative discussion and review  

Amount Reimbursed: $36.40 

 CPT 99448- Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/ requesting physician or other qualified health care professional; 21-30 minutes of medical consultative discussion and review  

Amount Reimbursed: $54.78 

 CPT 99449- Interprofessional telephone/Internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/ requesting physician or other qualified health care professional; 31 minutes or more of medical consultative discussion and review  

Amount Reimbursed: $73.16 

 CPT 99451-Interprofessional telephone/Internet/electronic health record assessment and management service provided by a consultative physician, including a written report to the patient’s treating/requesting physician or other qualified health care professional, 5 minutes or more of medical consultative time. 

Amount Reimbursed: $37.48 

Requirements: Need advance patient content. The consultative physician must be a qualified healthcare professional. Has a frequency limitation of once every 7 days for the same patient. The time reports are based on cumulative time spent. Not reported if the patient was seen by the consultant in the past 14 days, or if a transfer of care or a request for face-to-face consult occurs over the next 14 days.

For Requesting Physician

CPT 99452- Interprofessional telephone/Internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified health care professional, 30 minutes). 

Amount Reimbursed: $37.48 

 Requirements: Need advance patient content. The requesting physician must be a qualified healthcare professional.  The non face-to-face consult for medical advice or opinion that is requested must not be for a transfer of care. It requires a minimum of 16 minutes, which can include time preparing for the referral and and/or communicating with the consultant.  It has a frequency limitation of one every 14 days for a patient.

The Online Digital Evaluation Service (e-Visit) 

These codes are used when the purpose of the video call is not to determine if an office E/M service is necessary. If that was the case, a Virtual Check-in would have been used. Rather an e-visit is an online E/M visit, and so is treated just like an in person visit, but conducted online. It is for established patients.  Medicare describes it as patient initiated digital communications that require a clinical decision that would have been otherwise typically been provided in the office. 

Acknowledging non-physician healthcare practioners who will be conducting e-visits, Medicare is using HCPCS codes for on-line digital evaluation performed by these professionals who can’t bill E/M services. Notice, that instead of “evaluation and management” the definitions use the word “assessment.” 

For Non-physicians

HCPCS G2061- Qualified nonphysician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5-10 minutes 

Reimbursement Amount: $12.27.      

 HCPCS code G2062- Qualified nonphysician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11-20 minutes 

Reimbursement Amount: $21.65     

 HCPCS code G2063- Qualified nonphysician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes 

Reimbursement Amount: $33.92   

 For Physicians and Other Qualified Healthcare Professionals that may bill Medicare E/M Codes

CPT 99421- Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 5-10 minutes 

National non-facility payment: $15.52     National facility payment: $13.35 

 CPT 99422-Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11—20 minutes 

National non-facility payment: $31.04   National facility payment: $27.43 

 CPT 99423- Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 21 or more minutes 

National non-facility payment: $50.16    National facility payment: $43.67 

Notice how all e-visits have a time frame of 7 days, if any evaluation or assessment extend beyond this 7 day period, then they may be billed under remote patient monitoring. We cover remote patient monitoring reimbursement details in other posts, such as this one. It has its own set of conditions, as does chronic care. Remote Patient Monitoring and Chronic Care codes are two other examples besides Virtual Check In and e visits which were never considered telehealth to begin with, and thus were not restricted by the originating site requirement. 

Medicare Telehealth Visits

(The Real Beneficiary of The Changes)

For a complete list of telehealth services covered by Medicare, refer to this list. We’ll cover the common ones which can help you intake patients and begin a care plan for them so they get the treatment that they need. The Medicare Telehealth Visits are different from the virtual check ins and the -visits, in that the patient need not be established. HHS has said it won’t audit for existing relationship during this emergency period. Also, the originating site waiver applies to these codes, as everything else covered previously never had site restrictions to begin with. 

 In addition, the following codes can also be used to intake new patients, by means of telehealth consultations.

Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth
Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth
Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth

Conclusion 

Thus we can see that whether it is for established patients whose care may have been disrupted, or for first time patients who need care, there are telehealth codes in the books available to manage them. From March 6th, the traditional Medicare telehealth codes have temporarily joined the ranks of e-visits and virtual check ins, where the patient does not have to be in an originating site. So it must be said, that audio visual technology is an essential for any private practice, let alone a hospital. If you are at the stage of comparing features to determine what’s best for you, do get in touch with us. We can point you to the right direction. If you want to set up your telehealth program for the future, complete with care coordination features and remote patient monitoring capabilities, then we would love to learn more about your use case. Get in touch with us. 

 References

https://www.aappublications.org/news/2019/01/04/coding010419

https://www.aafp.org/journals/fpm/blogs/inpractice/entry/telehealth_algorithm.html

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/TelehealthSrvcsfctsht.pdf

https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

https://www.gottransition.org/resourceGet.cfm?id=352

A Guide to COVID-19 Reimbursement

A Guide to COVID-19 Reimbursement

Reimbursement Changes in Place for COVID-19

 COVID19 has broken the dams on telehealth reimbursement. It is to be seen for how long. But as we all try desperately to flatten the curve so healthcare organizations are not overburdened at this time capacity wise, it can be reasonably assumed that the pathway has been clearred for reimbursement for the foreseeable future. 

Medicare in USA

Beginning on March 6th, Medicare can now pay for all telehealth visits irrespective of originating site. Medicare beneficiaries, who are at higher risk of contacting COVID-19, will be able to receive a specific set of services through telehealth including evaluation and management visits (common office visits), mental health counseling and preventive health screenings. Thus they can get the care they need from their homes without putting themselves or others at risk. Escalation of cases will of course mandate an in location visit, but all healthcare that can be furnished non face to face by virtual means, must be done so! This is the message CMS is sending by waiving all telehealth reimbursement restrictions on originating sites for the time being.

Clinicians can bill immediately for dates of service starting March 6, 2020. Telehealth services are paid under the Physician Fee Schedule at the same amount as in-person services.

Taken from the Fact Sheet released by CMS yesterday (March 17th), here are 3 types of Virtual Services that Can be Provided to Medicare Beneficiaries:

MEDICARE TELEHEALTH VISITS:  Currently, Medicare patients may use telecommunication technology for office, hospital visits and other services that generally occur in-person. 

The provider must use an interactive audio and video telecommunications system that permits real-time communication between the distant site and the patient at home.  Distant site practitioners who can furnish and get payment for covered telehealth services (subject to state law) can include physicians, nurse practitioners, physician assistants, nurse midwives, certified nurse anesthetists, clinical psychologists, clinical social workers, registered dietitians, and nutrition professionals.

Codes

  • HCPCS codes G0425–G0427: Telehealth consultations, emergency department or initial inpatient 
  • HCPCS codes G0406–G0408: Follow-up inpatient telehealth consultations furnished to beneficiaries in hospitals or SNFs.

*Such visits have been made applicable to new patients as well. HHS will not conduct audits to verify if a prior relationship existed for submitted claims during this emergency. 

VIRTUAL CHECK-INS: In all areas (not just rural), established Medicare patients in their home may have a brief communication service with practitioners via a number of communication technology modalities including synchronous discussion over a telephone or exchange of information through video or image. We expect that these virtual services will be initiated by the patient; however, practitioners may need to educate beneficiaries on the availability of the service prior to patient initiation. 

Medicare pays for these “virtual check-ins” (or Brief communication technology-based service) for patients to communicate with their doctors and avoid unnecessary trips to the doctor’s office. These virtual check-ins are for patients with an established (or existing) relationship with a physician or certain practitioners where the communication is not related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours (or soonest appointment available). The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would generally apply to these services.

Codes

  • HCPCS code G2012: Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.
  • HCPCS code G2010: Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment.

E-VISITS:  In all types of locations including the patient’s home, and in all areas (not just rural), established Medicare patients may have non-face-to-face patient-initiated communications with their doctors without going to the doctor’s office by using online patient portals. These services can only be reported when the billing practice has an established relationship with the patient. For these E-Visits, the patient must generate the initial inquiry and communications can occur over a 7-day period. The services may be billed using CPT codes 99421-99423 and HCPCS codes G2061-G2063, as applicable. The patient must verbally consent to receive virtual check-in services. The Medicare coinsurance and deductible would apply to these services.

