Category: Medicare Reimbursement
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The new year continues to offer big opportunities for telemedicine and digital health companies, and one of the most notable developments is CMS’ decision to reimburse providers for remote patient monitoring (RPM). Effective January 1, 2018, the Medicare program will pay providers for RPM services billed under CPT code 99091. The service is currently defined as the “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, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.”
It is great to see CMS agree with health innovation advocates that RPM services can be a significant part of ongoing medical care and that the Medicare program should recognize these services for separate payment as soon as practicable. Providers and telehealth companies should act now to embrace this landmark shift by Medicare to directly pay for RPM services on a monthly recurring basis.
RPM is Not a Telehealth Service
RPM services are technically not considered a Medicare telehealth service. Instead, like a physician interpretation of an electrocardiogram or radiological image that has been transmitted electronically, RPM services involve the interpretation of medical information without a direct interaction between the practitioner and beneficiary. As such, Medicare pays for RPM services under the same conditions as in-person physicians’ services with no additional requirements regarding permissible originating sites or use of the telehealth place of service (POS) 02 code. RPM services do not require the use of interactive audio-video, nor must the patient be located in a rural area. The patient can even receive RPM services in their home.
CPT 99091 is not a newly-created code. Instead, Medicare “unbundled” it and designated it as a separately-payable service. Regardless of how CMS accomplished it, the final result is clear: Medicare will now pay providers a monthly fee for delivering RPM services.
Industry response was positive and telehealth advocates supported CMS’ action as another step in recognizing the increasing importance of RPM services.
Not All RPM Codes Made the Cut
When assessing whether or not Medicare should pay for RPM services, CMS also evaluated CPT 99090 as a potential covered service. That service is defined as the “analysis of clinical data stored in computers (e.g., ECGs, blood pressures, hematologic data).” Unlike CPT code 99091, CPT code 99090 does not state that the RPM information must be interpreted by a physician or other qualified health care professional, nor does it specify a 30 minute minimum. After considering the differences, CMS elected to keep CPT 99090 “bundled” and not allow its use for separate payment.
What Does CMS Require for CPT 99091?
It is true that CPT 99091 fails to optimally describe how RPM services are furnished using current technology. This may be due to the fact that the code description is years old and has never before been a separately payable service. The AMA’s CPT Editorial Panel is currently working on new codes intended to more accurately describe remote monitoring. But providers, patients, and CMS itself did not want to wait until those new codes were developed. Until new codes are published and approved by CMS, providers should use the current CPT 99091 for billing RPM services. Here are some of the core requirements to bill Medicare for RPM services under CPT 99010:
- The practitioner must get the patient’s consent for RPM services and document it in the patient’s medical record.
- For new patients or patients not seen by the practitioner within one year prior to billing RPM, the practitioner must first conduct a face-to-face visit with the patient (e.g., an annual wellness visit or physical). E/M services levels 2 through 5 (CPT codes 99212 through 99215) should qualify for this face-to-face visit. Transitional care management (TCM) services should also qualify. However, services that do not involve a face-to-face visit by the billing practitioner or which are not separately payable under Medicare (e.g., online services, telephone and other E/M services) would not qualify as an initiating visit.
- CPT 99091 should be reported no more than once in a 30-day period per patient.
- The service must include the physician or other qualified health care professional time involved with data accession, review and interpretation, modification of care plan as necessary (including communication to patient and/or caregiver), and associated documentation.
- CPT 99091 can be billed once per patient during the same service period as chronic care management (CCM) services (CPT codes 99487, 99489, and 99490), TCM services (CPT codes 99495 and 99496), and behavioral health integration services (CPT codes 99492, 99493, 99494, and 99484). This is allowed because CMS recognizes the kind of analysis involved in furnishing RPM services is complementary to CCM and other care management services. However, time spent furnishing these services cannot be counted towards the required time for both RPM and CCM codes for a single month (i.e., no double counting).
- Because RPM services are not considered telehealth services under Medicare, the patient can be at his/her home, and need not be in a rural area or qualifying originating site.
