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2021 CPT Codes by the CMS for Medicare Extension Care Management Programs

Chronic Care Management:

The chronic care management program was virtually untouched by the 2021 Final Rule from CMS. There are three main CPT codes and two add-on CPT codes in 2021 that may be billed by primary care providers for CCM services.

Requirements for CCM:

Non-Complex CCM:

Two or more chronic conditions expected to last at least 12 months (or until the death of the patient)
Patient consent (verbal or signed)
Personalized care plan in a certified EHR and a copy provided to the patient
24/7 patient access to a member of the care team for urgent needs
Enhanced non-face-to-face communication between patient and care team
Management of care transitions
At least 20 minutes of clinical staff time per calendar month spent on non-face-to-face CCM services directed by a physician or other qualified healthcare professional
CCM services provided by a physician or other qualified healthcare professional are reported using CPT code 99491 and require at least 30 minutes of personal time spent in care management activities

Complex CCM:

Shares common required service elements with CCM but has different requirements for:

Amount of clinical staff service time provided (at least 60 minutes)
The complexity of medical decision-making involved (moderate to high complexity)

CPT Reimbursement Codes for CCM Service:

Non-complex CCM:

CPT Code 99490– This code requires that patients must have two or more chronic conditions, as well as documented consent to enroll in the program AND receive at least 20 minutes of CCM services from clinical staff within a given month. A personalized care plan, which shows an assessment of all patient factors and identifies gaps and barriers to be addressed, is also required. Reimbursement Rates – CPT Code 99490 – $42/patient/month.
CPT Code 99439 (formerly G2058) -This code allows providers to bill for each additional 20 minutes spent for Basic CCM services in a given month, up to 2 times. For example, if CCM services were provided for at least 40 minutes with a patient in a given month that was not Complex, 99490 ($42) and 99439 ($38) would be billed together for that month. Reimbursement Rates – CPT Code 99439 (formerly G2058) – $38/patient/month.

Complex CCM:

CPT code 99487– This code has a higher rate of reimbursement than the Basic CCM CPT code. To bill using this code requires moderate or high complexity in medical decision making AND acknowledgment by both patient & provider of an acute exacerbation (generally defined as a sudden worsening of a patient’s condition that necessitates additional time and resources). The patient must receive at least 60 minutes of services from clinical staff within a given month to bill for this code. Reimbursement Rates – CPT Code 99487 – $93/patient/month.
CPT code 99489 – The same as with the Basic Chronic Care Management code, the Complex Chronic Care Management code also has an add-on CPT code to cover time spent beyond 60 minutes. It allows for billing for each additional 30 minutes spent for Complex CCM services within a given month. Reimbursement Rates – CPT Code 99489 – $45/patient/month.

Transitional Care Management:

Transitional Care Management (TCM) services address the hand-off period between the inpatient and community settings. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care.

Requirements for TCM:

Contact the beneficiary or caregiver within two business days following a discharge. The contact may be via the telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful.
Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision-making involved. The face-to-face visit is part of the TCM service and should not be reported separately.
Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit.
Obtain and review discharge information.
Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments.
Educate the beneficiary, family member, caregiver, and/or guardian.
Establish or reestablish referrals with community providers and services, if necessary.
Assist in scheduling follow-up visits with providers and services, if necessary.

CPT Reimbursement Codes for TCM Service:

CPT code 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge. Reimbursement rate – $175.76/patient/month.
CPT code 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge. Reimbursement rate – $237.11/patient/month.

Allowed reported services alongside TCM services include,

Prolonged services without direct patient contact (99358-99359);
Home and outpatient international normalized ratio (INR) monitoring (93792-93793);
End-stage renal disease (ESRD) services for patients ages 20 years and older (90960-90962, 90966, or 90970);
Interpretation of physiological data (99091); and
Care plan oversight (G0181-G0182).

Remote Patient Monitoring:

RPM involves the collection and analysis of patient physiologic data that are used to develop and manage a treatment plan related to a chronic and/or acute health illness or condition.

Requirements for RPM:

To qualify for CMS reimbursements for utilizing the RPM services efficiently, the service providers and hospitals need to ensure the following:

Medicare part B patients are imposed 20% of copayment (renouncing the copayments regularly can trigger penalties under the Federal Civil Monetary Penalties Law and also the Anti-Kickback Statute)
Patients must take the remote monitoring services and are required to monitor for a minimum of 16 days to be applicable for a billing period.
The RPM services must be ordered by skilled physicians or other qualified healthcare experts.
Data must be wirelessly synced for proper evaluation, analysis, and treatment.

