Healthcare is experiencing ongoing technological advancements and changing patient needs, making it crucial for physician groups and healthcare institutions to adapt and keep pace. Remote Care Management Services combine several modern healthcare components that enhance patient care, streamline operations, and improve resource allocation. Embracing Care Management Services can position your organization to deliver top-tier care while optimizing operational efficiencies.

Here are the primary components:

Remote Patient Monitoring (RPM)

Remote Physiologic Monitoring, also known as Remote Patient Monitoring or RPM, enables consistent tracking of patient vitals and extends care into the patient’s home, bridging the gap between routine office visits. It embodies a proactive approach to patient care, enabling healthcare providers to monitor patients’ health status in real time, ensuring timely intervention and personalized care. Currently, 88% of U.S. healthcare providers are investing in or assessing RPM technologies. 

Benefits: RPM improves patient outcomes by enabling providers to tailor care plans using real-time data. This gives patients the most appropriate care based on their up-to-date health status. RPM allows consistent monitoring and timely intervention, potentially preventing complications. It increases engagement by driving better communication and understanding between patients and providers and encourages patients to take an active role in their healthcare.

Reimbursement codes and Medicare’s 2023 national average amounts include:    

  • CPT Code 99453: This code covers the device’s initial setup, including patient education on its use and how to connect it with other devices. The reimbursement rate is $19.
  • CPT Code 99454: This code is for monthly remote monitoring with daily recordings and requires at least 16 days of monitoring each calendar month. The reimbursement rate is $56.
  • CPT Code 99457: This code covers monthly monitoring and treatment management services, which includes dialogue between the patient or caregiver, totaling at least 20 minutes during the calendar month. The reimbursement rate is $50.
  • CPT Code 99458: Add on code to 99457.  Each additional 20 minutes of monitoring and treatment management services are provided.

Challenges and Recommendations: Providers must address RPM’s challenges to optimize its benefits. For example, technology literacy among patients can hinder the effective use of RPM tools, and the absence of in-person interactions could impact compliance and the patient-provider relationship. Data security is a concern, as sensitive health information is transmitted and stored digitally. In addition, connectivity issues can impede the consistent flow of data. 

To overcome these, providers should:

  • Offer comprehensive and ongoing patient training, support, and frequent communication.
  • Foster collaboration and effective communication channels among healthcare teams, patients, and information technology professionals.
  • Stay up to date with healthcare regulations, standards, and reimbursement codes.
  • Consider a partnership with a well-established and reliable RPM service provider.

By proactively addressing these challenges, providers can improve the effectiveness and reliability of RPM services. 

Chronic Care Management (CCM)

Chronic care management is designed to address long-term health conditions. With 6 in 10 adults in the U.S. having a chronic disease, effective management is crucial. CCM provides structured oversight and planning for patients with two or more chronic diseases, ensuring they receive timely and appropriate care tailored to their needs.

Benefits: CCM fosters a coordinated and comprehensive care plan that enhances the management of chronic conditions. It ensures patients receive consistent and personalized attention, improving their overall health outcomes. For healthcare providers, CCM optimizes care processes, ensuring that resources are utilized effectively to manage and mitigate the impacts of chronic diseases.

Reimbursement codes and Medicare’s 2023 National average amounts include:    

  • CPT Code 99487: Complex chronic care management services with multiple chronic conditions for 60 minutes of clinical staff time.
    • CPT Code 99489: Add-on code for CPT code 99487.  Additional 30 minutes of clinical staff time for complex chronic care management services.
  • CPT Code 99490: Clinical Care staff provides 20 minutes of care planning and coordination. $62 
    • CPT Code 99439: Add on code for CPT 99490. Each additional 20 minutes of clinical staff time is $47.
  • CPT Code 99491: Chronic care management services are provided personally by a physician or other qualified healthcare professional for at least 30 minutes.

Each code has specific requirements and elements to fulfill, such as the number of chronic conditions, the expected duration of the conditions, the risk to the patient, and the establishment or revision of a comprehensive care plan. The Medicare Physician Fee Schedule Look-Up Tool has code-specific payment information by geographic location.

Challenges and Recommendations: Implementing CCM comes with challenges, such as ensuring continuous and effective communication among healthcare providers involved in patient care. Maintaining consistent patient engagement and adherence to care plans is crucial for managing chronic conditions effectively. 

Physicians must develop strategies to enhance patient engagement through educational resources, regular follow-ups, and personalized care plans. Additionally, navigating through and complying with various regulatory and reimbursement policies poses significant challenges to implementing CCM effectively.

Principal Care Management (PCM)

PCM focuses on patients with a single high-risk disease or complex chronic condition that puts them at significant risk of death, acute exacerbation/decompensation, or functional decline. PCM provides patients with at least 30 minutes of comprehensive care every month, bridging the gap between regular office visits.

Benefits: PCM provides patients with ongoing support and education for better disease control that can lead to better patient care, improved outcomes, and cost-effective healthcare delivery.

Reimbursement codes and Medicare national average amounts include:    

Providers:

  • CPT code 99424: First 30 minutes provided personally by the physician or other qualified health care provider per calendar month at a rate of $83.
    • CPT code 99425: Add on code to 99424. Each additional 30 minutes provided by a physician or other qualified healthcare provider is reimbursed at about $58.

Clinical Staff:

  • CPT code 99426:  First 30 minutes of clinical staff time,  $61
    • CPT code 99427: Add-on code to 99426. Each additional 30 minutes of clinical staff time is reimbursed at around $48.

