Population Health Insights

Why the RPM Codes for 2019 are Different, and – Most Importantly – SPOT ON!

why-rpm-codes-for-2019-are-different

CPT, CMS, RVU, RUC, ICT, DRG, AMA, QHP … so much alphabet soup! Just knowing how to “say” each of these terms is an accomplishment. (For the record, RUC is the only one that's phonetically pronounced; the others are spelled out.)

These organizations, processes, and codes are the operating mechanisms managing the $3,000,000,000,000+ spend in U.S. healthcare. I'm a bit of an aviation geek — and this reminds me a bit of air traffic control (ATC), where highly trained and skilled professionals are managing very complex situations with life-and-death consequences.

After all, both healthcare and ATC follow tightly defined processes AND always leave ultimate decisions up to the judgment of professionals — doctors and nurses, controllers and pilots. As most workers in either profession would be quick to tell you, achieving the right balance can be a challenge

Ultimately, when new procedures or services are made available for reimbursement from the Center for Medicare and Medicaid Services (CMS), those procedures are assigned a Current Procedural Terminology (CPT) code, which is used when submitting the claim for payment. Among other rules and restrictions, each code has a few essential characteristics:

  • What is the service?
  • Who can perform it"
  • How much is it worth?

Following the pattern of evolution in many other industries, we see the future of healthcare involving more remote care: When the people receiving care and the people providing the care are not in the same place.

New CPT codes must be added, and existing ones revised, to allow for this transition. See my earlier blog post here for insight into why this is necessary while the nation is transitioning to value-based care.

Care Innovations® and other leaders in remote care — in both the healthcare technology industry and the healthcare delivery industry — have been hard at work on that mission. We've made some initial progress in the changes to the available CPT codes for the 2018 calendar year, and the AMA and CMS recently announced significantly more progress being teed up for the 2019 calendar year.

A Closer Look at the Proposed 2019 CPT Code Changes, and What They Mean for Remote Care

So far, the code changes apply to patients who have been diagnosed with two or more chronic conditions. The codes expected for the 2019 year — currently in the “Proposed Physician Fee Schedule” — include:

99091: Collection and Interpretation of Physiological Data – 30 Minutes or More

This code was created in 2002 and has been available for reimbursement since January 1, 2018, paying approximately $59 per month. The challenge with this code is that it was conceived based on a model in which a patient collected vital signs, which are then submitted to their physician via email. That's a process that's quickly becoming obsolete, as today’s cloud-technology and provider supplied devices provide a much higher level of PHI protection. 

994X9: 20 Minutes or More - Clinical Staff Time for Remote Monitoring of Physiological Parameters - monthly

This is the “fix and modernization” for 99091, allowing clinical staff like registered nurses to perform the remote monitoring (as opposed to just the physician). This aligns with industry best practices, in which more work can be done at the direction of a physician, as with so many other similar activities. 994X9 pays approximately $53 per month.

990X1: Device Supply with Daily Recordings for Remote Monitoring of Physiological Parameters - monthly

This code provides for the supply of the RPM technology. In the original conception of 99091, patients would acquire their own equipment; for a host of reasons, though, the best practice today is for the health system to provide the patient devices. This code pays approximately $69 per month.

990X0: Initial Set Up and Patient Education for Remote Monitoring of Physiological Parameters – one-time per episode

This code provides for initial equipment setup and patient training on usage, and can be billed one time per RPM episode. This code will defray some of the costs of patient on-boarding. While providers may still have to cover some of the costs, they will recover some of the up-front cost during the duration of the program, which will help them remain focused on patient engagement and providing solutions that drive patient participation.

It's important to note that the following requirements apply to the newly proposed CPT codes (this is not an exhaustive list):

  • Patients must be diagnosed with 2+ chronic conditions
  • The technology solution must be a medical device as defined by FDA
  • A more specific code must be used if it exists; e.g., 93296
  • 990X0 or 990X1 cannot be reported for monitoring until after 16 days
  • 994X9 cannot be reported during the 30-day TCM period
  • Remote monitoring must be ordered by a qualified healthcare professional

Moving in the Right Direction

So, what does all this mean? There's a large body of evidence that well-run RPM programs reduce emergency room and hospital utilization. Patients already love the programs, and now, the final two pieces are falling into place:

  • The CPT codes for 2019 now align with remote patient monitoring best practices, and
  • Providers will be compensated fairly for delivering remote monitoring.

Just a note: These are proposed codes, and rules for CY2019 and are subject to change. Before billing any codes, ensure you understand the latest fee schedule and guidance from the Centers for Medicare & Medicaid Services (CMS).

About Marcus Grindstaff
Chief Operations Officer, Care Innovations

About Marcus Grindstaff, COO of Care InnovationsA business strategy and product technology leader with more than 20 years of experience in the high-tech industry, Marcus Grindstaff is the Chief Operating Officer for Care Innovations®, where he holds responsibility for sales and operations. Marcus joined Care Innovations at its formation in 2011, from the Intel Digital Health Group where he was a 17-year veteran.

Throughout his career, Marcus has focused on growing exceptional teams chartered with delivering strategy, technology, marketing and product execution throughout the U.S., Asia and Europe. He is also a passionate spokesperson for reforming the healthcare delivery system, and serves on the board of the National Alliance for Caregiving.