What is Remote Patient Monitoring (RPM)?
Broadly speaking, Remote Patient Monitoring (RPM) is a healthcare delivery method that uses innovations in information technology to allow the streamlined collection of patient data beyond the traditional healthcare setting. You may also hear it called remote patient management, remote health monitoring, or remote physiologic monitoring.
Health data may be collected manually and entered into a remote patient monitoring system or it may use biosensors, fitness trackers, and other wellness devices to automatically or continuously gather health data. The collected data is then securely sent to healthcare providers in another location for real-time update, assessment, and intervention. Providers may want to measure a patient’s heart rate, vital signs, sleep patterns, and glucose levels, among others. Through this system, clinicians can continue caring for their patients remotely.
The system may include
- Phones and tablets
- Mobile apps to upload food logs or identify how much insulin a patient needs based on their dietary intake and exercise,
- Wearables that would measure a patient’s heart rate, blood pressure, and sleeping patterns,
- Reminders on when they are supposed to take insulin or medication
- Ability to connect with providers via video or messaging
RPM models feel empowering for patients because it allows them to take better control of their health. For example, a recent article discusses how wearables are helping the elderly manage heart disease and detect Alzheimer’s early on
. For healthcare professionals, RPM increases patient engagement to give them better visibility of their patient’s health. Through the constant feed of information, they can decide on what treatments, procedures, and medications work.
Is Remote Patient Monitoring the same as Telehealth?
Sort of. While RPM falls under the telehealth umbrella, it does not encompass all the types of services included in telehealth. Telehealth is usually defined as a very broad set of healthcare and healthcare-related services delivered from a distance. This includes telemedicine
, clinical care, patient education, public health administration, professional development for providers, etc.
RPM is also considered one type or modality of telemedicine
. Telemedicine is usually more narrowly defined than telehealth, often focusing on the delivery of clinical services from a distance. These delivery methods include synchronous consults between a patient and provider via live video or phone. It typically includes store-and-forward services such as those pioneered by dermatology and radiology specialties, where images are uploaded or securely sent to a provider for an asynchronous diagnosis. It also includes RPM services where patients’ vitals and physiologic data are continuously collected via sensors and medical devices and monitored by providers. It can also include clinical services mediated by smartphones, tablets, and mobile devices. Based on the data from McKinsey, the adoption of telehealth, including remote patient monitoring has increased 65% during the COVID pandemic from 11% in 2019 to 76%.
You can learn more about how CMS defines telehealth services in their Fact Sheet here
When Did Remote Patient Monitoring Begin?
In the late 1960s physicians began transmitting EKG data over the telephone and by the 1970s a remote patient monitoring system was set up by Kaiser Foundation International and Lockheed Missiles and Space Company to manage healthcare on a Native American reservation in Arizona. The hope was to create a system that could be used to manage healthcare for underserved patients in rural areas around the world. Today, it is becoming a common healthcare service as Medicaid and private insurers expand their coverage of RPM and as smartphone adoption and technology improvements make it easier for patient consumers to manage and use RPM devices in the home.
How does CMS define remote patient monitoring?
According to CMS
, remote patient monitoring under the Medicare home health benefit is defined as:
‘‘The collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency
However, CMS also stated that “Visits to a beneficiary’s home for the sole purpose of supplying, connecting, and/or training the patient on the remote patient monitoring equipment, without the provision of another skilled service are not separately billable
The 2021 Physician Fee Schedule Final Rule can be found here
Remote Patient Monitoring Quick Facts
Does Medicare/Medicaid pay for remote patient monitoring?
Yes. Medicare/Medicaid does pay for remote patient monitoring. According to the Centers for Medicare & Medicaid Services (CMS), the coverage include the following 5 CPT codes: 99091, 99453, 99454, 99457, 99458
These are not the only codes that can be used to bill for RPM-type services. For example, there are specific codes for continuous glucose monitoring (95250) and for self-measured blood pressure monitoring (99473 and 99474). When there are more specific codes that can be billed, those should be used instead.
Law firm Foley & Lardner have extensively covered RPM billing and reimbursement here
Remote Patient Monitoring Solution
Complete Your Telehealth Services with RPM
What are the remote patient monitoring CPT codes?
Two of the above specified remote patient monitoring CPT codes are meant to cover practice expense costs including device and supplies costs and clinical staff time to set up and teach patients how to use the devices. The other three remote patient monitoring CPT codes cover clinical staff time for the review of patient data and communication. This includes CPT codes 99457, 99458, and 99091.
RPM codes are considered Evaluation and Management (E/M) services. This means that RPM can only be ordered and billed by physicians or E/M eligible non-physician practitioners.