Challenges and Recommendations: Much like CCM, challenges relating to PCM include resource allocation, implementation, patient engagement,  and coordinating care across multiple providers. It’s important to note that although these services are primarily delivered remotely, a hands-on, patient-centered approach remains vital. A dedicated, well-educated team must focus exclusively on one or more of these services. As the program grows, it is important to expand the staff accordingly.

Transitional Care Management (TCM)

TCM is a coordinated process between patients and their medical teams to ensure continuity of treatment and support as they transition from a hospital stay to their homes. It includes overseeing patients following treatment protocols, managing their medication, and remaining alert for adverse events or complications. 

Benefits: TCM facilitates a smoother transition for patients, ensuring they receive the necessary care and support as they move from a hospital setting back to their homes. By providing targeted care during the transition, TCM helps reduce the chances of patients being readmitted to the hospital by up to 75%, promoting better recovery outcomes. 

Medicare provides reimbursement for Transitional Care Management (TCM) services, which are crucial in managing the care of patients transitioning from an inpatient hospital to a community setting.

The TCM services include two CPT codes:

  • CPT code 99495: Encompasses communication with the patient or caregiver within two business days of discharge, medical decision-making of at least a moderate complexity, and a face-to-face visit within 14 calendar days of discharge. CMS National Average Payment Amount: $205.36
  • CPT code 99496: Applies to communication with the patient or caregiver within two business days of discharge, a high complexity of medical decision-making, and a face-to-face visit within seven calendar days of discharge. CMS National Average Payment Amount: $278.21

Certain healthcare professionals, including physicians and non-physician practitioners like nurse practitioners and physician assistants, must furnish the face-to-face visit included in the TCM service. The TCM services ensure patients receive timely, coordinated follow-up care to improve post-discharge health outcomes. Specific documentation, such as the date of the patient’s discharge and the dates of post-discharge communication and face-to-face visits, is required to bill for TCM services. 

Challenges and Recommendations: Transitioning patients from one healthcare setting to another raises several challenges. Communication gaps between the discharging facility and the receiving facility or caregiver can lead to inadequate care and potential health risks. Ensuring patients and their families are well-informed and prepared for the transition can avoid confusion, non-compliance, and anxiety. 

To address these challenges, coordination between healthcare professionals is essential. Providers must ensure medication instructions are clear and patients and caregivers understand them to encourage medication adherence and prevent errors. They must develop and communicate a tailored care plan for each patient and provide help accessing resources and support such as transportation, home care, and follow-up services. By utilizing health information technologies effectively, providers can share patient information, coordinate care, support decision-making, and ensure follow-up appointments, tests, or treatments are scheduled and that patients understand the importance of attending them.

Remote Therapeutic Monitoring (RTM)

Remote Therapeutic Monitoring (RTM) concentrates only on patients with musculoskeletal or respiratory conditions. Unlike RPM, which monitors patients’ physiologic (vitals) data, RTM focuses on non-physiologic data, such as therapy or medication management, and evaluates a patient’s response to the treatment. Also, contrary to RPM, which is most commonly used in internal medicine and some specialty providers, RTM providers such as physical therapists (PTs), occupational therapists (OTs), and speech-language pathologists can provide RTM services. Patients use connected devices to gather and securely transmit this information to their healthcare providers, allowing for evaluation and adjustment of treatments to suit the patient’s needs and improve effectiveness. 

Benefits: RTM enables the tailoring of therapies based on real-time data, ensuring patients receive care most suitable to their current condition. It drives increased engagement of patients in their healthcare, as they can actively participate and communicate their health status and responses to therapies between office visits. Providers gain access to real-time data on which to base treatment decisions. Continuous monitoring and the ability to adjust therapies based on real-time data improves patient outcomes, and enhanced communication improves understanding of a patient’s response to treatment. This enables a more responsive and adaptive approach to care.

Here are the CPT codes and their national average rates for 2023:

  • CPT Code 98975: Initial Set Up, Patient Education and Training, $19
  • CPT Code 98976:  RTM respiratory device, requiring 16 days of transmitted readings, $50
  • CPT Code 98977: RTM musculoskeletal device, requiring 16 days of shared readings, $50
  • CPT Code 98980: First 20 mins of care management and interactive communication by a physician, clinical staff member, or other qualified health care professional, $49
    • CPT Code 98981: Add on code to 98980.  Each additional 20 minutes of care management and interactive communication by a physician, clinical staff member, or other qualified healthcare professional is $39.

Reimbursement codes and national average amounts by region can be calculated by visiting the CMS Physician Fee Schedule page. 

Challenges and Recommendations: CMS introduced RTM as a covered service in 2021, but there have been several uncertainties regarding the specific devices eligible for RTM, the qualified providers and supervision necessary to provide the service, and the restricted range of conditions to which it applies.  In the 2024 Proposed Physician Fee Schedule, CMS articulates several clarifications around the appropriate use of RTM services and aims to allow these services to be used more freely and effectively in 2024.  We look forward to reviewing the Final Rule. 

Emphasizing the Human Factor

At RemetricHealth, we’re at the forefront of healthcare technology. However, we never lose sight of the human element. We understand that behind every data point is a person seeking help. That’s why our approach emphasizes the human factor, ensuring that technology complements, rather than replaces, the personal touch. Studies show that patients are 60% more likely to adhere to treatment plans when they feel an emotional connection alongside digital interventions.

For more information, please contact us and arrange a demonstration.