Understanding Virtual Care and Remote Monitoring Codes

Understanding Virtual Care and Remote Monitoring Codes

By Julie Wood

The American Medical Association (AMA) released its 2019 Current Procedural Terminology (CPT) code set and included several new codes. The AMA is urging the CMS to adopt the new codes and designate the related services for payment under federal health programs in 2019. The new codes are effective as of Jan. 1, 2019. 

Currently, there are ‘telehealth’ codes paid under Medicare: the term “telehealth services” refers to a specific set of services practitioners normally furnish in-person, but for which CMS will make payment “when they are instead furnished using interactive, real-time telecommunication technology.” The Social Security Act governs which telehealth services are and are not covered under Medicare. Generally, there are five statutory conditions required for Medicare coverage of telehealth services:

1. The beneficiary is in a qualifying rural area;
2. The beneficiary is located at one of eight qualifying originating sites;
3. Services are provided by one of 10 distant site practitioners eligible to furnish and receive Medicare payment for telehealth services;
4. The beneficiary and distant site practitioner communicate via an interactive audio and video telecommunications system permitting real-time communication between them; and
5. The Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCs) code for the service itself is named on the list of covered Medicare telehealth services.

So long as the distant site practitioner complies with each of the above requirements, the telehealth service furnished via a telecommunication system will substitute for an in-person encounter—and it should meet the requirements for Medicare coverage so long as other standard coverage provisions are met.

Expansion of Telehealth Coverage

The new codes allow for an expansion of Medicare’s current telehealth coverage, if adopted. 

“Brief Communication Technology-Based Service” HCPCS code GVCI1

• If adopted, providers could bill for a “brief non-face-to-face check-in with a patient via communication technology, to assess whether the patient’s condition necessitates an office visit.”

“Remote Evaluation of Pre-Recorded Patient Information” HCPCS code GRAS1

• If adopted, providers could bill for a review of “recorded video and/or images captured by a patient in order to evaluate the patient’s condition” to determine whether an office visit is necessary.

The traditional telehealth reimbursement codes are severely limited in terms of qualifying providers, site and location. CMS’ proposal to cover asynchronous telemedicine and non-face-to-face services is a major step forward for the validity of store-and-forward medical care on the national level. These codes will not require the use of interactive AV technology, as CMS today only pays for asynchronous telehealth in limited demonstration technology. Asynchronous telemedicine is efficient and patient-centered, and aligns to how many service providers deliver services today.

New codes for internet consulting between professionals could be extremely useful in the care coordination of complex patient cases.

“Interprofessional Internet Consultation,” not listed under telehealth services

CPT Codes- 994X6 or 994X0, have been added to current codes 99446, 99447, 99448, and 94449. The new codes are specifically for non-verbal communication technology.

• If adopted, providers could bill for “assessment and management services conducted through telephone, internet or electronic health record consultations furnished when a patient’s treating physician or other qualified healthcare professional requests the opinion and/or treatment advice of a consulting physician…with specific specialty expertise to assist with the diagnosis and/or management of the patient’s problem without the need for the patient’s face-to-face contact with the consulting physician.”

Codes for New Remote Patient Monitoring (RPM)

Three new codes for RPM allow doctors to connect with patients at home and gather data for care management and coordination. These are not included in telehealth services as proposed, but in an entirely new and separately reimbursable service under Medicare.

The three new RPM codes were retitled “Chronic Care Remote Patient Physiologic Monitoring”, aimed to better reflect how RPM services can be delivered to patients. The specific codes are CPT 990X0, CTP 990X1, and CPT 994X9.

Currently, Medicare for RPM had been allowed using CPT 99091. The new codes have a few key changes for reimbursement:

1. Less treatment time needed to qualify for reimbursement.

CPT code 99091 required at least 30 minutes per 30-day period to be eligible for reimbursement. The new code only requires 20 minutes per calendar month, making it easier to track and requiring 33% less time for eligibility.

1. Additional reimbursement for RPM setup and patient education.

CPT 99091 does not allow for additional reimbursement to providers for time spent setting up any RPM equipment or educating their patients on its use. The new proposed codes would offer additional reimbursement for on-boarding a new patient, setting up the RPM equipment, and educating patients on equipment.

1. New medical staff eligible for reimbursement.

CPT 99091 expressly states RPM-delivering providers must be “physicians and qualified health care professionals” leaving out key medical and clinical staff such as RNs, medical assistants, etc. This requirement means the physician or qualified health care professional had to perform the full 30 minutes per 30-day period to be eligible for reimbursement. Many providers could not justify spending that amount of time and resources for the $58.68 per month reimbursement rate from CMS. The new code allows RPM services to be performed by clinical staff, clearing a key hurdle for providers across the country.  

New Codes

These new codes are intended as a follow-up and expansion to CMS’ current coverage of RPM code 99091:

1. CPT 990X0 Remote monitoring of physiologic parameter(s) (e.g. weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education of use of equipment;
2. CPT 990X1 Remote monitoring of physiologic parameter(s) (e.g. weight, blood, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days; and
3. CPT 994X9 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.

Note: CPT codes that contain an ‘X’ (e.g., 994X9) are placeholder codes that are intended, through the first three digits, to give readers an idea of the proposed placement in the code set of the potential code changes. These codes will not be used for claims reporting and will be removed and not retained when the final CPT Datafiles are distributed. To report the services for ‘X’ codes, be sure to refer to the actual codes as they appear in the CPT Datafiles publication.