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.

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COPD Education – Onboarding

Objective

To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Actors
Patient, Educator (Nurse, RT, the Physician could also be the educator)

Timelines
One 60-90 min session with the Educator

Description
  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
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COPD Education – Continuous Maintenance

Objective 

To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

Description
  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
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COPD Respiratory Status Follow-up

Objective

Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Actors
Patient, Educator (Nurse, RT or Physician)

Timelines
Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

Description
  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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