Medicare Part B also pays for E-visits or patient-initiated online evaluation and management conducted via a patient portal. Practitioners who may independently bill Medicare for evaluation and management visits (for instance, physicians and nurse practitioners) can bill the following codes:

  • 99421: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 5–10 minutes
  • 99422: Online digital evaluation and management service, for an established patient, for up to 7 days cumulative time during the 7 days; 11– 20 minutes
  • 99423: Online digital evaluation and management service, for an established patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

Clinicians who may not independently bill for evaluation and management visits (for example – physical therapists, occupational therapists, speech language pathologists, clinical psychologists) can also provide these e-visits and bill the following codes:

  • G2061: Qualified non-physician healthcare professional online assessment and management, for an established patient, for up to seven days, cumulative time during the 7 days; 5–10 minutes
  •  G2062: Qualified non-physician healthcare professional online assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 11–20 minutes
  • G2063: Qualified non-physician qualified healthcare professional assessment and management service, for an established patient, for up to seven days, cumulative time during the 7 days; 21 or more minutes.

 

 

COVID-19. Response from The Healthcare Industry.

COVID-19. Response from The Healthcare Industry.

History and Current Response

Crisis and Telehealth are two peas in a pod. It was natural calamities like hurricane Katrina which revealed just how important telehealth was in fighting back in times of crisis. The need back then was of course more due to the lack of access because of geographic restriction. People’s access to care was severed due to a geographical barrier, which telehealth helped overcome. In pandemics like the COVID-19, the need is more due to an infectious restriction, where the barrier is not imposed by lack of access but because of their chances of transmitting the virus to the rest of the population. 

A lot of companies, including providers, payors and vendors are stepping up at this time to combat the further proliferation of this contagion. Governments of both USA and Canada have allocated funds to deal with this public health crisis, but the responsibility of planning and executing programs still lies with the organizations who will be fighting COVID-19 on the ground. It’s one thing to authorize funds, it’s another to use them efficiently. Players in the healthcare industry  in North America have done a variety of things thus far to combat this outbreak. Such acts are also being implemented by other organizations, who have joined in the movement.  

Who is Doing What? 

Payors 

  • Blue Cross Blue Shield Association will increase access to prescription drugs, waive prior authorizations and increase coverage for COVID-19. 
  • Kaiser Permanente will contribute $1 million to leading public health organizations and collaborate with CDC foundation to strengthen the USA’s public health infrastructure and response systems. 

Providers 

  • Spectrum Health has announced free virtual screenings for all Michigan residents who are symptomatic of COVID-19. People are to call a hotline number, after which they will be instructed to download Spectrum Health’s telemedicine app and scheduled a video visit. 
  • Boston Children’s Hospital has come up with a model for the COVID-19 using AI. The want to project how the virus will spread in real time, and keep track of case fatalities. Doing so will enable all to be better prepared from here on.  This is very helpful for planning supply chains. 
  • Greenwich hospital is limiting visitor access to its main campus and outpatient facilities. Only one visitor per patient is allowed, and symptomatic visitors are barred apart from certain restrictions. Additionally, all visitors are to be screened before entering. Hospitals across USA and Canada have adopted very similar measures. one such example is Wichita Wesley hospital in Kansas, that is screening all entrants at the gates. 52 out of their 57 entrances are shut down. They have cancelled any large-group employee meetings indefinitely and enacted a 30-day ban on travel for employees.  
  • Yale New Haven Health is offering a call center for patients who have questions about COVID-19. Again, hospitals across the land have introduced such lines to maintain a proper channel of communication dedicated to COVID-19. It has become a very popular response, where people are in need of information as much as they are in need of care.  

 

Vendors 

  • Bright.md has announced a free COVID-19 evaluation and screening tool for all hospitals in USA for their patients. The tool reviews the patient’s symptoms, health history and travel history for a diagnosis. 
  • Bioufourmis’s clincal grade wearables and AI powered remote care analytics platform is being used in Hong Kong to track the condition of COVID-19 patients. While the scope of care is outside of North America in this case, Biofourmis is based out of Boston. 
  • Vivify Health has developed a Coronavirus Pathway which allows the self-screening of patients. Such a pathway can start by patients using their own device or using a delivered kit, which is the case of Current Health.They are offering remote triaging by drop shipping a kit to the patient’s front door, so they can be self-isolated but also be continuously monitored for condition.  
  • Based out of California, VivaLnks’s continuous temperature sensor is being used in China to monitor potential and affected patients. Shanghai Public health Center is the designated site to treat quarantined patients, and remotely monitoring patients ensures that the healthcare professionals are safe from the virus. 
  • Aetonix, based out of Canada, is offering free remote screening for potential patients to all healthcare organizations, both in Canada and USA. Using a virtual care call, healthcare professionals are able to safely triage patients who have been pre-screened for the Corona virus on the aTouchAway App.  

