Although CMS has been encouraging the use of chronic care management (CCM) and remote patient monitoring (RPM), the services are being eyeballed for compliance with billing and other requirements, attorneys say. For example, the HHS Office of Inspector General (OIG) has reviews underway of RPM and has already released two audit reports on CCM, and recovery audit contractors are all over RPM.
“If your organization is engaged in CCM or RPM or is partnering with a third party to provide these services, it’s important to make sure your organization has robust guardrails,” said attorney Lauren Gennett, with King & Spalding, at a May 29 webinar sponsored by the firm.
CCM services have been covered since 2014 for Medicare patients with two or more chronic conditions (e.g., arthritis and diabetes), said attorney Taylor Whitten, with King & Spalding. They include comprehensive care management, recording patient information, managing care transitions and sharing patient health care information. CMS hopes to keep patients with chronic care conditions out of the hospital.
“One cool aspect of CCM services is they don’t have to be provided in person,” Whitten noted. Also, billing practitioners—physicians and nonphysician practitioners (NPPs)—aren’t required to personally provide CCM, which may be delegated to clinical staffers (e.g., nurses) who provide the services incident to the physician. But patients must have an initiating visit with the physician before embarking on CCM if they’re new or haven’t been seen in a year.
Here are two main CPT code categories for CCM:
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99491: CCM provided by a physician or NPP for at least 30 minutes per patient per month.
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99490, 99487 and 99489: CCM provided by clinical staff. Time spent by the billing practitioner may also count toward the time threshold if not used to report 99491.
RPM Again Requires 16 Days of Data Collection
RPM involves the use of a device to collect and transmit patient data (e.g., respiratory flow rate, blood pressure) remotely to their care team. CMS started covering RPM in 2018 and quickly expanded coverage, Whitten said.
“RPM has its own quirks,” she noted. For example, only established patients are eligible for RPM and their data must be collected for 16 days in a 30-day period and billed only once by a practitioner for that patient. During the public health emergency (PHE), it was only two days per 30-day period for patients with confirmed or suspected cases of COVID-19.
Here are the CPT codes for RPM:
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99091: collection and interpretation of physiologic data digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional.
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99453 (initial set-up and patient education on use of equipment), 99454 (30-day device supply with transmission of daily recordings or programmed alerts), and 99457 (RPM treatment management, at least 20 minutes in a calendar month, including at least one interactive communication with the patient or caregiver).
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99458 (additional payment for each additional 20 minutes of RPM treatment management).
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99473 (patient education and training and device calibration) and 99474 (self-readings, collection of data reported by the patient or caregiver, report and subsequent communication of a treatment plan).
The use of CCM and RPM is growing, although far more physicians could be providing the services, said attorney Rick Zall with King & Spalding. Two-thirds of Medicare patients have two or more chronic conditions, and one study found that the CCM program saved Medicare $884 per patient per year in decreased hospital care. But, in 2021, only 12,000 physicians billed Medicare for CCM when there are one million participating providers. Partly it’s a function of the obstacles, Zall said. For example, “providers and beneficiaries have to opt in after being informed of the benefits of the program and how to participate” and providers have concerns about satisfying Medicare CCM requirements.
The uptake of RPM has been more significant, partly because of the COVID-19 PHE, Zall said. The number of providers who routinely billed for RPM grew from about 400 in 2019 to about 3,700 in 2021, and there has also been an increase in the number of vendors that help physician practices provide CCM and RPM services. “CMS regulations anticipated the use of vendors to provide the services,” he said. “They recognized many practices don’t have the ability to do this with their current staff.”