- CPT codes 99457 and 99458 provide reimbursement for 20 minutes of interactive communication, both in-person and telehealth, between the provider and the patient over a calendar month.
- CPT code 99091 can have once a month billing for a minimum of 30 minutes for reviewing patient data by doctors or qualified health practitioners only.
- CPT code 99453 includes billing for remote monitoring of physiologic parameters, such as oxygen saturation via pulse oximetry, weight, respiratory flow rate, blood pressure, and its initial setup and training of equipment use. The billing is every 30 days.
- CPT code 99454 includes billing for remote monitoring of physiologic parameters, such as oxygen saturation via pulse oximetry, weight, respiratory flow rate, blood pressure, and the initial supply of devices and daily recordings and programmed alert transmission for 30 days.
Please note that these CPT codes can only be billed by a single specialty (practitioner), during a set period of time, even though any specialty is allowed to enroll a patient in a program. Furthermore, the 99453 and 99454 CPT code may only be billed once during the set period of time regardless of the number of devices/parameters being monitored. CMS commentary says:
“even when multiple medical devices are provided to a patient, the services associated with all the medical devices can be billed by only one practitioner, only once per patient, per 30-day period, and only when at least 16 days of data have been collected.”
So even if multiple physicians want to enroll the patient in an RPM program, only one physician can bill for it. This means if the primary care physician (PCP) puts the patient in a program to monitor blood pressure and then their cardiologist also wants to monitor the patient’s EKG and pulse oximeter, the cardiologist may not bill the same CPT code until the patient has completed the program with their PCP.
Another issue is if the PCP (the billing practitioner) wanted to add a new parameter to monitor. According to this CTEL webinar
, the PCP would not be able to bill for that additional parameter until the first program has been completed. Please note that this is an interpretation of how some health systems bill for RPM.
Also, since RPM rules are updated annually, it’s important to take note of the annual changes.
Who qualifies for RPM?
Initially, CMS limited the use of RPM to patients with existing chronic conditions. But, recent updates in the 2021 Final Rule stated that clinicians may provide RPM services to patients with acute and chronic conditions.
Take note that RPM services are only applicable for established patients to qualify. Clinicians must first establish a relationship, collect relevant patient history, and conduct a thorough physical examination before they can make use of an RPM service that would allow them to provide the best possible care and develop an effective treatment plan. In many states a physician-patient relationship can be established via telehealth.
Who can perform RPM?
It depends on the CPT code. CPT code 99091 is exclusive to physicians and qualified healthcare professionals while CPT codes 99457 and 99458 can be performed by a physician, healthcare professionals, or clinical staff with direct supervision of the physician. Examples of qualified healthcare professionals include:
- Registered nurses
- Nurse assistants
- Physician assistants
- Certified registered nurse anesthetists
- Certified nurse-midwife
- Clinical nurse specialist
- Clinical social worker
- Anesthesiologist assistant
- Physical therapists
- Occupational therapists
- Speech therapists
- Massage therapists
Based on the 2021 Final Rule, CMS allowed auxiliary personnel along with clinical staff to perform CPT codes 99453 and 99454, provided they are under the supervision of the primary practitioner. Auxiliary personnel is defined
by Medicare “as an employee, a leased employee, or an independent contractor of the physician or legal entity billing and receiving payment for the services”
In cases when the physician will not be present in the treatment room, they must be available within the office to assist whenever necessary.
What are the benefits of remote patient monitoring (RPM)?
Remote patient monitoring (RPM) offers a multitude of benefits for both patients and clinicians. Some of them include:
- Improved quality of care: For patients with chronic conditions, close monitoring and continuous management is necessary, and remote patient monitoring provides clinicians the opportunity to carry these out for their patients.
- Better patient outcomes: With remote patient monitoring, patients and clinicians can catch out-of-range and alarming values that would warrant alteration of management programs and treatment options.
- Real-time management: Clinicians can reduce health risks and complications because they can get access to real-time data, allowing them to provide care the soonest time possible.
- Reduced readmissions: With immediate access to care, patients can reduce hospitalizations and even emergency room visits. Ultimately, it can decrease the burden on the healthcare system.
- Easier access to care: With looming physician shortages, access to healthcare is becoming more difficult for patients. Remote patient monitoring can help physicians provide care for more patients wherever they may be.
- Additional revenue stream: Remote patient monitoring provides the opportunity for more physicians and clinicians to expand their care and reach more patients, which can lead to an additional revenue stream. Ultimately, this can lead to better provision of care to patients as it eases access to more caregivers.