CPT Reimbursement Codes for RPM Service:

CPT code 99453 – It is a one-time practice expense reimbursing for the setup and patient education on RPM equipment. This code covers the initial setup of devices, training and education on the use of monitoring equipment, and any services needed to enroll the patient on-site. Reimbursement rate – $18.77/patient/month.
CPT code 99454 – This code covers the supply and provisioning of devices used for RPM programs, and the code is billable only once in a 30-day billing period. Reimbursement rate – $64.44/patient/month.
CPT code 99457 – This code covers the direct monthly expense for the remote monitoring of physiologic data as part of the patient’s treatment management services. To receive reimbursement, the physician, QHP or other clinical staff must provide RPM treatment management services for at least 20 minutes per month. Reimbursement rate – $51.61 (non-facility); $32.84 (facility) /patient/month.
CPT code 99458 – This code is an add-on code for CPT Code 99457 and cannot be billed as a standalone code. This code can be utilized for each additional 20 minutes of remote monitoring and treatment management services provided. Reimbursement rate – $42.22 (non-facility); $32.84 (facility) /patient/month.

Principal Care Management:

PCM codes are intended to cover services for patients with only one complex chronic condition that requires management by a specialist. Like other chronic care management (CCM) codes (chronic care management, transitional care management), the PCM codes are intended to reimburse physicians for the additional work they do to take care of high-risk, complex patients. This includes the extra time and work required for medication adjustments, creating a care plan, patient follow-up, and more.

Requirements for PCM:

One complex chronic condition lasting at least 3 months, which is the focus of the care plan,
The condition is of sufficient severity to place the patient at risk of hospitalization or has been the cause of recent hospitalization,
The condition requires development or revision of a disease-specific care plan,
The condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities

CPT Reimbursement Codes for PCM Service:

CPT Code G2064 – requires 30 minutes of provider (allergist, NP, PA) time each calendar month to care for the patient. This code can be billed monthly (in addition to appropriate E/M codes) and approximate reimbursement is $52/patient/month.
CPT Code G2065 – requires 30 minutes of clinical staff time directed by a provider each calendar month for patient care. Provider supervision does not require the provider to be onsite while clinical staff performs PCM services. This code can be billed monthly (in addition to appropriate E/M codes) and approximate reimbursement is $22/patient/month.

Annual Wellness Visit:

The Annual Wellness Visit (AWV) is a yearly appointment with your primary care provider (PCP) to create or update a personalized prevention plan. This plan may help prevent illness based on your current health and risk factors. Keep in mind that the AWV is not a head-to-toe physical.

Requirements for AWV:

For G0438 (initial visit),

Billable for the first AWV only.
- Patients are eligible after the first 12 months of Medicare coverage.
- For services within the first 12 months, conduct the Initial Preventive Physical Exam (IPPE), also referred to as the Welcome to Medicare Visit (G0402).
The patient must not have received an IPPE within the past 12 months.
Administer a Health Risk Assessment (HRA) that includes, at a minimum: demographic data, self-assessment of health status, psychosocial and behavioral risks, and activities of daily living (ADLs), instrumental ADLs including but not limited to shopping, housekeeping, managing own medications, and handling finances.
Establish the patient’s medical and family history.
Establish a list of current physicians and providers that are regularly involved in the medical care of the patient.
Obtain blood pressure, height, weight, body mass index or waist circumference, and other measurements, as deemed appropriate.
Assess a patient’s cognitive function.
Review risk factors for depression, including current or past experiences with depression or mood disorders.
Review patient’s functional ability and safety based on direct observation, or the use of appropriate screening questions.
Establish a written screening schedule for the individual, such as a checklist for the next 5 to 10 years based on appropriate recommendations.
Establish a list of risk factors and conditions for primary, secondary, or tertiary intervention.
Provide personalized health advice to the patient, as appropriate, including referrals to health education or preventive counseling services and programs.
At the patient’s discretion, furnish advance care planning services.

