CMS is getting even more serious about keeping people out of the hospital, with each newly issued rule reflecting that commitment.
Starting at the beginning of this year, the Centers for Medicare and Medicaid Services sought to further incentivize providers by building in reimbursement for home health monitoring applications and the labor required to make these systems successfully operate. In a final rule issued last November, the CMS clarified their stance, highlighting the three CPT codes in question, along with their explanation and further information surrounding the decision-making process that led to the final ruling.
You can find far more detailed information (over 2,300 pages of it, in fact) within the Federal Register document, but for our purposes and for sanity’s sake, I want to emphasize the three codes in question, quoted directly from the CMS final rule:
Chronic Care Remote Physiologic Monitoring (CPT Codes 99453, 99454, and 99457)
- CPT code 99453 (Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment).
- CPT code 99454 (Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days).
- CPT code 99457 (Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month).
By attributing your services to these codes within your reporting policies, you can gain reimbursement for tactics that keep chronic patients out of the hospital, thus making it a financially sound investment for both providers and patients.
For those who are looking to enter this arena, you need to follow a few guiding principles in order to establish a program that’s successful in keeping your patients healthy and ensures you’ll receive the maximum reimbursement.
Decide on Your Software and Hardware Applications
To those just beginning this transition to ongoing patient monitoring, the first step is also the biggest leap: deciding on the hardware and software you’ll use to actually make the entire endeavor function.
Thankfully, the consumer technology market has provided an abundance of riches in recent years. We’ve seen a proliferation of products and apps dedicated to monitoring and disseminating vitals. You have items dedicated exclusively to health, such as FitBit, Jawbone, Apple Watch and Garmin devices, but then you also have apps that come bundled within Smartphones or that you can download quickly and easily from an App store.
One question you’re bound to run into is the security of these devices. If you’re relying on software or hardware that has the backing of an Apple, an Amazon or one of the other heavy hitters in the consumer electronics market, you have certain assurances that information will be stored and transmitted in a secure manner. Nevertheless, you should work together with your IT team to determine and address any potential security concerns.
Another benefit of using one of the more widely known consumer devices, even if supplemented with an app specific to your remote monitoring needs, is that consumers largely already understand this technology and thus will be in a healthy spot to continue utilization in the long term. Nevertheless, there’s another consideration you’ll want to pay attention to
The average patient may have a level of knowledge of their Smartphone and Apple Watch bordering on the expert, but that doesn’t mean every patient has this level of acuity, and it certainly doesn’t mean they’re well versed in the apps being used or understand the importance of maintaining vital readings over the long-term. Education comes in three specific levels. Let’s look at each of those in turn.
Some specific demographics, such as older or lower-income patients, may not be attuned to “Smart” devices, posing the first challenge to your team. You’ll need to develop a program and educational materials centered on explaining how to use, for instance, a Smartphone or a wearable tracking device.
Although it might feel condescending to explain fairly basic concepts such as retrieving notifications or adjusting brightness and readability settings, these details are crucial for initial setup and ongoing participation by the patient. You may be able to skip over these steps for the majority of patients, but you’ll want those policies in place for that section of the population unfamiliar with the parameters we all take for granted.
Your next step, and this is one that applies to numerous patients, even those who use their phones and wearables as extensions of self, is to educate the patient on the specific app you’ll need them to passively monitor or even actively enter information in to.
Even “techie” persons will need at least a baseline understanding of, for instance, the app where they’ll be entering their daily vital signs, such as blood pressure or glucose levels. The fewer technical hurdles, the better. Explain the intricacies of the system and the warning signs to look out for within readings, and detail what they can expect should the need for intervention arise.
Also make sure to explain the difference between passive and active monitoring software, detailing the steps you need the patient to take versus those they don’t need to worry about. Be sure to emphasize that the passive software can only work if given access to certain streams of data from other apps and if worn/carried at all times.
The final educational aspect to consider is that of ongoing usage. We’ve seen it many times where, recently discharged from the hospital and back in a home care setting, patients have the details of their care plan fresh in their mind and are eager to stick to the regimen prescribed by their physician. But as the weeks and months go by, that enthusiasm wanes. Suddenly it doesn’t seem so important to wear a device every day or to input a certain vital statistic every six to eight hours.
You want to educate patients with chronic conditions on the importance of long-term monitoring so they aren’t at risk for readmission. Don’t just do this at the beginning of their post-acute care journey. A case manager can check in at pre-designated intervals to ensure they remain on track long into the future.
Develop Clinical Intervention Workflows
The next step is to plan for those moments when, despite all your best intentions, things inevitably go wrong.
Sometimes, despite the best education in the world and the best efforts of patients, a patient will let their monitoring fall by the wayside. Plan for this from the beginning and have a workflow in place to get in touch with that individual to set them on the right course. You might consider escalating these touch points as the behavior continues over time. The first instance of a patient neglecting to wear their Smart device or check their Wi-Fi signal to ensure connectivity may trigger a simple phone call, but subsequent episodes could necessitate a visit from a case worker in order to ascertain the patient’s concerns or identify what’s getting in the way of optimum use.
The other clinical intervention plan you’ll need in place is for those times when a patient’s vital signs aren’t where they need to be and their health isn’t progressing the way you intended. This requires an in-depth consultation with your physician and other members of the care team to figure out the best medication or therapy to get that patient back to a healthy baseline.
This will necessarily depend upon each patient’s chronic condition, but for the most common diagnoses, you should have an interventional care plan in place to address fluctuations in recovery. The best care plans are fully digital and engage the patient in the flow of information so that they feel similarly empowered to report any deviations from the norm.
Assess Your System Over Time
The last step you’ll need to take is one that happens regularly over time: evaluating the monitoring you have in place. At regular intervals, use analytics to take a look at your entire patient population. Analyze the broad spectrum of users, but also section each chronic population into its own silo so you can see both macro- and micro-level views of the system you’ve put together.
Remote patient monitoring is an adjustment from the days of discharge and semi-regular check-in, and the vast majority of organizations are still getting their feet underneath them when it comes to implementing these strategies. To ensure the CMS’s new reimbursement rule brings revenue in the long-term and patients remain out of the hospital, you’ll need to constantly re-evaluate where you’re at and make adjustments to accommodate the changing times and the needs of your patients.
This isn’t something that ends. It’s ongoing, and it’s a fantastic opportunity for healthcare organizations and patients around the country.
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