Aug 25, 2017
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As remote patient monitoring through mobile medical technologies continues to proliferate, Medicare coverage for physician services using these technologies has remained largely stagnant. Unfortunately, over the past years there have been few new areas of coverage or incentives. The good news is that there have been some important recent developments that may change this situation dramatically.
On July 13, 2017, the Centers for Medicare & Medicaid Services (CMS) announced the release of the 2018 Physician Fee Schedule (PFS) proposed rule. The PFS is issued annually to update Medicare payment and policies for physicians and other clinicians who treat Medicare patients during the subsequent calendar year. Of all the payment rules issued by CMS, none can affect telehealth and remote monitoring services more directly than the fee schedule.
It’s no secret that, today, federal Medicare reimbursement for telehealth services are almost non-existent — totaling just $28.75 million in 2016 out of their $990 billion overall CMS budget.1 The amount is so low because CMS narrowly defines what is permissible as a telehealth service. Even murkier are the rules governing remote patient monitoring services. CMS reminds us in this year’s fee schedule that remote patient monitoring services are not generally considered Medicare telehealth services but rather services that involve the interpretation of medical information without a direct interaction between a practitioner and beneficiary. While these services are paid under the same conditions as in-person physician services, the reality is that Medicare reimbursement for remote patient monitoring of physiologic information is non-existent.
In fact, there is no commonly recognized service by CMS for remote patient monitoring. A 2017 U.S. Government Accountability Office (U.S. GAO) report on telehealth and remote monitoring highlights that CMS has not even conducted a separate analysis of remote patient monitoring services, stating that the “number of Medicare beneficiaries who use this service is unknown.” A Medicare Payment Advisory Commission (MedPAC) report showed how in calendar year 2014 Medicare spent $70 million for remote cardiac monitoring services accounting for 265,000 beneficiaries. That same year, Medicare spent $119 million for “remote monitoring” of heart rhythms through implantable cardiac devices (such as pacemakers) accounting for 639,000 beneficiaries. But this is not widespread federal reimbursement for remote patient monitoring of physiologic data derived from home-use or mobile medical devices such as weight scales, blood pressure monitors, pulse oximeters, glucometers, thermometers, asthma inhaler sensors, etc.
What a welcomed surprise it was to find in this year’s fee schedule a “comment solicitation” on remote patient monitoring. CMS is asking whether it should make separate payments for CPT codes that describe remote patient monitoring (the short answer is yes). But CMS is seeking comments regarding two existing CPT codes (99091 and 99090), in addition to others that describe “extensive use of communications technology” for future rulemaking. One of the two codes covers “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 health care professional (QHCP), qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.” The other code covers “Analysis of clinical data stored in computers (e.g., ECGs, blood pressures, hematologic data).” Notice that neither code mentions the word “remote.”
For many years, these codes received modest attention from the mobile health community as remote patient monitoring service codes that CMS should cover and reimburse. Both these codes are “miscellaneous services” codes assigned a “bundled” status by CMS. Meaning they don’t have separate coverage or payment, but can be reported with other codes that do have coverage and payment. These codes provide physicians or other clinicians a means to track miscellaneous services (i.e., monitoring) that are adjunct to other covered and paid services. Furthermore, under one of the codes, if the physiologic monitoring is provided on the same day a patient goes to the doctor, the monitoring is considered part of the visit’s evaluation and management. These two codes are promising, but are imperfect at best. One is even vague as to the health care professional’s involvement, time increments, conditions, and most importantly has no assigned relative value.
Coding is vital to the proliferation of mobile health technologies. Coding is the foundation upon which everything is built when it comes to medical nomenclature for procedures, services, and claims processing. The two codes that CMS highlighted are part of the Current Procedural Terminology (CPT) code set that is maintained and copyrighted by the American Medical Association. CPT is the most widely accepted listing of descriptive terms and identifying codes used by every physician and health care provider in the United States to provide a uniform language and harmonized communication among CMS, physicians, and other stakeholders in the health care ecosystem.
