Acute interventions have traditionally dominated the American public health system, while chronic disease management has had limited support. There are five chronic diseases responsible for two out of every three deaths in the country: cancer, heart disease, stroke, COPD, and diabetes. Chronic conditions account for almost three-fourths of the total healthcare expenditures.
Given the facts, it is essential to focus on managing chronic diseases with Virtual Care. There is a growing acceptance of utilizing Virtual Care Management Platforms among both patients and healthcare providers which includes remote patient monitoring (RPM) for ongoing management of chronic diseases. These virtual care solutions not only create reimbursement prospects for healthcare providers but also give them access to extensive patient data for better delivery of care, coordination, and improved health outcomes.
Virtual Care Management Program Types
Management of virtual care
Remote patient monitoring platforms are integrating innovative cellular RPM devices and services to improve virtual care capabilities for healthcare organizations and allow patients to receive more connected care and attention outside of clinics and hospitals. In addition, virtual care strategies can be used to provide care management services for patients in underserved populations.
Providing new and expanded reimbursement options for virtual care management programs that enable better management of chronic conditions while patients remain at home is the focus of the Centers for Medicare and Medicaid Services (CMS) to support and promote these digital systems. As CMS support increases, healthcare providers must also keep up with a greater number of billing and coding rules.
Remote Patient Monitoring (RPM)
As a key component of telehealth and virtual care, remote patient monitoring is one of the key emerging subcategories. By using cellular remote patient monitoring devices and other communication technologies, healthcare providers can obtain patient-generated health data (PGHD) in order to monitor the patient’s chronic condition and provide timely and targeted care.
A good cellular RPM program can provide important physiological data, such as blood pressure, blood sugar, blood oxygen saturation, pulse rate, body weight fluctuations, and body temperature. A connected remote monitoring device allows the care team to receive real-time patient data, which they can analyze in order to provide appropriate and timely care.
Remote monitoring technology has demonstrated its usefulness in cases like chronic care, post-surgery, and senior care. With access to a wealth of patient information, HCOs can intervene more efficiently to enhance patient wellness as well as minimize clinic visits and hospitalization while also promoting better communication between doctors and patients. In addition, businesses are utilizing RPM programs to monitor workers’ compensation cases, helping ill or hurt employees make an expeditious recovery.
It is possible for care managers to deliver population health management services in communities with limited resources by leveraging RPM. By providing family, community, and health services at affordable health care costs, patients are more likely to seek medical attention on time, reduce health risks, and engage in their healthcare.
RPM Technology
In remote patient monitoring programs, advanced platforms and connected devices are used. In addition to providing reliable connectivity, wide-ranging access, ease of use, and cost-effectiveness, cellular technology has become a gold standard for RPM devices. By integrating remote patient monitoring into electronic health record systems, gaps in care planning can be filled and seamless care can be provided.
Among the most commonly used cellular RPM devices are:
- Monitors for measuring blood pressure
- Glucose meters
- Oximeters for measuring blood oxygen levels
- Scales for weighing
- Infrared thermometers
Hospital-at-Home (HAH)
The HaH (hospital-at-home) model provides patients with hospital-grade medical care at their homes through an innovative care model. Developed by the Johns Hopkins School of Medicine and Public Health, the HaH model has been successfully tested at several medical centers across the country. This high-quality care model is adopted by caregivers and patients alike and is recognized for improved care, reduced complications, and lower costs by almost one-third.
In addition to improving treatment quality and patient outcomes, the hospital-at-home program provides a comprehensive alternative to acute hospital care for older adults with acute conditions. It results in better functional outcomes, higher patient satisfaction, and lower caregiver stress as compared to hospitalized patients with similar HaH. It reduces mortality rates and reduced use of delirium sedative drugs.
During the Covid-19 pandemic in 2020, CMS launched the Acute Hospital Care at Home (HaH) program that freed up hospital beds. The use of HaH has increased rapidly since then. Clinicians and care teams provide 24/7 backend support for HaH, which may be an ideal fit for patients who need hospitalization, but are stable enough to be treated at home. HaH is delivered remotely, with clinicians and care teams providing 24/7 backend support.
HaH is a popular option for individuals with long-term illnesses including heart issues, COPD, cancer, kidney conditions, stroke, diabetes, septicemia, Alzheimer’s, multiple sclerosis and serious injuries. As of April 2021, 53 healthcare systems across 29 states have taken part in the Acute Hospital Care at Home initiative. Fee-for-service is typically used for HaH with CMS’ Transitional Care Management then offered for a 30 day period after discharge.
