Fred Ashbury, PhD and Devan Birch, BA
Even before the global pandemic, facilitating the care of cancer patients during treatment and the post-treatment survivorship setting who reside in rural/remote locations has been a major challenge. These challenges, to name some, can include limited access to transportation to attend clinic visits, financial toxicities associated with time off work, and a dearth of health care support services such as labs and imaging centers.
Telehealth technologies have emerged as one means to mitigate remote patient monitoring concerns; however, there have been implementation challenges to establish what solutions are most effective, practical challenges deploying these technologies particularly in rural/remot
e areas, technology literacy, low trust in these technologies to protect personal health information, poor performance, and competing priorities among members of the health care team 1.
The Centers for Medicare & Medicaid Services (CMS) has established rules for remote patient monitoring (RPM) delivery and reimbursement codes to facilitate monitoring and treatment of patients in remote settings.
How can RPM be delivered?
Technologies such as telemedicine can be used to facilitate monitoring of patients in their home or other remote location, in other words, outside of common clinical settings. These technologies increase access to care and decrease healthcare delivery costs. The principal goal is to significantly enhance patients’ quality of life, reduce patients’ financial toxicities, and mitigate treatment management problems (e.g., toxici
ties) which can lead to greater use of health care services (e.g., emergency rooms and hospitalizations).
RPM requires use of a medical device (e.g. blood pressure cuff) that automatically records patient data. Patient Entered Data does not qualify for RPM.
Billing for RPM has changed.
Remote Patient Monitoring (RPM) services can now be billed “incident to” a physician using general patient supervision as opposed to direct (in-person or in-location) supervision. In the past, RPM services could only be billed when the physician was present in the same location as the member of the care team who provided the services to the patient. Under general supervision, a physician does not need be in the same building and could use telemedicine services to exercise general supervision.
RPM has an existing code (99457) which is to be used when the patient receives 20 minutes of RPM services within a given month. Important to note that this code covers any amount of time from 0-20 minutes (e.g. if I spend 5 minutes, I can bill).
A new CPT Code (99458) has been created that allows for billing when a patient receives an additional 20 minutes of RPM services within a given month. This new code took effect on January 1, 2020. The reimbursement rate indicated for 99458 is calculated based on valuations and RVU’s provided by Medicare in the Federal Register 2 https://federalregister.gov/d/2019-24086).
Medicare has established specific reimbursement rates according to the RPM billing code used, as illustrated in the following table3.
Remote Therapeutic Monitoring (RTM) – What it is and how it works?
The addition of RTM codes increases the use cases for remote monitoring of patients further than the existing RPM codes that necessitate use of medical devices. Five new codes have been added for RTM, including those for initial creation, continuing collection of RTM data, and provider intervention. These codes are exclusively aimed at non-physiological data. Patients can self-report information their status (example, qualit
y of life measures). Published reimbursement rates were not currently available but they are indicated to “parallel” those rates of the RPM codes. The RTM codes are presented below4:
(RTM) Toxicity Management: Using VieCure’s mobile app, a patient responds to a toxicity questionnaire. The system’s algorithm grades the toxicity based upon the patient responses. In VieCure’s platform, provider and other members of the patient’s care team are alerted that the patient has reported a toxicity using the mobile app. The provi
der or designated member of the healthcare team views the toxicity, determines the appropriate course of action (facilitated by VieCure’s artificial intelligence capability), and selects the actions (e.g. sends an e-prescription to patient’s default pharmacy). The platform messages the patient that the toxicity has been evaluated and sends a prescription to their local pharmacy along with appropriate instructions on how to manage the given toxicity. In this scenario, the patient avoids an unnecessary trip to clinic or ER. This is a billable interaction.
TM / RPM) Patient Message: Using the mobile app, a patient chooses to send a direct message to the oncology care team. The patient explains what her status is and messages are exchanged with a representative of the care team. On the basis of the exchange, the provider determines the appropriate action, and the patient is instructed on how best to handle scenario. The patient avoids an unplanned visit to the clinic or ER. This is a billable interaction.
(RTM) Medication Compliance: A patient is on a take-at-home daily therapy medication per the treatment protocol. VieCure’s AI platform alerts the provide that the patient has not reported taking their medicine on the mobile app. In this scenario, the provider’s standing order is to contact the patient regarding the medication. The patient reports that the medication is making them feel unwell and they have stopped taking it. The patient is given guidance to mitigate the side effects and is encouraged to continue with at-home therapy and to use the mobile app to report any side effects. The patient gets back
on the therapy and to follow the protocol as intended. This is a billable interaction.
(RTM) Review of Systems: The patient fills out a review of systems using the mobile app prior to their infusion next week. When reviewing the patient’s responses, VieCure’s AI capability alerts the provider to consider focusing on a few areas of concern. The provider messages the patient that he would like to have a few lab tests completed prior to next week’s infusion visit. The patient gets the tests completed and the results are sent to the provider. The results show some problems that indicate the patient is not well enough for treatment, and the platform signals this consideration to the provider and the appropriate action to take. The provider puts a 2-week hold on the treatment plan and intervenes as appropriate. Then, the provider messages the patient explaining what the situation is and instructs the patient on how to manage the complications that were identified. The patient avoids a scenario where they come all the way in to the clinic the next week and it is discovered they can’t be treated thereby wastin
g their day, time, and money, while also allowing the problem to persist longer than necessary. This is a billable interaction.
(RPM) Physiological Monitoring: The patient is wearing a heart rate monitor that is tethered to their phone. During a given month, the device records daily data and transmits these data through the mobile application back to the provider web app. On day 20 of the month, the data reported are processed by VieCure’s platform and the platform alerts the provider that the patient may be experiencing an issue. The provider contacts the patient to determine the severity of the issue and provide any necessary guida
nce. This is an example of RPM and is a billable interaction.
Remote patient and remote therapeutic monitoring are key to successful cancer patient outcomes. CMS has provided billing codes to facilitate reimbursement for these important activities. The VieCure platform has been architected to enable cancer practices to undertake RPM/RTM to improve the quality of life of cancer patients, mitigate patients’ financial toxicity, reduce healthcare costs, and ensure appropriate reimbursement.
Chan RJ, Crichton M, Crawford-Williams F, van den Hurk C, et al. The efficacy, challenges and facilitators of telemedicine in post-treatment cancer survivorship care: an overview of systematic reviews. Annals of Oncology 2021;32(12):1552-70.
Centers for Medicare & Medicaid Services, Federal Register: https://federalregister.gov/d/2019-24086
Fredrick D. Ashbury, PhD
Chief Scientific Officer, VieCure Professor (Adj), Department of Oncology University of Calgary Professor (Adj), DLSPH, University of Toronto
Lead Business & Quantitative Analyst, VieCure