For G0439 (subsequent visit),

Billable for subsequent AWV.
The patient cannot have had a prior AWV in the past 12 months.
Update the HRA.
Update the patient’s medical and family history.
Update the current physicians and providers that are regularly involved in providing the medical care to the patient, as developed during the initial AWV.
Obtain blood pressure, weight (or waist circumference, if appropriate), and other measurements, as deemed appropriate.
Assess a patient’s cognitive function.
Update the written screening schedule checklist established in the initial AWV.
Update the list of risk factors and conditions for which primary, secondary, and tertiary interventions are recommended or underway.
Provide personalized health advice to the patient, as appropriate, including referrals to health education or preventive counseling services and programs.
At the patient’s discretion, the subsequent AWV may also include advance care planning services.

CPT Reimbursement Codes for AWV Service:

The four CPT codes used to report AWV services are,

G0402 Initial Preventive Physical Exam – This code is used for patients visiting within 12 months after enrolling in Medicare.
G0438 Initial Visit – This visit is eligible within 11 calendar months from the date of IPPE.
G0439 Subsequent Visit – This code is used for every subsequent visit. Patients are eligible for this benefit every year after their Initial AWV.
CPT 99497/99498 – Patients are eligible for an Advance Care Planning (ACP) at any time. But if performed during an AWV, the patient has no copay.

Behavioral Health Integration:

Integrating behavioral health care with primary care (“behavioral health integration” or “BHI”) is an effective strategy for improving outcomes for millions of Americans with behavioral health conditions. Medicare makes separate payments to physicians and non-physician practitioners for BHI services they furnish to beneficiaries over a calendar month service period.

Requirements for BHI:

Any mental or behavioral health condition being treated by the billing practitioner, including substance use disorders, that, in the clinical judgment of the billing practitioner, warrants BHI services.
The diagnosis or diagnoses could be either pre-existing or made by the billing practitioner and may be refined over time.

CPT Reimbursement Codes for BHI Service:

The CPT code used to report BHI services is,

CPT Code 99494 – Initial or subsequent psychiatric collaborative care management, each additional 30 minutes in a calendar month of behavioral health care manager activities, in consultation with a psychiatric consultant, and directed by the treating physician or other qualified healthcare professional.

References:

https://signallamphealth.com/2021-medicare-cms-chronic-care-management-ccm-cpt-code-updates/

https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1

https://college.acaai.org/new-principal-care-management-cpt-codes/#:~:text=G2064%20requires%2030%20minutes%20of,is%20%2452%2Fpatient%2Fmonth

https://www.aafp.org/family-physician/practice-and-career/getting-paid/coding/transitional-care-management.htm

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

The Evolution Of The Health Tech: Positive Change Through Interoperable Solutions

The American Healthcare Industry has experienced many large-scale changes in the past few decades. This timeframe has afforded us many drastic reforms in the industry such as the Affordable Care Act (ACA) or the widespread shift towards Value-Based Care. However, the most noteworthy and significant change is the gradual adoption of software solutions into the healthcare industry. The digitization of healthcare has brought numerous benefits to healthcare organizations that are able to streamline their day-to-day operations. More importantly, these solutions have made life easier for care providers and patients by simplifying the delivery of care. In order for these complex systems to operate, they need to display competency in Interoperability.

How Interoperability Ties It All Together

Interoperability in the context of healthcare refers to the use of many complex systems and information technology (IT) to exchange and interpret health-based data. As many software systems were designed for specific tasks, the transfer of data between different systems emerged as a significant challenge. Interoperability allowed for different computer systems that operate on different platforms to interact with each other. This gave health organizations the ability to employ multiple systems for their varying needs. At the foundational level, interoperability is present in roughly 75% of health systems in the US. The incorporation of more advanced levels allows organizations to expand the scale of their services.

How Technology is Combatting COVID-19

The COVID-19 Pandemic has proved to be a challenging obstacle for the healthcare industry. While the pandemic continues to test the industry’s existing abilities, the prevalence of computer systems currently in use have helped in the fight to control COVID-19. The use of virtual health services has skyrocketed since the outbreak as clinics across the country shift their focus to COVID-19. Patients are able to access health services like routine check-ups from their tablet or computer. The significance of this service is that it ensures patients with chronic conditions can receive medical services without the risk of being infected with COVID-19. It also helps clinics establish stable cash flow and make up for revenue shortfall due to the pandemic.