HaH Technology
Through the Hospital at Home model, telehealth services and remote patient monitoring (RPM) are combined in a unique way. The high level of medical care provided through this program calls for the use of hospital-grade RPM devices that are capable of collecting patient data continuously or periodically in real time.
Remote Therapeutic Monitoring (RTM)
Medical devices that can gather and transmit non-physiological patient data are used in remote therapeutic monitoring, also known as RTM. In 2020, the American Association introduced the concept of RTM. CMS has not yet defined clearly what constitutes non-physiological data.
RTM, however, is intended to be used to monitor patients with certain health conditions that are outside of the general scope of remote patient monitoring, according to the proposed Medicare Physician Fee Schedule 2022. A proposed rule by CMS indicates that non-physiological data may include respiratory system status, musculoskeletal system status, medication/therapy adherence, and medication/therapy response.
Care providers and therapists can use remote therapeutic monitoring to collect and manage patient data, such as physical status, therapy, and medication adherence, and deliver data-driven therapy in the form of coaching sessions or patient education. RTM could provide therapy for certain health conditions or therapy following a serious injury or surgery.
Chronic respiratory conditions, such as chronic obstructive pulmonary disease (COPD), and musculoskeletal conditions, such as recovery after surgery, have been reimbursed by CMS so far. A number of therapies will be covered under remote therapeutic monitoring by CMS in the future, according to health analysts.
RPM and RTM are considered to be two distinct concepts in the CMS proposed rule. This has the following implications:
Remote therapeutic monitoring may be able to be billed by healthcare providers who are not eligible to bill for remote patient monitoring.
Medical devices designed to measure non-physiological patient data can collect RTM data.
As defined currently, RTM covers patient-generated data as long as the code requirements are met.
RTM Technology
The concept of remote therapeutic monitoring involves using technology, platforms, or devices to monitor and engage patients in real-time. It is possible that some of the RTM devices will be the same as those used for RPM programs. Using telehealth, mobile apps, or simply telephonic talk, remote therapeutic monitoring can provide patient education as part of the medical therapy.
Chronic Care Management (CCM)
Home care management
This is a similar approach to chronic care management to RPM in that it involves managing patients with chronic diseases like cardiovascular disease, cancer, or kidney disease. Chronic care management differs from RPM in that it does not require continuous monitoring of vital signs, unlike RPM.
Chronic care management goes beyond a routine visit to the doctor’s office and includes ongoing patient assessment, guidance, and assistance. Providing continuous monitoring, coordination of care, and coaching to patients with chronic diseases, CCM primarily involves nurses calling up patients to check on their condition, coordinate care, and provide coaching.
As with remote patient monitoring, chronic care management benefits patients with chronic conditions, including heart disease, cancer, stroke, diabetes, kidney disease, chronic respiratory conditions, septicemia, pneumonia, influenza, Alzheimer’s disease, and post-injury recovery.
CCM Technology
Similarly to remote patient monitoring, chronic care management may involve the use of different technologies and systems. It is, however, quite limited in how much technology is needed. Using a telephone, care teams can contact patients and update the care plan using software or apps. Besides the electronic health record, CCM also involves the use of other devices, such as time trackers.
Principal Care Management (PCM)
The Centers for Medicare and Medicaid Services (CMS) launched a new program in 2020 called PCM, or Principal Care Management. The goal of this service is to provide additional care to patients that have been diagnosed with one chronic condition or allow healthcare providers to treat patients with multiple chronic diseases by singularly focusing on just one of those chronic diseases.
In the past, CMS allowed reimbursement under the CCM program only when a practitioner would treat a patient with at least two chronic conditions. It has been recognized that many practitioners treat patients with a single chronic condition. In order to fill this gap, Principal Care Management (PCM) has been implemented.
One of the key objectives of PCM is to focus on the patient’s chronic condition as fast as possible and deliver targeted care to stabilize their condition. By doing so, the primary care physician can restore patient care quickly, thereby reducing patient healthcare costs significantly.
With nearly 60% of Americans having a single chronic condition, the PCM program is set to benefit large sections of the population. As with CCM, PCM is expected to have a significant impact and become an integral part of primary care. It will result in improved patient outcomes and reduced healthcare costs.