 

In the Coming Days 

Whether it be insurance companies, healthcare organizations, or remote patient monitoring/tele health solutions, everyone is pitching in to slow down the spread of COVID-19. North American companies especially, are making a worldwide impact to stifle this pandemic. Expect this list to burgeon in the coming days, as more firms throw their hats into the mix, if they haven’t already. 

Differences between Remote Patient Monitoring (RPM) and Chronic Care Management (CCM)

Differences between Remote Patient Monitoring (RPM) and Chronic Care Management (CCM)

Why They May Seem Similar

The most popular application for remote care by far is its use for chronic care. Both RPM and CCM can be billed in the same month, which is a testament to RPM’s supplementary nature to CCM. Thus, the two usually go together in the minds of people. As remote care is so commonly associated with chronic care, it is easy to forget that they have two different purposes. This post attempts to hash out the differences between Remote Patient Monitoring (RPM) and Chronic Care Management (CCM).

In the following table, the differences are discussed first, followed by the similarities.

                                    DIFFERENCES

  RPM CCM

Purpose

Has multiple purposes, that include chronic care management, principal care management (just 1 chronic condition), acute care, neonatal care, etc. Has only one purpose, that is, to manage the care of those patients with two or more chronic conditions as designated by CMS.

Requirement (With Clinical Staff)

1) Initial set-up and patient education on use of equipment.

2) Device(s) supply with daily recording(s) or programmed alert(s) transmission, 16 or more days a month.

3) 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

Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.

 

 

Care Activities

Interpretation of the received data and interaction with patient on a treatment plan.

Comprehensive care plan must be established. It must then be implemented, revised, or monitored on a monthly basis.

 

It can involve the following:

·        Systematic assessment of the patient’s medical, functional, and psycho-social needs.

 

·        System-based approaches to ensure timely receipt of all recommended preventive care services.

 

·        Medication reconciliation with review of adherence and potential interactions.  

 

·        Oversight of patient self-management of medications.

 

·        Coordinating care with home- and community-based clinical service providers.

Min. Monthly Reimbursement

($52 for non-facility/ $32 for facility) +$64 for monitoring $42 for non-facility/ $32 for facility

Complexity of Cases

Does not have separate codes for medium to high complexity cases. Has separate codes for medium to high complexity cases.

Possibility of Increments

In increments of 20 minutes. In increments of 20 minutes, however if 60 minutes will be required a month, it is encouraged to bill a complex care code that starts at 60 minutes monthly.

Requirement

(Without Clinical Staff)

Collection and interpretation of physiologic data digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified healthcare professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month.

24/7 Access to Care

No Yes
                                                       SIMILARITIES

Initiation

For new patients or patients not seen within 1 year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner. Has to be initiated by an Annual Wellness Visit, Initial Preventive Physical Exam, etc.

Staff Involved

Physicians, Qualified Health Professionals, Clinical Staff

Billing Cycle

Monthly

Supervision

General Supervision

Patient Consent

Required

Location of Patient

Anywhere outside of the hospital. Does not have to be in an originating site, as it’s typically the case with telehealth services.

Cost Sharing

20% patient copayment (if there is no supplemental insurance)

From the table above, one can appreciate how it is easy to meddle RPM and CCM together, given that the similarities section is almost as long as the differences section. But in reality, one is a program (CCM), the other is more like a tool (RPM) which can be used in other programs besides CCM. The healthcare organization’s need should always dictate what to implement, and if it is necessary to use the two together.