Examples of Interoperable Health Tech Solutions:

Telehealth

Telehealth involves the transfer of healthcare services through a telecommunications platform. While the primary use of telehealth is for virtual conferencing between patients and physicians, it is also used for monitoring and educating patients. The most popular form of telehealth is video conferencing where patients and physicians can perform most tasks required in a typical check-up. According to the American Hospital Organization (AHA), 3 out of every 4 hospitals offer some form of telehealth service. Telehealth has proven to be a valuable tool in the fight against COVID-19, while also eliminating long wait times and nonessential clinical visits. Telehealth must be interoperable with other platforms in order to share Electronic Health Records (EMR). Reviewing these records is crucial for physicians who are deciding the next course of action for a patient.

Remote Patient Monitoring

Remote Physiological Monitoring (RPM) uses real-time technology to collect vital parameters such as heart rate, blood pressure, weight, or any other relevant health-based measure. These devices are worn by patients to track the parameters of their health while simultaneously sending the results to a qualified health professional. This professional can analyze the information and intervene if there is any abnormal data. These gadgets have been extremely helpful for chronic care patients who can avoid the hassle of regular clinical visits. Clinics who effectively use these devices can significantly reduce the number of readmissions, which costs the industry over $41 billion a year. Interoperability is crucial in the RPM care delivery as data must be transferred from the patient’s device to the health system without any errors.

Workflow and Referral Management

The goal of Workflow Management is to streamline the patient workflow by eliminating inefficiencies in the process. Tech solutions such as Smart Rooming help nurses room the patient and transfer the responsibility of care in a time-efficient manner. Referral Management is also an extremely crucial part of clinical operations. Referral Leakage, which occurs when a patient’s Referral loop is not closed, costs the industry millions of dollars a year. Interoperable platforms would transfer information from the physician to the specialist in a timely manner and without any gaps.

Artificial Intelligence and Machine Learning

While still extremely developmental in nature Artificial Intelligence (AI) and Machine Learning (ML) provide a glimpse into the future of healthcare. AI and ML both use machines to perform human activities such as comprehension, interpretation, and analysis. Despite a limited role, they are both currently used for routine activities like streamlining workflows, patient education, diagnosis, and predictive analysis. AI/ML can help health tech innovators attain interoperability by assisting computer systems in receiving and analyzing data.

Primary Benefits

The influx of interoperable systems has revolutionized the healthcare industry. Listed below are the main benefits of these solutions.

Improved Patient Experience: One of the main focuses of these innovative software solutions was to improve the overall experience of patients. The introduction of Telehealth and RPM increases access to healthcare for all patients. Tools such as AI and ML are life-saving as they quickly and accurately diagnose conditions.

Simplifying the Care Journey: In the traditional Care Journey, patients may have to spend an entire day in a clinic while physicians shuttle back and forth to tend to them. Software Solutions have streamlined this process by assisting clinics with scheduling, rooming, and diagnosis. Nurses, Physicians, and Clinical staff can allocate their time more efficiently, resulting in a smoother Care Journey for patients.

Optimal Operational Efficiency: Health Organizations are able to maximize the use of their resources thanks to health tech solutions. Using tools like Referral Management and Care Orchestration allows organizations to streamline patient workflows. This helps them serve more patients without having to expand or increase costs.

Increased Profit: Perhaps the greatest benefit for organizations is the ability to increase clinical profits. Efficient software solutions help organizations identify and eliminate inefficient practices. At the same time, solutions like RPM provide additional revenue streams for clinics with little additional cost. While Interoperable solutions may incur an initial cost, effective development and use of the product will have a positive impact in the long run.

Talk to us to understand more about the advancements in the healthcare industry and we will guide you to achieve our common goal “Quality Care for All” seamlessly.

Innovative RPM Developments that will revolutionize Care Delivery

The efficiency and effectiveness of Remote Physiological Monitoring (RPM) has allowed it to emerge as a popular practice in the healthcare industry. RPM has greatly increased the accessibility of healthcare, especially for chronic care patients. It has also allowed care providers to increase their revenue through the CPT reimbursement codes. The industry shift towards a patient-centric, Value-Based Model has allowed for sustained growth for RPM devices in the market. The current innovations in RPM devices have the opportunity to reshape the overall Patient experience.

How COVID-19 is accelerating RPM growth

The COVID-19 Pandemic has expedited the large-scale adoption of RPM. As health centers across the world focus on treating COVID-19, patients with other conditions have been encouraged or instructed to avoid health facilities. This has caused a large deficiency in the transfer of care. This disproportionately affects small clinics that need periodic cash flow and chronic care patients who require frequent clinic visits. RPM devices allow patients to bypass the restrictions by monitoring their health conditions from home. These machines help patients and providers stay up to date with their care plan progress. It also allows clinics to recover some of their lost revenue due to the pandemic. Moving forward, it appears that RPM will increasingly become an integral part of care delivery.