What are the Differences Between these Remote Care Programs?
| RPM | RTM | CCM | PCM | |
| Objective | Monitoring of specific physiological parameters between office visits | The monitoring of specific therapeutic or non-physiological parameters (including self-reported data) between office visits | Care coordination between regular office visits for patients with two or more complex conditions | The management and coordination of chronic conditions between regular office visits for patients with one complex condition |
| Device and Reading Requirements | FDA-defined device with a minimum of 16 readings per month | FDA-defined device with a minimum of 16 readings per month | None | None |
| Diagnosis Requirement | No specific diagnosis requirement but RPM must be medically necessary | No specific diagnosis requirement but RTM must be medically necessary | Multiple chronic conditions (2+) lasting 12+ months | Single high-risk disease lasting 3+ months |
| Ordered by: | Physicians or qualified health care professionals (QHCPs) who can bill for E/M services | A physician or qualified health care professional (QHCP) who is able to bill general medicine codes, including physical therapists, occupational therapists, dieticians, and psychologists. | Physician or Qualified Health Care Professional (QHCP) | Physician or Qualified Health Care Professional (QHCP) |
| Clinical Care Team Requirement | Requires minimum of 20 minutes by clinical staff per month | Requires minimum of 20 minutes by clinical staff per month | Requires minimum of 20 minutes by clinical staff per month OR physician or QHCP must spend at least 30 minutes personally with patient | Requires minimum of 30 minutes by clinical staff, physician or QHCPper month |
| Monitoring Provided Incident to the Billing Practitioner | QHCP or clinical staff, including nurses under the general supervision of the billing practitioner | QHCP or clinical staff under the direct supervision of the billing practitioner | QHCP or clinical staff under the general supervision of the billing practitioner | QHCP or clinical staff under the general supervision of the billing practitioner |
| CPT® Codes | CPT® Codes 99453/99454/99457/ 99458 | CPT® Codes 98975/98976/98977/ 98980/98981 | CPT® Codes 99490/99491/99439/99437 | CPT® Codes 99424/99425/ 99426/99427 |
Coding, billing, and compliance
Remote Patient Monitoring (RPM)
As opposed to CCM, remote patient monitoring (RPM) reimburses healthcare organizations for providing remote monitoring and care to patients via devices (such as blood pressure monitors and glucometers) that collect physiologic information. Collection, analysis, and interpretation of vital physiological data are covered by the CPT codes for RPM.
CMS requires that physiologic data from RPM devices be electronically obtained and transmitted for billing. Patients cannot self-report the data. The reimbursement rates for 2022 for RPM CPT codes include:
99453 is a CPT code
In addition to setting up the device, it includes educating the patient on how to use it.
The Medicare rate for 2022 is $19 (one-time).
99454 is a CPT code
A minimum of 16 days of remote monitoring is required per 30-day period.
The Medicare rate for 2022 is $56 (once every 30 days).
99457 is a CPT code
In a calendar month, it covers the first 20 minutes of interactive patient communication and care management.
The Medicare rate for 2022 is $50 (once a month).
99458 is a CPT code
Each additional 20 minutes used for remote monitoring and care management is covered.
(per additional 20 minutes per month) Medicare Rate for 2022 = $41
The second method is remote therapeutic monitoring (RTM).
As a result of the changes to the CPT RTM codes for 2022, as well as the addition of new RTM codes, Medicare coverage has been extended for patients beyond the scope of RPMs. To support healthcare providers who are not eligible to bill for remote therapeutic monitoring, the following CPT codes have been developed for RTM in 2022:
98975: patients are instructed on how to use RTM equipment as well as initial setup.
98976: Device supply with 30 day recording and/or transmission of programmed alerts for therapeutic monitoring of the respiratory system.
98977: Device supply with scheduled recording and/or transmission of alerts for therapeutic monitoring of the musculoskeletal system every 30 days.
98980: Remote monitoring and treatment management services for the first 20 minutes of the calendar month with at least one patient-caregiver interaction.
98981: In the calendar month, remote monitoring and treatment management services for at least one patient-caregiver interactive communication are provided.
CCM (Chronic Care Management)
According to the CPT code 99490, a patient must have at least two chronic conditions and receive CCM services for a minimum of 20 minutes within a month in order to be eligible for billing.
99490: Clinical staff involvement for the first 20 minutes – $64.03 for 2022.
99439: Involving clinical staff every 20 minutes – $48.45 for 2022
99491: Rate for 2022 @ $86.18 – Involving a physician or non-physician practitioner for the first 30 minutes
99437: Involving a physician or non-physician practitioner for every additional 30 minutes – Rate for 2022: $61.26
Is it possible to use the CPT codes together?
A patient may be eligible for both a remote monitoring program and chronic care management at the same time. The Centers for Medicare and Medicaid Services (CMS) has determined that RPM or RTM can be beneficial to those with complex chronic conditions, which are part of CCM, and should be offered to improve care delivery. Keep in mind, however, that the same time invested in providing these services cannot contribute to both; double counting is prohibited, so the applicable hours for each should be fulfilled separately.