Remote patient monitoring is tailor made to boost the clinical efficiency and outcome of chronic care cases. In today’s age, one cannot simply rely just on telephonic communication any longer, or afford to not receive daily readings from the patients. Hence Remote Patient Monitoring is a natural and essential component for any successful Chronic Care Management Program. But should you only consider RPM for chronic care programs? Not at all. There are many examples of acute care programs made successful by RPM. Pre and post-surgery coordination, and temporary rehabilitative care are very popular use cases for RPM.

I hope you found this article useful is discerning the differences between CCM and RPM. If there are any questions, do not hesitate to reach out to me at rahat.haque@aetonixsystems.com. Also make sure to follow us on our Social Media channels so you can be up to date on all our latest publications.

10 Remote Patient Monitoring Programs from 10 Different States

10 Remote Patient Monitoring Programs from 10 Different States

  By now, everybody has heard of the good things RPM can do for your health organization or private practice. But RPM case studies are not as widely publicized as they should. Only vendor websites boast testimonials that gives the reader some level of insight about the organization who implemented it, and the results that were achieved. It’s important to comb through these case studies, not just to demonstrate the efficiency of the vendor, but to showcase how actual RPM implementation looks like.  

  As RPM is such a new space, going through so many legal and technological changes, its value case has overshadowed its use case. Everyone now knows that RPM can add value, but they simply do not know where to begin. Nor do they know what RPM in action looks like. This post is purposefully written for them. I write the Remote Care Intel (RCI), a bi-weekly intelligence report on all things Remote Care. In my research process, I sometimes come across projects undertaken by hospitals and health systems. Thus, I thought it would be a good idea to not just focus on the present, but go back a few years as well, to pull out all the famous RPM case studies that I could find. I have compiled them here. It is very interesting, that the 10 cases were from 10 different states. It just goes on to show how USA as a country, have embraced RPM.  

  Healthcare is an extremely contextual business. Different organizations have different payor mix, different usage of payment models, and different specialties. So, while it’s good to hear about the benefits of RPM, unless you see how others have done it, you still treat it as an academic concept. These 10 examples will show you that it is very much a real-world concept, applied by hospitals and health systems. Perhaps, one of them will fit your vision of what you thought was possible with RPM.  

  This article will not cover cases where telemedicine is the only modality. There needs to be some level of monitoring health signals beyond the hospital, for us to consider it as a case of health system deploying RPM. In no particular order, here are the cases. 

10. University of California Los Angeles Health System (UCLA Health) 

UCLA’s Cardiac Telehealth program monitors patients who undergo heart surgery. Post-discharge, they receive a cardiac telehealth kit. Patients can send the nursing staff daily updates about their recuperation via a questionnaire. They are able to send videos and images of the incision site. Furthermore, daily health indicators are transmitted remotely through devices in the kit. For example, your weight, heart rate, blood pressure and blood oxygen levels can be measured via scale, heart rate monitor, blood pressure monitor and pulse oximeter respectively.  

Healthcare providers can immediately detect problems such as shortness of breath, abnormal heart rhythm, adverse reactions to medication, fluid retention etc. With the ability to access such information and conduct video visits as necessary, the success of the recovery process is enhanced. Readmission due to post-surgical complications is reduced. 

State: California 

Use Case:  Wherever there is risk of readmissions, RPM is a very attractive plug in to stop regression and readmission. Post-acute care is one of two major applications of RPM. Chronic care is the other one. 

9. University of Virginia Health System (UVA Health) 

UVA health has launched multiple RPM programs, geared at chronic care patients. Through its Advanced Diabetes Management Clinic, it tracks patient’s glucose levels, and alerts providers in case of dangerous sways in readings. Also for diabetic patients, retinopathy screenings are conducted remotely via cost-effective screenings. Retinopathy is a leading cause of blindness. 

Heart failure patients are given tablets through which they can upload and transmit their vital signs. Through the same tablets, they are also required to participate in a twice-weekly online education and physical activity sessions. 

State: Virginia 

Use Case: Just two cases in, Chronic Care makes its first, and not last, appearance in the list. And why not? Chronic care is the single biggest market for RPM. It is commendable how UVA is using RPM to not just address chronic care, but screen for specific conditions that can arise from it, such as Retinopathy. 