Robot Assistants

The prospect of robotic devices has long been entertained in the healthcare industry. Developments in Artificial Intelligence (AI) and Machine Learning (ML) in the past decade have made a future with these devices more realistic. Acting as a personal assistant to long-term patients is one way that robots could make their way into mainstream healthcare. Many patients with chronic conditions require periodic monitoring and extended hospital stays. Robot Assistants could track the vitals of the patients and input the results into the patient’s Electronic Health Record (EHR). These machines would be especially beneficial to patients at rural or undermanned health clinics. It is at such places where Robot Assistants would significantly enhance the quality of care without replacing a human. A significant issue associated with Robot assistants are liability/legal concerns. Should any issues arise while the patient is under the robot’s care, it is unclear who would be responsible.

Remote Surgery Robots

A more complicated manner in which Robots can enter the industry is through Remote Surgery. These machines can assist surgeons by simplifying complex procedures in ways that are not humanly possible. For example, they can use AI or ML to improve the accuracy of existing practices. Another benefit of Remote Surgery is the opportunity for long-distance procedures. An advanced Remote Surgery Robot could allow for a surgeon to perform on a patient thousands of miles away. The primary hurdle facing Robot devices involve high development and operational costs. Both the software and hardware of these machines are extremely intricate in nature. If this concern is addressed, Robots could become a cornerstone of modern healthcare.

Wearable Devices

Wearable RPM devices are already in common use by chronic care patients across the country. In a more loosely defined manner, fitness and smartwatches can also be considered as they perform many similar tasks as a medical RPM device. In this sense, over 20% of Americans already use one of these wearable devices. The main reason wearable RPM devices have yet to take off is the lack of multi-use devices. While a smartwatch has multiple functions, many medical RPM devices have very specific uses. This causes many patients to shy away from making a financial commitment to these products. An example of how this issue can be solved is exemplified in DexCom’s partnership with Apple. DexCom is using the Apple Watch as a platform for people to access their Glucose monitoring products. By using an established, multi-dimensional platform, DexCom is able to generate a larger outreach. A breakthrough in wearable RPM devices would greatly benefit patients with diabetes or cardiovascular issues. A device that they could wear around the clock would provide medical professionals with the data to better understand their condition.

Future of RPM

The RPM market has significant potential for growth in the upcoming decades. The shift towards a more patient-centric focus has resulted in a positive outlook for future RPM development. Advancements in the overall quality and scale of RPM devices can transform the Patient Care Journey of tomorrow.

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Emerging Technologies that will shape the Future of the Healthcare Industry

The Healthcare Industry has witnessed a great deal of innovation over the past few centuries. Some pioneering breakthroughs include the discovery of vaccines, antibiotics, and insulin. Developments such as these have drastically increased the overall quality of life for billions of people across the planet. These substantial improvements over the past two centuries have led to the emergence of recent tech-based health innovations.

How the move to Value-Based Care affects Innovation

The Healthcare industry has witnessed a shift towards “Value-Based Care” over the past few decades. This model focuses on the patient outcome more than any other factor. This has influenced technological innovations to be patient-centric rather than purely profit-focused.

RPM Devices

Remote Physiological Monitoring (RPM) is a form of real-time telehealth that employs the use of technology in the live collection of vital parameters such as heart rate, blood pressure, weight, or any other relevant measure. These compact gadgets track and send these parameters to qualified health professionals who can analyze the results. RPM devices give patients the opportunity to monitor their condition on a daily basis without constant clinical visits. These devices have allowed providers to remain updated with their patients when a physical visit is not possible. Effective use of these devices is proven to decrease the number of readmissions, which costs the industry over $41 billion a year. The RPM market is expected to grow to $2.7 billion by 2020, per a projection by Research and Markets. If RPM devices can prove their value in a competitive health tech market, they may become an integral part of human life. Their compact nature can allow them to become as ubiquitous as a wristwatch, especially for aging populations.