Entrepreneurs and companies offering RPM technologies should take steps now to understand the new billing opportunities under Medicare. With the forthcoming new CPT codes for more RPM services, this looks to be an area of significant upside potential over the coming years. Hospitals and providers using telehealth and non-face-to-face technologies to develop patient population health and care coordination services should take a serious look at RPM services billing opportunities, and keep abreast of developments that can drive recurring revenue and improve the patient care experience.
For more information on telemedicine, telehealth, virtual care, and other health innovations, including the team, publications, and other materials, visit Foley’s Telemedicine Industry Team and Digital Health Group.
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Medicare Claims Appeals: D.C. Circuit Reverses and Remands in Case Seeking Relief From Processing Delays
Summary of AHA v. Price, 2017 U.S. App. LEXIS 14887 (D.C. Cir. Aug. 11, 2017)
On August 11, 2017, the D.C. Circuit reversed the district court and held that the district court abused its discretion by ordering the Secretary of HHS to clear the backlog of administrative appeals of denied Medicare reimbursement claims within four years, because it failed to seriously test the Secretary’s assertion that this result was impossible. The underlying action demanded relief to address the Secretary’s inability to keep up with “an unexpected and dramatic uptick in appeals [that] produced a jam in the process” starting in fiscal year 2011.
In the initial proceedings, a group of hospitals sought a judicial order compelling the Secretary to provide relief from what they considered to be unreasonable delays in resolving Medicare claims appeals at the administrative appeals level. The federal district court for the District of Columbia granted the Secretary’s motion to dismiss for lack of jurisdiction, but the D.C. Circuit reversed. The Circuit Court remanded the case back to the district court, with instructions to consider the merits of appeal, i.e., whether relief should be granted and if so the form of the relief.
The Four-Year Plan to Reduce the Backlog
In addressing the merits of plaintiffs’ allegations on remand, the district court adopted the hospitals’ so-called four-year plan and ordered the Secretary to reduce the current backlog of cases pending at the Administrative Law Judge level by 30% by the end of 2017; 60% by the end of 2018; 90% by the end of 2019; and 100% by the end of 2020. The Secretary then appealed the district court’s order to the D.C. Circuit. On appeal the Secretary argued that it would be impossible to comply with the timetable, because the only means of meeting the timetable would be to pay claims through mass settlements regardless of their merits, which (according to the Secretary) would be in violation of the Medicare statute.
Without finding whether in fact the Secretary would be unable to lawfully comply with the district court’s order, the D.C. Circuit held that because the Secretary represented that lawful compliance with the district court’s order was impossible, the district court committed reversible error by ordering the Secretary to comply with the timetable without first finding that lawful compliance was indeed possible. The Circuit Court also held that it was an error for the district court not to evaluate the Secretary’s assertion that the timetable would increase, not decrease, the number of backlogged appeals, because the timetable would generate an incentive for claimants to file additional appeals and hold out for big payouts.
The Case is Remanded to District Court to Determine Feasibility of Compliance Timetable
The D.C. Circuit therefore remanded the case again to the district court and ordered the district court to determine whether the Secretary’s compliance with the timetable is impossible. However, the Circuit Court noted that the Secretary will bears a “heavy burden to demonstrate the existence of an impossibility.” The Court further noted that if the district court finds on remand that the Secretary failed to carry his burden of demonstrating impossibility, it could potentially reissue its order without modification.
What Does this Decision Mean for Hospitals?
Many Medicare coverage appeals involve a hospital appealing the denial of a short stay on the basis that admission was not medically necessary, and that the patient could be treated as an outpatient. However, because CMS does not allow hospitals to rebill under Part B (except during the one year period following discharge, which in the majority of cases will have expired long before the RAC reopens and denies the inpatient claim), hospitals believe that they have no choice but to appeal. It is important to keep in mind that although the D.C. Circuit faulted the district court for not considering the issue of whether the Secretary could legally comply with the prescribed timetable, the fact that the Secretary will bear the burden of proof on this issue may mean that the district court may end up issuing the same type of relief as it did before.
We will be following this case as the district court determines whether the Secretary’s compliance with the timetable is legally possible and will follow up once a decision is rendered.
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