A lack of available remote monitoring codes has practical implications. Take for example the Care Beyond Walls and Wires (CBWW) congestive heart failure program, a collaboration in which Qualcomm Wireless Reach took part, that has since expanded into a home health monitoring program through Qualcomm Life. The program has shown the amazing results that remote patient monitoring can provide. Enrolled patients that have been diagnosed with various conditions such as heart failure are provided upon discharge a remote monitoring kit that includes wireless home-use medical devices such as a blood pressure cuff monitor, weight scale, pulse oximeter, thermometer, and a Qualcomm Life 2net Hub (a communications device that sends remote patient data). Daily measurements are communicated via the 2net Hub over a 3G/4G wireless network to a digital health software platform. Care managers monitor patients’ data uploads and call them as needed. Patient data and medical notes are also uploaded into the patients’ electronic health record for other medical providers to review. If care managers see warning signs, they can call the patient, alert the provider, order testing, or change medications as needed. Importantly, there currently is no Medicare coverage and reimbursement for these services. And, the existing codes are useless to the hospital since the services are remote and monitoring is not being performed with other services, nor is it being provided on the same day a patient presents for evaluation and management. CPT codes that adequately describe remote monitoring services need to be established and implemented.
This lack of digital medical codes is not lost on the American Medical Association (AMA). For nearly three years I’ve been collaborating with the AMA on issues related to telehealth, digital medicine advocacy, and coding. In 2014, the AMA created a Telehealth Services Workgroup (TSW) to recommend solutions for the reporting of non-telehealth services when provided remotely utilizing telehealth technology. That work lead to the convening of the Digital Medicine Payment Advisory Group (DMPAG), a volunteer body of clinical subject matter experts with decades worth of experience utilizing digital medicine services and tools in clinical practice. I’ve had the honor of serving on that group since its inception, working on a range of issues to support digital medicine and its adoption.
A top priority for the DMPAG has been identifying pathways to clinical integration of digital medicine, specifically remote patient monitoring coding, valuation, coverage, and program integrity. As a result, several formal coding applications requesting the additions of new codes for physiologic monitoring and management have been submitted by the DMPAG to the CPT Editorial Panel for consideration during its upcoming September 2017 meeting. These applications include two for physiologic monitoring and management. One application requests the addition of a code to report the physician/provider services of chronic care monitoring/management of a patient using remote monitoring technology, the other addresses the technical component and set up.
There is no guarantee they will be approved by the CPT Editorial Panel, but digital medicine will not move forward unless it’s represented in the foundational medical nomenclature code set. CPT’s partnership and understanding of the evolution of medical practice and current services are crucial. Should these codes gain approval, it doesn’t mean CMS will begin automatically covering or paying them. But the process of creating codes is methodical and requires thorough assessments of medical practice and procedures based on validated evidence, scientific backing from medical societies, the involvement of the medical community, well defined criteria, and clinical expertise. The path to CMS coverage and payment typically runs through CPT and then through the AMA’s RUC (Relative value scale Update Committee) which has a separate and equally rigorous process to make recommendations and assign relative values to codes.
The existing codes CMS has highlighted are insufficient to cover the full gamut of remote monitoring. We hope to have at least two new codes created by CPT in September. CMS needs to look beyond the established codes and into the future of digital medicine while working with the AMA and the entire stakeholder community. Medicine has changed and it’s time for the CPT code set to evolve as well as for CMS to cover those new codes and reimburse for remote monitoring and digital medical services.
Qualcomm is fully supportive of CMS’ solicitation for comments on the existing codes. We look forward to expressing our views on valuation, circumstances under which those codes may get reported for separate payment, differentiation, cost sharing by patients, and utilization assumptions for PFS rate setting.
I encourage all stakeholders to comment on the proposed 2018 Physician Fee Schedule, which can be found here. Comments are being accepted through September 11, 2017.
 See: HHS FY 2016 Budget in Brief - CMS – Overview https://www.hhs.gov/about/budget/fy2018/budget-in-brief/cms/index.html; Medicare Spending on Telehealth Continues to Climb https://www.politicopro.com/f/?id=0000015d-c3db-da7a-a5df-dbfbba880001