Shelley Riser, BSN, MSHA, Vice President, Consulting Services and Clinical Innovation
Sponsored by Geneia

Reimbursement for Reducing Admissions and Readmissions with RPM

Let me say at the outset that there is a growing body of evidence showing that telemonitoring and remote patient monitoring reduce hospital admissions and readmissions. Three of many studies demonstrating its effectiveness are:

  • CHRISTUS Health System used remote patient monitoring to reduce hospital readmissions by 65 percent and overall cost of care by 90 percent for high-risk patients.
  • Geisinger Health Plan’s four-year study, 500-patient study showed remote patient monitoring of heart failure patients reduced readmissions by 38 to 44 percent and produced a return on investment of $3.30 on the dollar.
  • Geneia’s 12-month study resulted in a decline of hospital admissions by 76 percent for monitored members and 31 percent for the control group, a net difference of 45 percent. Per member per month medical spend was 50 percent less for monitored members.

CMS Reimbursement is Advancing

wellness

As the Centers for Medicare & Medicaid Services (CMS) has embraced value-based care, it has moved to improve reimbursement for telehealth and remote patient monitoring, albeit more slowly than many would like. As of January 1, 2018, CMS increased the list of reimbursable telehealth services by seven, adding “various psychotherapy services, counseling services, interactive complexity, administration of health risk assessments, and assessments for patients requiring chronic care management services.”

In particular, CMS added some existing codes to the list of telehealth services. For the benefit of providers looking to increase their telehealth reimbursement, the services that have been added and associated codes are:

  • Visit to determine low dose computed tomography eligibility (HCPCS code G0296)
  • Interactive complexity (CPT code 90785)
  • Health risk assessment (CPT codes 96160 and 96161)
  • Care planning for chronic care management (HCPCS code G0506)
  • Psychotherapy for crisis (CPT codes 90839 and 90840)

I am most encouraged by the addition of the code for care planning for chronic care management (HCPCS code G0506), which builds upon CMS’s decision to reimburse for non-face-to-face chronic care management for Medicare patients with two or more chronic conditions (CPT code 99490) beginning in calendar year 2015.

At the same time, CMS reduced the administrative burden to physicians billing CMS for telehealth services. Determining that the reporting of the telehealth modifier GT was redundant, CMS eliminated this requirement. In short, CMS has acknowledged the contributions of telehealth to improve the quality and cost of care along with the additional work of providers using these services to benefit their patients.

The most significant development was Medicare’s decision to finalize separate pay for providers billing for remote patient monitoring services under CPT code 99091. By unbundling the existing code 99091 from more restrictive telehealth rules, providers are now “able to get reimbursed separately for time spent on collection and interpretation of health data that is generated by a patient remotely, digitally stored and transmitted to the provider, at a minimum of 30 minutes of time.”

The bottom line is: Medicare is now paying providers a monthly fee for delivering RPM services.

There’s more work to do to improve remote patient monitoring reimbursement.

The decision by CMS to pay providers a separate, monthly fee for remote patient monitoring services is thought to be an important first step. Undoubtedly, there is more to do. That’s why nearly 50 organizations have called on CMS to improve RPM reimbursement. In a letter to CMS Administrator Seema Verma, the group urged CMS to expand opportunities for reimbursement of RPM in the patient’s home saying,

While CMS has taken this commendable step forward in unbundling CPT 99091, we believe CMS must continue the commitment [to remote patient monitoring.] We stand in agreement with CMS that RM [remote monitoring] are paid under the same conditions as in-person physician services and can be a significant part of ongoing medical care.

To me, it seems virtually inevitable that CMS will continue to recognize the contributions and efficacy of telehealth and remote patient monitoring in helping to achieve the Quadruple Aim, and accordingly, increase reimbursement for these services. The combination of the Silver Tsunami, that is, 10,000 Americans per day aging into Medicare, and the increasing prevalence of chronic disease means we need to expand access to proven solutions that leverage the best of technology. I am confident that patients, physicians, health care organizations and the entire health care field stand to benefit.