Navigating CMS Regulations: Ensuring Compliance with Remote Patient Monitoring

Amol Shete
July 5, 2024
1:55 pm
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Did you know that Remote Patient Monitoring reduced hospital readmission by 76%?

According to a report by the University of Pittsburgh Medical Center, RPM played a very crucial role in reducing the total expenditure on healthcare. But why was it necessary?

Well, the Center for Medicare and Medicaid Services (CMS), in order to reduce the overall healthcare cost, introduced the RPM program. This not only marked the transformation of healthcare practices from traditional to digital but also instilled value-based practices.

Being the initiator of the digital landscape of the healthcare industry in the United States, navigating through CMS regulations for RPM can be the way to streamline your care practices with RPM.

Furthermore, CMS covers RPM services under certain circumstances, and providers must comply with the necessary healthcare regulations for the success of their RPM program.

In this blog, let’s navigate through the key considerations for RPM program implementation along with CMS regulations and how you can ensure compliance with RPM.

Understanding Eligible Services & Billing Codes

There are a wide range of services being offered under remote patient monitoring. Despite being the regulatory body, the Centers for Medicare and Medicaid Services (CMS) has not actually specifically approved the types of monitoring services to be provided under this program.

However, it regulates its control by establishing guidelines for medicare reimbursement through the CPT or Current Procedural Terminology codes. Under this, it guides healthcare practices to collect, store, monitor, and analyze patient’s physiological data, which can be remotely monitored. Some examples of approved monitoring data include weight, blood pressure, blood oxygen levels, and respiratory flow rate.

Along with the RPM billing codes, CMS also requires proper documentation for medicare reimbursements. This documentation generally includes the patient’s healthcare journey. Some of the essential elements required in medical records for billing compliances include patient consent, patient’s medical history, physician order for optimizing telehealth visits for RPM services, personalized care plan, monitoring data, detailed communication records, and CPT codes.

CPT codes play a crucial role in medicare reimbursement and also in providing remote monitoring services. Here’s a breakdown of the CPT codes for RPM and the services it covers:

RPM CPT Codes	Services Covered & Reimbursement Rates
CPT Code 99453	Initial Set-up cost and patient education on using the RPM Devices. The national average for this CPT Code is $19.04.
CPT Code 99454	Usually billed every month for the subsequent month of remote monitoring with collecting and transmission of data. The national average for this CPT Code is $55.72.
CPT Code 99457	This CPT Code covers the initial 20 minutes of monitoring for patients after a face-to-face visit with the healthcare provider. The national average for this CPT Code is $50.18.
CPT Code 99458	This is an additional code to CPT Code 99457 which covers the additional 20 to 40 minutes of monitoring of patient’s data. This code can be used twice in a month depending on the complexity of the situation. The national average for this CPT Code is $40.82.
CPT Code 99091	This CPT Codes covers the services provided by physicians for monitoring the patient’s health and data for a minimum of 30 minutes. This code can be billed every month and the national average for this CPT code is $56.47.

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Patient Selection & Informed Consent

The Center for Medicare and Medicaid Services has established specific criteria for patient selection to be treated under the remote patient monitoring program. Let’s take a closer look at the eligibility criteria for optimizing telehealth visits for RPM Services:

1. Chronic Condition: To enroll the patient under a remote patient monitoring program, the patient must have at least one documented chronic condition requiring medical diagnosis for at least six months. Along with that, the patient must also be at risk for serious complications to enable medicare coverage under the RPM program for better chronic disease management.

2. Medical Necessity: The monitoring requirements set by CMS for the RPM program require the patient to remotely monitor the physiological data to improve their health conditions and prevent complications with proactive preventive care.

3. Established Patient-Provider Relation: CMS requires a documented and established relationship between the patient and provider to enroll under the RPM program. This is enacted to ensure continuity of care and facilitate effective patient-provider communication with already established patient engagement in their healthcare activities.

4. Patient Suitability: Remote patient care heavily depends on the RPM software, devices, and the patient’s capability to use the technology to enable remote monitoring. CMS has recognized this and has listed some of the factors in its guidelines for enrolling patients in the RPM program. These patient suitability guidelines include access to necessary equipment, basic technical skills to operate monitoring devices and transmit data, and the patient’s mental capacity to understand and actively participate in the program.

5. Patient Consent: The most important aspect for patient selection other than all the four elements mentioned above is patient consent. Without patient consent one cannot enroll patients into the CMS RPM program and cannot even receive reimbursement for the services provided to them. The informed consent can be verbal or written from the patient indicating their wish to join the program and receive remote patient care.

The first four pointers mentioned above act as your guiding light for selecting the patients to enroll in the RPM program. Furthermore, with patient consent, you can actually enroll the patient in your remote patient monitoring program.

However, since most of the patients enrolling under this program will be of aging population which are not very technology friendly. That is why CMS has dedicated one specific CPT code for patient education and training. To further ease the process for your users you can implement handson extensive training programs on how to effectively use the RPM software and devices along with providing them with sufficient education material.