Telehealth

Telehealth involves the transfer of healthcare services through a telecommunications platform. While it includes monitoring and education, it is most commonly used as a tool for virtual appointments between providers and patients. Commonly used Telehealth platforms involve the use of a video/audio system with the ability to send EHR/EMRs or other health records by message. Telehealth acts as an added revenue stream as the CMS reimburses providers who employ telehealth services. For patients, telehealth means they can access high-quality healthcare from the comfort of their homes. The use of telehealth has rapidly grown over the past decade as 75% of hospitals utilized a telehealth platform in 2017 as opposed to 35% in 2010. In the long run, telehealth can help eliminate nonessential patient visits which waste both time and resources. With technological advances, telehealth might soon adopt a “virtual reality” based format. This can increase patient-provider interaction while enhancing the quality of care.

Artificial Intelligence

Artificial Intelligence (AI) involves the use of machines to perform human activities such as comprehension and analysis. In a healthcare setting, it can be used to make an advanced interpretation of health-based data. The amount of investment in health-based AI is projected to grow from $600 million to $6.6 billion between 2014 and 2021. AI can make patient-specific care plans by accounting for millions of variables involving the patient’s health condition and trajectory. AI could potentially open the door for “Precision Medicine,” which could be a landmark development in modern medicine. While this method is still highly experimental and embroiled in controversy, the prospects of an effective model remains promising.

The Impact of COVID-19 on Health Tech Innovations

The COVID-19 Pandemic has placed a heightened focus on the current capabilities of the Healthcare industry. The pandemic has offered both challenges and opportunities for technological innovation. One of the primary flaws of the industry that COVID-19 has highlighted is the prevalence of unnecessary and inconvenient patient visits. As health centers across the country have been focused on tackling the pandemic, patients with other conditions have been encouraged to stay home and receive virtual care. Many patients are able to mitigate their existing conditions without time-consuming visits to a clinic. At the same time, this provides an opportunity for a widespread adoption of telehealth services. Many providers have experienced the efficiency of virtual health services and will continue to invest in these solutions. Clinics without such platforms will likely adopt telehealth to address their lack of virtual care services. The pandemic will no doubt leave an enduring mark on the healthcare industry. The lessons learned from the pandemic will surely shift the focus of innovations towards virtual health solutions.

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The Importance of Clinical Call Center Nurses in the RPM Care Journey

The emergence of Remote Physiological Monitoring (RPM) has greatly contributed to the rapid adoption of virtual health services. This practice would not be possible without the work of clinical call center nurses, who observe the condition of patients and accordingly make relevant health decisions.

How does RPM work?

RPM uses technology to track a patient’s vital parameters such as heart rate, blood pressure, weight, etc. This data is recorded by the device and sent to health professionals involved with the patient’s care. The care provider can then make informed decisions on the patient’s health. RPM devices notify the care provider if any abnormal vitals are detected. They also allow patients to receive quality health care from a virtual setting. Effective RPM systems result in higher patient satisfaction while increasing the revenue of care providers.

The role of Call Centers in RPM

Clinical Call Centers play a crucial role in the RPM care journey. RPM devices track a large number of complex metrics relating to the patient’s health. Any data recorded by an RPM device is useless until a qualified health professional is able to analyze it. This is where call center nurses factor into the Care Journey. The RPM device emits data through the provider’s RPM software to the clinical center. Here the data can be received and analyzed by the nurses in charge of the virtual patient care. They can record a patient’s progress and better understand how a patient responds to treatment. If there are any slight deviations from the care plan, nurses can video conference with the patient to identify and address the source of the irregularity. If there are any concerning metrics, the nurses can immediately connect the patient with the necessary professional.

How RPM help Call Center Nurses

Call Center Nurses may be in charge of monitoring hundreds of patients in a virtual manner. Without a Remote Monitoring option, nurses need to manually contact individual patients. RPM devices can connect with these patients on a daily basis, without constant human interaction. These devices can collect the data of hundreds of patients and send these results to the call center in just a few minutes. RPM also allows patients to track their health from the comfort of their homes-meaning providers are able to turn their attention to their most at-need patients.

RPM and the COVID-19 Pandemic

The COVID-19 pandemic has heightened the importance of virtual care services like RPM. The pandemic has greatly decreased the healthcare industry’s focus on combating non-COVID related ailments. However, providers with existing RPM mechanisms are benefiting from the ability to monitor health through a virtual platform. In addition, patients who suffer from chronic conditions are still able to receive daily updates on their health.