8. University of Mississippi Medical Center (UMMC) 

UMMC has a very comprehensive RPM program. It enrolls patients suffering from diabetes, hypertension, heart failure and other chronic conditions into four to six months programs. These programs are customized to the patient’s specific needs, and they are given a tablet which acts as the conduit of the programs. It contains educational material through which they can learn about their conditions, and the best practices to manage them. A UMMC registered nurse regularly checks on the progress of the patients through messaging and video chats, also available on the tablet. The patient is kept up to date on all results. With a provider referral, RPM care is usually covered by the patient’s insurance or Medicaid plan. 

State: Mississippi 

Use Case: UMMC also treats chronic care, and it emphasizes the care coordination aspect of such care. Nurses carry a lot of responsibility to administer such a program. Indeed, in most chronic care programs, they have the all-important role of being the manager of care plans. 

7. Emory Healthcare 

Out of Atlanta, Emory Healthcare is doing something slightly more advanced than the typical monitoring of the vital signs. In their RPM program, they are monitoring ECG data through a wearable patch. It has the ability to continuously monitor patients for 72-hour stretches, in both inpatient and outpatient settings. Since the patch stays on the body, and does not need to take a reading manually per se, such continuous monitoring at a stretch is made possible. Coronary heart disease is the subject of this treatment. The autonomic function of patients undergoing angiography is monitored, as prior research has established connection between lower heart rate variability and subclinical myocardial ischemia.  

State: Georgia 

Use Case: If RPM is a science, cardiology is its greatest source of potential discovery. There are no patient signs which mirror the complicacy of ECG data. Accordingly, some institutions have developed RPM programs just for matters related to the heart, that includes special focus on data analytics.  

6. University of Pittsburg Medical Center (UPMC) 

UPMC has a heart RPM program very similar to UCLA’s, called Telemedicine Heart Failure. But instead of post-acute care, it is meant for chronic care. More specifically congestive heart failure (CHF) patients. Patients are given a tablet and peripheral devices as a part of a kit. The idea is to have patients manage their illness from the comfort and convenience of their homes, while still having nurses monitoring so they can intervene as necessary. Monitoring the patients in such fashion leads to greater compliance in medication and diet. The kit is given to patients for 90 days. Nurses can ask follow-up questions based on the care plan, or forward patient’s questions or concerns to their physician. Two-way video visits can be started anytime. 

State: Pennsylvania 

Use Case: CHF is a bit different from other coronary heart diseases because it can be congenital in nature. Thus, often, the patient’s condition cannot be improved, but managed at a reasonable level, which is still better off than exacerbation to worse states. So the focus shifts from just analytics, to more longer term management via various diet, exercise, medication management features. UMPC demonstrates how. 

5. Munson Healthcare 

Munson Healthcare takes pride in being the only organization in northern Michigan to offer remote patient monitoring services. It advertises it as a great alternative to doctor’s office and home visits. Patients are asked multiple questions every morning on a tablet that they receive. Questions are both qualitative (how they are feeling) and quantitative (heart rate, blood pressure, weight, etc.) Responses are transmitted through a cellular network to the home care registered nurse, who receives it in a designated online portal. It’s the nurses that quarterback such home care, and they can suggest next steps in the form of in-person visits if necessary. Patients themselves can engage in video visits. The tablet is also loaded with education videos surrounding their conditions.  

State: Michigan 

Use Case: Munson focus on not just treating the disease in question, but changing healthcare practices as we know it. By eliminating both doctor’s office visits, and home care visits, it truly ushers the management of diseases into the digital era.  

4. MultiCare Health System  

MultiCare has a Telehealth Chronic Disease Management program that connects providers with patients dealing with a variety of chronic diseases, chiefly: heart disease, Chronic Pulmonary Obstructive Pulmonary Diseases (COPD) and pneumonia. The program has approximately 100 nurses overseeing remote care for 80-90 patients per person. The solution is yet again tablet based. It enables caregivers to collect vital signs of the patient, manage their medications, monitor their compliance and also schedule appointments. It is a big jump from how such remote care was conducted before, which was just a phone call.  

State: Washington 

Use Case: COPD makes an entrance for the first time. Often overshadowed by Congestive Heart Failure (CHF) or diabetes, COPD is just as a big a threat to long term health and well-being as any.  Many hospitals and health systems such as MultiCare have it in their strategic long-term vision to tend to COPD, and are already doing so. Often, such programs will sync with existing pulmonary rehabilitation programs, as living with COPD is a big deal to those who have the condition and their family members.