Technology Requirements & Data Security

CMS has recognized that technology is necessary for the sustainability of the RPM program. However, technology can be used in a different way, which can put crucial patient data at risk. So here are some of the technology requirements set by CMS for RPM programs:

1. CMS-Approved RPM Devices: Though CMS has not directly approved any specific RPM devices for the RPM program, CMS requires the RPM devices to be qualified or approved by FDA (Food and Drug Administration). Along with that, the device should be capable enough to automatically collect and transmit data to the provider’s system.

2. Permissible Devices: Some of the examples of permissible devices are:

Blood Pressure Monitors
Blood Glucose Monitors
Pulse Oximeters
Weight Scales, etc.

3. Data Security & Privacy Measures: Since the RPM programs deal with the collection and transmission of sensitive patient health information, it is necessary to safeguard their data and maintain telehealth platform security while remotely monitoring patients. Adhering to regulatory bodies like HIPAA, HITECH Act, etc., can not only help in ensuring data security in RPM programs but also avoid legal complications.

4. HIPAA Compliance: CMS has emphasized the importance of HIPAA compliance in protecting patient data. This is because of the strong guidelines that it has set for protecting patient data.

Coding, Billing & Reimbursement

Here are some of the must preferred strategies for successful rpm billing and reimbursement set by CMS for the RPM program:

1. Accurate Coding Practices: The CMS requires you to use the right CPT codes for the services provider under the RPM program. Since proper documentation is necessary for every code, incorrect coding can lead to reimbursement claim denials.

2. Documentation for Billing Claims: To support RPM claims that you are submitting to CMS, you need to document every service you provide to your patients. For example, detailed documentation of 20 minutes of care planning is required when using CPT Code 99457.

For detailed information about the RPM billing codes and guidelines, here is the link to the official website here.

Continuous Quality Improvement and Auditing

The sustainability and relevance of the RPM program depend on various processes involved in providing care. Establish processes for continuous quality improvement. This is important because it directly impacts the efficiency of your healthcare practice, and improving that will directly improve patient health outcomes.

Conduct frequent internal audits to ensure that the devices and all the things are complying with the healthcare regulations. Since CMS constantly monitors the progress of remote patient monitoring, it keeps on improving the process by introducing various rules and changes in CPT codes.

Identify the issues promptly and maintain program integrity by addressing them upfront. This will not only improve the internal communication with care providers but also impact the effectiveness and efficiency of your program.

Conclusion

CMS is the reason why we are able to harness technology in healthcare services. It has not only reduced the burden and overall spending on healthcare services but also made receiving healthcare more convenient.

The best way to navigate through the CMS regulations for RPM is to adhere. Consider all the things that are necessary for the program and check for their compliance with the CMS. This will ensure that the success of the program is on track and that you will be paid rightly for the service you provide.

Being the regulatory and healthcare provider starting out the RPM program, you must be updated with the latest updates in CMS RPM regulations. This will make you proactive in ensuring compliance with the healthcare regulations and will allow you to make informed decisions.

Frequently Asked Question’s

1. What are the key CMS regulations related to remote patient monitoring?

Here are some key CMS regulations for RPM:

Eligible patients: Must be chronically ill and have a condition that can be monitored remotely.
Patient consent and education: Patients must consent to remote monitoring and understand how their data will be used.
Billing provider: A healthcare professional must order and oversee the remote monitoring.
Data security: CMS requires HIPAA compliance to protect patient privacy and data security.
Minimum data collection: At least 16 days of data collection per 30-day period is required for certain services.
Established patient relationship (RPM only): For RPM services, a prior in-person visit is required, with some exceptions.

2. How can healthcare providers ensure compliance with CMS guidelines?

Here are some key ways healthcare providers can ensure compliance with CMS guidelines:

Stay informed: Regularly review updates to CMS regulations and guidelines.
Internal controls: Implement procedures to monitor and track compliance within your practice.
Regular audits: Conduct internal audits to identify and address any gaps in compliance.

Seek guidance: Consult healthcare compliance experts for assistance.

3. What are the consequences of non-compliance with CMS regulations in RPM?

Here are some of the consequences of non-compliance with CMS regulations in RPM:

Financial penalties: Non-compliance can result in significant fines levied by regulatory bodies.
Data access restrictions: Regulatory bodies may restrict access to your data in order to investigate non-compliance.

These are just two of the potential consequences, and compliance is important to avoid these risks.

4. What role does technology play in facilitating compliance with CMS guidelines for remote patient monitoring?

Technology plays a crucial role in facilitating compliance with CMS guidelines for RPM by:

Enabling secure transmission of patient data between monitoring devices and healthcare providers.
Streamlining data collection and storage through wearable sensors and mobile apps, reducing manual burden.
Facilitating real-time monitoring and generating alerts for concerning vitals, ensuring timely intervention.
Supporting remote care coordination by allowing providers to remotely review patient data and adjust treatment plans.