Reimbursement for Remote Patient Monitoring

(Effective January 1, 2015)

The final rule from CMS for 2015 includes a provision that would cover remote chronic care management using a new current procedural terminology (“CPT”) code, 99490 (with a monthly unadjusted, non-facility fee of $42.60). Notably, 99490 is available nationwide, and is not considered by CMS as rural-only “telehealth” services.

Source: CMS Expands Telehealth Reimbursement in New Rule

CPT 99490 (a monthly unadjusted non-facility fee of $42.60)
Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health professional, per calendar month, with the following elements:

  • Multiple (two or more) chronic conditions expected to last at least 12 months, or until death of the patient;
  • Chronic conditions that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline;
  • Comprehensive care plan established, implemented, revised, or monitored

Codes 99495 ($163.88) and 99496 ($230.86) are used to report transitional care management services (TCM). These services are for an established patient whose medical and/or psychosocial problems require moderate or high complexity medical decision making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient’s community setting (home, domiciliary, rest home, or assisted living). TCM commences upon the date of discharge and continues for the next 29 days.

Reimbursement for Medicare Telehealth Services

CMS defines Medicare Telehealth services to include consultations, office visits, office psychiatry services, and any additional service specified by CMS when delivered via an interactive telecommunications system. CMS defines an interactive telecommunications system as “multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way real time interactive communication between the patient and the practitioner at the distant site.” CMS notes that telephones, fax machines, and email systems do not meet this definition.

The law provides for coverage of and payment for consultation services delivered via a telecommunications system to Medicare beneficiaries provided that the health care professional is licensed under state law to deliver the service being furnished via a telecommunications system, eligible providers at the distant site include physicians, physician assistants, nurse practitioners, clinical nurse specialists, nurse-midwives, clinical psychologists, clinical social workers, or registered dietitian or nutrition professionals.

CMS added seven new procedure codes for Telehealth services in 2015, including annual wellness visits, psychotherapy services, and prolonged services in the office.

Psychotherapy services: CPT codes 90845 (Psychoanalysis) $88.12; 90846 (family psychotherapy (without the patient present) $99.96; and 90847 (family psychotherapy (conjoint psychotherapy) (with patient present) $103.54. Prolonged services in the office: CPT codes 99354 (prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; first hour (list separately in addition to code for office or other outpatient evaluation and management service) $94.70; and, 99355 (prolonged service in the office or other outpatient setting requiring direct patient contact beyond the usual service; each additional 30 minutes (list separately in addition to code for prolonged service) $91.78.

Annual wellness visit: HCPCS codes G0438 (annual wellness visit; includes a personalized prevention plan of service, initial visit; and, G0439 (annual wellness visit, includes a personalized prevention plan of service, subsequent visit)

Source: Summary of payment provisions within the 2015 proposed Medicare physician fee schedule