Characteristics of a functional RPM platform

The following characteristics can be found among all effective RPM systems:

Reduce Emergency Situations: RPM devices can track any abnormal patterns and immediately report them to a health center. Emergency situations are of increased danger to the health of chronic care patients. RPM devices can provide a timely intervention and allow the patient to receive care before an emergency situation unfolds.
Reduce Readmissions: An efficient RPM platform can prevent patients from being readmitted for their existing conditions. By tracking the trajectory of the patient’s health, nurses can notify patients when they deviate from their care plan. This helps patients stay on top of their treatment while decreasing the probability that they are readmitted.
Increased Patient Involvement: The interactive nature of RPM gives patients the opportunity to be more involved in their care. This means patients are more informed on their condition and the treatment plan referred to them. Ultimately a more involved patient increases the likelihood of recovery.

The increased importance of virtual care has allowed RPM to emerge as a powerful tool in care delivery. The proper use of these technologies greatly enhances the convenience and effectiveness of health care.

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Chronic Care Remote Physiological Monitoring (RPM) and its Medicare Reimbursement Codes

Chronic Care Remote Physiological Monitoring (RPM) or Remote Patient Monitoring is a healthcare practice that involves the use of technology to monitor patients in a virtual manner. This practice has gained popularity in recent years and is being utilized with great success in the treatment of chronic care patients.

Specifics of RPM

RPM is a form of real-time telehealth that employs the use of technology in the live collection of vital parameters such as heart rate, blood pressure, weight, or any other relevant measure. This information is then sent to health professionals, who can analyze the data and make informed decisions on the patient’s health. Another beneficial factor is RPM devices often notify both patients and care providers if any abnormal vitals are detected.

How do patients benefit from RPM?

An extensive RPM system gives patients increased access to healthcare. New innovations in the health-based tech industry have afforded patients with high-quality devices to track their health progress. Patients with chronic care conditions that require extensive care are able to monitor any changes to their health on a daily basis. The interactive nature of RPM allows patients to be more involved in their care. RPM is also proven to decrease both readmission and emergency situations. The combination of these factors ultimately results in higher patient satisfaction.

How do providers benefit from RPM?

RPM has given providers an opportunity to stay updated with their patients, even when they cannot physically meet with them. The rapid growth of RPM technologies has also presented care providers with additional streams of revenue. The CMS has recognized this and introduced new codes that provide reimbursement for virtual care related to RPM. RPM also increases the number of patients a clinic can serve as well as the efficiency of care.

RPM and COVID-19

The ongoing Covid-19 pandemic has brought an increased level of attention to RPM practices. Patients and providers with existing RPM infrastructure are greatly benefiting from the ability to monitor health through a virtual platform. Observing a successful model of RPM use during the pandemic will convince many providers to adopt such practices moving forward.

Different Medicare CPT Codes within RPM

Care Providers can use the following CPT codes to generate revenue from the establishment and monitoring of RPM practices.

CPT 99453

CPT 99453 is an RPM code that is used when establishing RPM technologies and educating the patient about safe practices. In 2020, the average revenue received when issuing this code is $19. It must be noted that this code can only be issued one time when installing the necessary technology. Any additional support related to technology or patient education cannot be issued using this code.

CPT 99454

CPT 99454 is an RPM code that can be used to cover the transmission of biometric recordings and program alerts. ThIn 2020, the average revenue received when issuing this code is $64. The reimbursement cost also covers the cost of the device(s) involved in the care. This code is to be issued every 30 months. In order to issue this code, all RPM devices used in the care process must be FDA approved.

CPT 99457

CPT 99457 is an RPM code that can be issued for any care that is at least 20 minutes per month and is monitored by a qualified health professional. In 2020, the average revenue received when issuing this code is $52. This code covers any non-face-to-face interactions between providers and patients that involve the patient’s RPM progress. Providers must not issue CPT 99457 or any other code for any care that is less than 20 minutes per month.

CPT 99458

CPT 99458 is a new RPM code that addresses care provided by a qualified health professional for every additional 20-minute interval after the first 20 minutes of RPM services, which is currently billed under CPT 99457. This code came into effect on January 1, 2020, and has an estimated reimbursement rate of $42. This code must be used as an add-on to the existing RPM’s CPT 99457 for billing.

Challenges with RPM

Despite the previously mentioned benefits of an RPM scheme, there are still a few challenges that have prevented such programs from being widely accepted.

Despite these challenges, RPM technology remains a promising force in the healthcare industry. Its revolutionary nature is reshaping the patient-provider relationship for the better. This care model will help move from reactive care to proactive care. Providing immediate attention will help reduce readmission rates, reduce hospital admissions, etc. thereby helps reduce the overall cost.

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