3. Goshen Health  

Goshen Health has a telehealth program for chronic diseases such as heart failure, COPD, hypertension and diabetes. They describe the process as first getting a prescription for telehealth services from your physician. Subsequently the necessary devices and technology are installed and explained to you at your home by Goshen Home Care specialists. From there on, your main task is to work the daily measurements into your routine and monitor your vital signs. The home care nurse assigned to you is also there to remotely delegate care. 

Goshen’s Heart & Vascular Center also uses remote patient monitoring for post-acute care. After a procedure such as stent placement, pacemaker insertion or cardiac ablation, people need to protect their hearts post-discharge by proper diet, exercise, medication adherence and stress management. They also need to monitor readings from any implanted devices. Through monitoring such implanted devices remotely, it saves the patients time and money. More importantly perhaps, it is more efficient as someone from the care team is continuously monitoring data from pacemakers and defibrillators. Medicare/Medicaid and most insurance companies cover costs for telehealth services. 

State: Indiana 

Use Case: The technology used for maintaining optimum heart functionality is evolving every day. Similarly, chronic care or acute care programs must keep up so they can remotely extract, monitor and infer from this data. Goshen does a good job in standardizing such cases. Also, COPD makes its second appearance. In reality, most chronic care programs implicitly include the treatment of COPD, even it if is not mentioned.  

2. NewYork-Presbyterian Hospital 

NewYork-Presbyterian is no stranger when it comes to remote innovation in healthcare. It previously made headlines for its teleparamedics and telestrokes unit. Everything is on board in the ambulance including the virtual presence of specialists, lifesaving medication and all equipment that is necessary to conduct any relevant tests. It is remote acute care at its best. 

More recently, New York Presbyterian has expanded its virtual care capabilities with remote patient monitoring. Physicians can now monitor patients’ vital signs and send them short questionnaires on their health status. Patients from their end can remotely transfer their vital signs using devices that is connected to a tablet. Thus, they too, have joined the act on chronic care.  

State: New York 

Use Case: Remote care is great for solving the most urgent problems due to the frequency of access and speed it provides to those in need. When ambulatory care is not fast enough, remote care helps by possibly preventing life threatening situations. With the shift to population health management, more is being done to prevent emergency situations in the first place. So yes, if it was anyone providing chronic care, NewYork-Presbyterian would be one of the first institutions to come to mind.  

1. Children’s Health 

Children’s Health, out of Dallas, has a comprehensive pediatric RPM program. The pilot RPM program consisted of 50 pediatric patients of various ages, who were dealing with organ transplants. The RPM platform helped adolescent patients adhered to complicated medication regimens. Previously they also had rolled out a neonatal RPM program, where infants could be monitored wirelessly, and their cases could be consulted virtually. Zooming out of the home, they  also set up digital care points in the form of kiosks at retail pharmacy locations. 

State: Texas 

Use Case: With this example, the third major form of care to embrace RPM makes an entry, that is neonatal care. In Neonatal ICUs, health indicators are absolutely essential, and it just makes it easier if it can be done remotely via sensors. For those children who are older and suffering from various complications, it helps that they are more tech savvy, thus RPM is a great way to provide care to such a population.  

I hope you enjoyed reading the article. If you have any questions/suggestions, please reach out to me at rahat.haque@aetonixsystems.com. Also make sure to follow our Social Media pages above. We would love to hear from you.

We are Aetonix. We Simplify Complex Care.

Reimbursement

Reimbursement

DOWNLOAD THE REIMBURSEMENT GUIDE

  CMS has released its final rule for the 2020 Physician’s Fee Schedule. We have previously covered how one can set up a chronic care management program in 5 steps. We have also covered the available CPT codes that can be used to bill for chronic care management, which also includes remote patient monitoring. The great news is none of those CPT codes have been modified for 2020! So a provider organization or practice can use those codes to finance their CCM and RPM programs. Especially those who have not gotten into the habit of using those CPT codes, now would be the time, as they have remained the same for the next year. Check out this Reimbursement Guide that covers both Chronic Care Management (CCM) and Remote Patient Monitoring (RPM). It will allow you to formulate your reimbursement strategy for the year ahead.