Studies and Evidence for Improved Patient Outcomes
As remote patient monitoring becomes widely utilized, it has proven to provide convincing results for improved patient outcomes.
RPM studies for Cardiology, Congestive Heart Failure (CHF), and COPD show that it can:
- Reduce emergency room visits by 68%.
- Curb in-patient admissions by 35%
- Cause a 19% reduction for all-cause mortality and all-cause hospitalizations following telephone intervention.
RPM studies for asthma show that:
- 96% of patients found RPM equipment for asthma monitoring easy or very easy to use.
- 92% of asthmatic patients prefer using the equipment in the future.
- Patients with severe asthma noted a significant reduction in hospitalizations over 12-months.
RPM studies for stroke management highlight:
- Increased stroke awareness, including understanding stroke symptoms and remedial actions, improved patient outcomes by decreasing delay in hospitalization.
- Follow-up assessments using video-conferencing show better functional outcomes more than telephone assessments.
RPM studies for a hospital at home show that:
- A large percentage of patients have strict adherence to daily measurements.
- Many develop better physical self-awareness and education about managing their health.
Comprehensive RPM studies
- There is a notable 14% decrease in the incidence of hip fractures and a 22% decrease in risk of death among patients with Parkinson’s disease as RPM allowed them to get direct access to a neurologist.
- For patients with behavioral concerns, patients posted a 75% average of adherence to RPM sessions for six months, and a 25% reduction in bed days spent in care.
- Smokers using RPM models also showed improved long-term quit rates.
- More patients report satisfaction on remote consultations done via live videoconferencing due to enhanced interaction and better visual information, particularly for those in remote areas.
What are the barriers to RPM?
The use of RPM has been growing with Medicare’s expanding coverage of RPM services. It has been further accelerated by the spread of the COVID-19 virus and the need to find alternative ways to provide and receive care from a distance. However, its widespread adoption still has much room to grow. It is hindered by several factors, including:
Technology, Cost, and Accessibility
One of the main issues is connectivity. In some rural areas high-speed connectivity is still an issue and network interruptions can have a significant impact on the ability to provide continuous monitoring. Another problem is access to devices. Patients may need to have a smartphone or tablet that can connect to the Internet at any given time and biosensors or healthcare devices to collect the biodata. While the cost of healthcare and wellness devices and fitness trackers have dropped over the years, it is still a significant cost to purchase and maintain devices, as well as to clean and to manage the sending and collecting of devices to patients’ homes. Patients may also have technical challenges using the devices either because of the device malfunctioning or because they have trouble correctly using it.
Another important obstacle that can hinder the success of remote patient monitoring systems is the reimbursement from Medicare/Medicaid and insurance plans. While there have been requests to expand the coverage to include additional providers, the final notes only allowed physician and non-physician providers qualified to render evaluation and management (E/M) services may bill for RPM.
Since most Medicaid programs are subject to telehealth laws per state, it can discourage clinicians from adopting the system for their patient care. Currently, there are 37 states plus the District of Columbia that have parity laws mandating private payer reimbursement for telehealth including real-time videoconferencing. Given this, private payers have the liberty of establishing their own copay policies when it comes to remote patient monitoring services.
FDA approvals are critical to ensure that remote patient monitoring programs and devices meet regulatory standards
. However, they can also pose a challenge for manufacturers and developers. They need to ensure that the RPM systems and devices are compliant with FDA and healthcare standards before they can be allowed for patient use. In some cases, patient worthiness certifications, quality assurance certifications, and life cycle assessments can take a while to process or cause an increase in costs due to related overhead expenses.
Privacy and Security Concerns
In-person consultations are more secure and private than remote patient monitoring systems. While most platforms have high levels of encryption and comply with Health Insurance Portability and Accountability Act (HIPAA), it is not 100% secure from potential data breaches. For patients, it can become a barrier to wider acceptance and implementation.
Understand the Legal Nuances in Remote Patient Monitoring
What are the advantages and disadvantages of RPM?
Remote patient monitoring does come with advantages and disadvantages. Some benefits it provides include:
Real-Time Patient Care
RPM allows patients to send their data to their clinicians in real-time. This opens the possibility of providing immediate treatment and management, particularly for patients with chronic or serious illnesses. Patients no longer have to visit a medical facility to perform routine tests and send it to their doctors. Physicians, in turn, can make better and informed decisions based on the patient data sent to them.
