Population Health Insights

CMS Unbundles CPT Code 99091, Increasing Reimbursement Allowance for Remote Care

cms-unbundles-cpt-code-99091-increasing-reimbursement-allowance-for-remote-care

2018 brings with it significant promise for the more widespread use of remote patient management (RPM). And not least among these positive steps is the unbundling of the Medicare/Medicaid CPT code 99091, an act that has immediately increased the amount of billable Medicare hours available for doctors and clinicians who utilize remote care services such as Health Harmony from Care Innovations®.

Already effective as of January 1, 2018, the unbundling of CPT code 99091 by the Centers for Medicare and Medicaid Services (CMS) means that eligible practitioners can bill to receive separate reimbursement “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” (as explained by Crowell & Moring’s C&M Health Law blog).

Before 2018, CMS rules mandated that certain remote care tasks could not be billed for the same patient during the same service period in conjunction with many of the treatments that commonly (and increasingly) utilize RPM services — specifically:

  • CPT codes 99487, 99489, and 99490, covering Chronic Care Management (CCM), including diabetes, hypertension, cardiovascular disease, and chronic obstructive pulmonary disease (COPD), among others
  • CPT codes 99495 and 99496, covering Transitional Care Management (TCM), or services involving the period of care in which a patient is discharged from a hospital, rehab, nursing or similar facility to a home or assisted living setting
  • CPT codes 99492, 99493, 99494, and 99484, covering General Behavioral Health Integration (BHI) services and a psychiatric collaborative care model (CoCM), including psychosocial assessment and preventive care recommendations and oversight of patient self-management/medications

With the new CPT coding rules in place, however, remote care services that fall under CPT code 99091 can now be billed once per patient during the same 30-day service period as any of the above listed codes, significantly expanding the scope of Medicare reimbursement for remote treatment.

Changes to CPT Code 99091 Called ‘Important Step Forward’ for American Healthcare

The unbundling of CPT code 99091 is being heralded as an encouraging move toward widespread implementation of remote patient management, a method of clinical delivery that’s been shown to improve quality of care for patients, maximize efficiency for clinicians, and boost cost effectiveness for payors and providers.

“These new rules are an important step forward for America’s connected health innovators, doctors, and most importantly patients,” as the Connected Health Initiative (CHI) stated in a news release. “Until now, connected health technologies have been effectively locked out of the most important part of America’s healthcare system, Medicare and Medicaid.”

And this, apparently, is just the beginning: CMS has expressed that this move is simply “a first step toward recognizing remote patient monitoring services for separate payment,” the C&M blog points out, while noting that “it will continue to closely track the AMA’s CPT Editorial Panel activities as they further refine and value the code sets for remote monitoring.”

This intent may be best illustrated by the fact that the unbundled CPT code is not subject to restrictions based on originating sites or technology, which apply to other telehealth services under previous CMS coding stipulations. And this not only allows for greater leeway in reimbursing for services specifically defined as remote care, it also serves to distinguish remote care as a separate entity from the larger catch-all terminology of telehealth and telemedicine. (What’s the difference between RPM and telemedicine? Get a quick rundown here.)

What Practitioners & Practices Should Know about the New CPT Code 99091

Of course, as with any CPT coding procedure, there are still a series of carefully-defined requirements that must be met. The code is payable in both facility and non-facility settings; however, to ensure an eligible transaction, healthcare providers must first:

  • Hold a face-to-face consultation with patients who are new (or who have not been seen within one year of the implementation of the remote care services)
  • Obtain advanced beneficiary consent for the services, and document this in the patient’s electronic medical record (EMR)

To remain eligible for reimbursement under CPT code 99091, the provider must also:

  • Include the time spent assessing, reviewing and/or interpreting the data in the billing code
  • Include time spent communicating with the patient (and family caregiver, if applicable), along with the details of the conversation, in the billing code
  • Make use of digital tools “in such a way that allows them to provide ongoing guidance and assessments for patients outside of the in-office visit,” including “the collection and use of” patient-generated health data (PGHD) (via the C&M blog)
  • Make use of platforms and devices that work as part of an “active feedback loop,” providing data in real time (or near-real time) to the care team as well as offering patients automatic and ongoing one-way guidance

About that last point: It’s important to note that the CMS considers “passive platforms or devices” that collect but do not transmit PGHD as ineligible for reimbursement under the RPM code.

It’s also worth noting that the provider’s billing time under CPT code 99091 should be considered as equivalent to the typical times for evaluation & management (E/M) office visits. These are “assumed times, established through physician survey by the American Medical Association … for how much time the billing practitioner spends himself or herself each month, but are not exact times,” as the CMS notes in a fact sheet.

For instance, as the fact sheet explains, “the billing practitioner’s time could be spent in activities such as directing clinical staff; personally performing clinical staff activities; or in the case of complex CCM, performing moderate to high complexity medical decision making.”

Finally, though the use of the unbundled CPT code is applicable to doctors, physician assistants, nurse practitioners, certified nurse midwives, clinical nurse specialists and their teams, services are ineligible if provided via subcontractor. And each member of the clinical care team — including all providers, care coordinators, and relevant staff — must:

  • Be certified to practice in the capacity in which he or she is working
  • Be part of the billing practice/organization
  • Have a relationship with the patient

Stringent as they may seem, these are all basic stipulations, representing no significant diversion from previous CMS coding criteria. Indeed, most telehealth advocacy organizations are regarding the CMS code change as a welcome affirmation of remote care as a delivery system that merits separate CMS reimbursement.

“This represents a major improvement in the process, outcomes, and most importantly, accessibility of the healthcare system,” as the CHI statement explains. “This change will enhance accessibility to healthcare services for those that need it most: working parents who can't miss a day in the office, chronically ill seniors with mobility issues, economically disenfranchised patients who can't afford ongoing specialist visits, people with disabilities.”

Got questions about how the changes to CMS code 99091 may affect your practice or organization? We’re standing by to provide further clarification: Please contact us here to schedule a complimentary consultation with a Care Innovations RPM specialist.

Contact Care Innovations