  The only changes that have happened for 2020 are the inclusion of other codes to bill extra periods of time worked on a patient, and making the RPM codes furnishable via general supervision. It was only possible to furnish them via direct supervision prior.

  Both changes are extremely beneficial. First, they do not displace any existing codes, thus organizations and clinicians alike do not need to relearn anything. The only thing they need to do is start familiarizing themselves with the existing CPT codes(as found on the reimbursement guide), and begin using them.  

  Second, the new changes make it easier to implement the codes because of a more relaxed stance on supervision. They also allow more options when providing care as far as the time allotted to patient goes. We cover the changes below. Going forward in 2020, one can bookmark this page to see all CPT codes that are available to them (existing ones and new ones included).  

Before covering all reimbursement scenarios, let’s cover some definitions first. 

General Supervision: “General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required”. 

Qualified Healthcare Professionals (QHP): A qualified healthcare professional is an individual who is qualified by education, training, and licensure/regulation and/or facility privileges (when applicable) who performs a professional service within his or her scope of practice, and independently reports that professional service.”  

Examples of QHPs who can bill for CCM: Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists and Certified Nurse Midwives.  

Clinical Staff: “A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service but who does not individually report that professional service.” 

Examples of clinical staff: Licensed practical nurse, medical assistants and registered nurses.

 Looking at the language of how everything is framed, there seems to be two general options available for reimbursement strategies. 1)With Clinical Staff 2) Without Clinical Staff. Hiring clinical staff is obviously an expense that must be considered. It especially makes sense when there is a large number of patients involved.

If you Have Clinical Staff 

1st Year

*Optional Codes dependent on if the patient requires more time.

G0438 initial visit ($164)- For new first-time patients who have been enrolled with Medicare for more than one year. 

CPT 99490 ($42 for non-facility/ $32 for facility) “Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month. Assumes 15 minutes of work by the billing practitioner per month.” 

*G2058($31)( reportable a maximum of two times within a given service period for a given beneficiary) – “Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.” 

CPT code 99453 ($19): “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.” 

CPT code 99454 ($64): “Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.” 

CPT code 99457($52 for non-facility/ $32 for facility): “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.” 

*CPT code 99458 ($26):  “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.”

Minimum Annual Revenue Per Patient= $[164+(42 x 12) + 19+ (64 x 12) +(52 x 12)]= $2079

For 40 minutes of general supervision monthly.

Revenue will increase if a patient needs more time.

2nd Year

Everything remains the same except G0438 is switched with G0439, and there is no need for CPT99453 as set up is already done.

G0439 subsequent visit ($109)- For returning patients who have had the AWV before. A patient is only eligible for a subsequent visit a year after the initial visit. 

Minimum Annual Revenue Per Patient= $[109+(42 x 12) + (64 x 12) +(52 x 12)]= $2005

For 40 minutes of general supervision monthly.

Revenue will increase if a patient needs more time.

If you Don’t Have Clinical Staff 

1st Year

*Optional Codes dependent on if the patient requires more time.

G0438 initial visit ($164)- For new first-time patients who have been enrolled with Medicare for more than one year. 

CPT 99491($84 for non-facility and facility) “Chronic care management services, provided personally by a physician or other qualified health care professional, at least 30 minutes of physician or other qualified health care professional time, per calendar month.” 

*G2058($31)( reportable a maximum of two times within a given service period for a given beneficiary) – “Chronic care management services, each additional 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.” 

CPT code 99091($58 for non facility and facility): “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 healthcare professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days.” 

*CPT code 99458 ($26):  “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.”

Minimum Annual Revenue Per Patient= $[164+(84 x 12) + (58 x 12)]= $1868

For 60 minutes of work monthly.

Revenue will increase if a patient needs more time.

2nd Year

Everything remains the same except G0438 is switched with G0439.

G0439 subsequent visit ($109)- For returning patients who have had the AWV before. A patient is only eligible for a subsequent visit a year after the initial visit. 

Minimum Annual Revenue Per Patient= $[109+(84 x 12) + (58 x 12)]= $1813

For 60 minutes of work monthly.

Revenue will increase if a patient needs more time.