AMARILLO, TX – There is a shift in the health care space away from reactive health care to proactive health care. Historically, physicians, hospitals, therapists, third party payors (“TPPs”) and other stakeholders have been reactionary when it comes to providing health care to patients. Simply speaking, a patient “gets sick” and goes to the physician or the hospital ER. This triggers exams, tests, procedures and medications…all designed to help the patient “get well.” And then this cycle repeats itself. This type of reactionary health care is inefficient and expensive.
And so TPPs, governmental agencies and other health care stakeholders are pushing health care into a proactive/preventative model. It is more efficient, less expensive, and better for patients for patients not to end up at the physician’s office or the ER – but rather – to stay healthy.
A mechanism to accomplish this is RPM. A relatively new phenomenon, RPM is designed to allow physicians to monitor their patients (in their homes) to determine if patients meet certain metrics on a daily basis. If patients fail to meet the metrics, then RPM is designed for the physician to intervene with the patient to proactively solve the problem…thereby alleviating the need for a trip to the hospital. While CMS has given us some direction regarding RPM, there are still some uncertainties. CMS will address these uncertainties over time. The purpose of this article is to summarize what we know so far regarding RPM.
A DME supplier may desire to offer RPM equipment and services to physicians … so that the physicians can efficiently offer RPM to their patients. In exchange for these services, the physicians will compensate the DME supplier; and the physicians will be responsible for submitting their own claims for RPM services. The challenge is that to date, CMS has not published guidance on the use of third parties to manage data collected through remote monitoring devices. Physicians must meet all of the requirements to bill the RPM codes (i) as outlined by the CPT Codebook and (ii) as required by TPPs.
Generally, the RPM codes are billed for physiologic monitoring; the CPT code book and CMS guidance provide examples of data that can be collected such as weight, blood pressure, and pulse oximetry. The monitoring device must meet the definition of “medical device” outlined in the Federal Food, Drug, and Cosmetic Act. With respect to the types of devices that are eligible for billing under 99453 and 99454, CMS provided the following guidance:
[T]he medical device should digitally (that is, automatically) upload patient physiologic data (that is, data not patient self-recorded and/or self-reported). We also noted that use of the medical device or devices that digitally collect and transmit a patient’s physiologic data must, as usual for most Medicare covered services, be reasonable and necessary for the diagnosis or treatment of the patient’s illness or injury or to improve the functioning of a malformed body member. Further, we noted that the device must be used to collect and transmit reliable and valid physiologic data that allow understanding of a patient’s health status in order to develop and manage a plan of treatment. 85 FR 84543 (Dec. 20, 2020).
Based on this language, metrics such as weight, blood pressure, and pulse oximetry are not strictly required in order to bill under 99454; however the data must be (1) uploaded digitally (i.e., automatically) and (2) reliable and valid physiologic data that allows the practitioner to develop and manage a plan of treatment. It is likely that the data collected must be more than information to confirm compliance with a plan of care.
Per the CPT Codebook, at least 16 days of data each 30 days must be collected and transmitted to meet the requirements of 99453 and 99454. If the monitoring is less than 16 days, then the requirements are not met. For 99454, the data must be digitally recorded and uploaded for the practitioner’s review. No in-person or telephone communication is required for 99454.
In order to bill 99457, clinical staff, the practitioner, or other qualified health care professional must have live, interactive communication with the patient for at least 20 minutes in a 30 day period. There is no definitive guidance whether this activity can be outsourced by a patient’s physician. The physician should review TPP billing requirements to ensure that the physician meets the requirements to bill for RPM. The person speaking with the patient must be a physician, clinical staff, or other qualified health care professional. An “other qualified health care professional” includes nurses, PAs, and speech/occupational therapists.
CPT Code 99458 is billed for additional 20 minutes of live, interactive communication within a 30 day period. For example, if a physician spends 40 minutes during a 30 day period on live, interactive communication pertaining to remote physiologic monitoring management, then the physician can bill 99457 for the first 20 minutes and 99458 for the subsequent 20 minutes. There does not appear to be a limit on the number of times 99458 can be billed in a month if all requirements are met. However, the CPT Codebook includes the following guidance:
Do not use 99457, 99458 for time that can be reported using more specific monitoring services (eg, for the patient that requires reevaluation of medication regiment and/or changes in treatment). Codes 99457, 99458 may be reported during the same services period as chronic care management services….transitional management services…and behavioral health integration services…however, time spent performing these services should remain separate and no time should be counted toward the required time for both services in a single month.
Do not report 99457, 99458 for services of less than 20 minutes. . . Do not count any time on a day when the physician or other qualified health care professional reports an E/M service (office or other outpatient services…domiciliary, rest home services…inpatient services). Do not count any time related to other reported services (eg, 93290, 93793, 99291, 99292).
AAHOMECARE’S EDUCATIONAL WEBINAR
Properly Working with a Manufacturer … and Pitfalls to Avoid
Presented by: Jeffrey S. Baird, Esq., Brown & Fortunato & Todd A. Moody, Esq., Brown & Fortunato
Tuesday, April 6, 2021
1:30-2:30 p.m. CENTRAL TIME
“Manufacturers and DME suppliers are dependent on each other. It is important to suppliers that manufacturers be able to produce quality products and sell them at fair price. On the other hand, it is important to manufacturers that suppliers have the ability to purchase and resell the products. It is increasingly common for manufacturers and suppliers to collaborate in order to facilitate the success of both parties. As they work together, manufacturers and DME suppliers need to be careful to avoid violating the federal anti-kickback statute (“AKS”), beneficiary inducement statute and related laws. This program will (i) discuss the federal laws that govern manufacturer/DME supplier relationships; (ii) the types of collaboration that are legally acceptable; and (iii) the types of collaboration that “cross the line” and implicate federal anti-fraud laws. In particular, the program will focus on (i) discounts and rebates in accordance with the Discount safe harbor to the AKS; (ii) cooperative marketing arrangements; (iii) sample programs; and (iv) the transmittal of leads from the manufacturer to the supplier.”
Jeffrey S. Baird, JD, is chairman of the Health Care Group at Brown & Fortunato, PC, a law firm with a national health care practice based in Texas. He represents pharmacies, infusion companies, HME companies, manufacturers and other health care providers throughout the United States. Baird is Board Certified in Health Law by the Texas Board of Legal Specialization and can be reached at (806) 345-6320 or firstname.lastname@example.org.