Expansion of Healthcare
Through RPM, healthcare becomes available and accessible to many patients, mainly those who find it difficult to seek consultation due to physical disability. It also makes healthcare accessible for individuals who cannot afford routine check-ups. Medical facilities can also serve more patients without overcrowding their clinics. Cost-Effectiveness
RPM can bring considerable savings to patients. With their devices, they can get prescriptions based on their test results without the need to go to a clinic. With this alone, they can save on transportation and doctor’s fees.
Beyond the advantages, RPM still does come with disadvantages, such as:
Some RPM systems need intensive training for users. In some cases, this can present a challenge for increasing adoption, particularly in the elderly age group.
Additional Software Requirement
Depending on the RPM device, some require IT departments to redirect data from electronic medical records systems (EMRs) through several third-party applications. This may pose a security risk for some patients.
Remote patient monitoring also brings into question malpractice liability when it comes to practice standards, informed consent, and supervision assurance for non-physician health providers.
What are some key considerations for implementing RPM?
To effectively run a successful RPM program, healthcare organizations should follow these key practices:
Know Patient Goals
What you want to achieve for your patient can help you decide the type of RPM platform or system to use. If you want your patient to take control of their health management, use an RPM device that will make them feel empowered. Consider programs that will bring the optimal results for your patients. Factor in your personalized patient care plan whenever considering RPM systems.
Form a Core Group
RPM systems can only work if there is a dedicated core group that will determine the course of the program. It should have a clinical group that would deal with health data such as manner of monitoring and the devices to use. Will the patient need glucose or cardiac monitors?
It is also critical to have an IT team responsible for addressing technical concerns, such as technological implementation. They may also be the point persons to set up the equipment and train the patients.
Having a dedicated technology partner that matches your patient goals is ideal, but you also have to factor in safety and security concerns, especially if you are integrating your EMR system with the RPM platform. There are many companies that will help you manage, staff, and run your RPM program.
RPM requires building compliance into your RPM program, so it is a big team effort that requires coordinating workflows and checkpoints across multiple teams and departments including IT, compliance, billing, clinical directors, finance, etc.
Identify Necessary Devices
Most clinicians and medical facilities will have multiple options when managing RPM devices. Some may choose to go in-house, where they purchase and configure the devices themselves and take responsibility for feeding pertinent patient data to their electronic health record system. Others completely outsource their RPM program, having the vendor take care of everything from equipment set up and delivery to case management. Still others may take a middle ground approach where they work with the vendor to decide which parts of the program logistics will be managed in-house and which will be managed by the vendor.
In such cases in which patients will use their own device, they will get an enrollment link via their email to download the app and connect the required peripherals to inform them of the programs they will use. Depending on the patient’s case, they may also be required to purchase a glucometer and a smartphone that can accept and/or record video calls.
Before you dive into the remote patient monitoring program, you have to have a realistic budget. Some RPM solutions will require you to make an upfront investment, while others will lease you their devices or factor in the costs on the platform fees. To determine how much you can invest in an RPM, identify if you have enough patients that will qualify for a program. Roughly, an annual RPM Medicare reimbursement for each qualified patient amounts to $1,400. From there, you can make projections on your potential income and which RPM platform will suit your goals.
Factor in the different logistics, including costs for shipping and maintenance. It would also be useful to think about the potential costs of damaged, lost, and unreturned devices. You can decide to have one dedicated solution provider responsible for shipping, customer support, management, and even scaling of the operations to make connected health as streamlined as possible while keeping costs low
Engage Patients and Their Family
One of the primary goals of remote patient monitoring is to encourage patients to take control of their health
. In some cases, it is also used to help families cope with the illness and its management. Using an RPM can increase engagement because there is a better understanding of their physiologic parameters with their symptoms. Family members can be educated to use devices, such as glucometers, pulse oximeters, pedometers, and blood pressure monitoring devices. Along with real-time monitoring, rapid intervention is possible.
More Resources for Getting Started with RPM
- A series of short videos with expert discussions about telehealth and remote patient monitoring from the National Consortium of Telehealth Resource Centers. Remote Patient Monitoring Implementation Playbook
- This playbook provides healthcare providers with a step-by-step guide on how to properly implement RPM services. Remote Patient Monitoring Toolkit
- This toolkit guides providers on how they can successfully implement remote patient monitoring, complete with a checklist from pre-implementation to planning and monitoring stages. State Telehealth Laws & Reimbursement Policies
- Get all details about the laws and reimbursement policies relating to telehealth and remote patient monitoring across different states. CTEL Remote Patient Monitoring Billing Webinar
- Presented by Northwell Billing and Reimbursement Manager Amanda Buonocore, CPC, and UCSF Telehealth Business Operations Manager, Carol Yarbrough, MBA, CPC (Nov. 2020) Slides here