How CMS Plays a Role in the Future of Remote Monitoring?

How CMS Plays a Role in the Future of Remote Monitoring?

Finally, the largest payer in the U.S, the Centers for Medicare & Medicaid Services (CMS), has acknowledged that remote patient monitoring (RPM) plays a major role in the future of healthcare delivery. The good news is that CMS is incentivizing the use of remote patient monitoring technology for collecting and analyzing patient-generated health data.

Since the beginning of 2018, healthcare providers have been able to charge for the time they spend recording the patient data transferred by remote patient monitoring software. They were able to utilize the newly unbundled reimbursement code CPT 99091 for this very purpose. This move by the CMS has helped accelerate the adoption of remote monitoring tools into clinical practices.

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The 2 Final QPP Rules from CMS       

Though the continuing shifts of CMS policies can be a bit confusing, each new measure represents CMS’s effort to aid health care providers in giving the best care possible by encouraging innovation and competition within the American healthcare system. These rules offer physicians the opportunity to take advantage of the latest reimbursement schemes as CMS shifts towards a more value-based care that offers alternative care methods to its participants. CMS administrator, Seema Verma revealed that these rules help strengthen the patient-provider communication and empower patients to understand the value of care rather than volume of tests.

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CMC had released two new rules for healthcare providers affected by MACRA, in November 2017, of which the ‘2018 Quality Payment Program (QPP) Final Rule’ came in to effect on 1st January 2018. This rule affects participants in QPP as it made vital changes to the reimbursement for remote care. The second rule, namely the ‘the 2018 Physician Fee Schedule Final Rule’ focuses on the payment models for Medicare. A new system for performance data submission for the QPP was launched on January 2nd, 2018, which allows to significantly streamline the processes for participating physicians.

QPP Rule No: 1 - Upgradation of PGHD to Higher Ratings

The Quality Payment Program was initially created as a part of the MACRA in 2015 with the intention of aiding the transition of health care providers from pay per service over to a more value-based care.

A notable change in the 2018 QPP Final Rule was the upgradation of Patient-Generated Health Data (PGHD) to a higher rating which allowed the health care providers to get a better score in the CPIA category for to engaging patients by using remote health monitoring system. CMS had recognized the clinical value of ‘Patient-Generated Health Data’ and they have recommended that physicians offer digital services that improve patient engagement and give continuous support to patients wherever they are, outside the hospital or the doctor’s office.

Physicians do need to take note that the use of passive devices for recording patient health data is not reimbursed by the CMS as these devices are unable to transmit PGHD in real time. So, in order to be reimbursed, the care providers must use active devices that transmit and receive PGHD and clinical feedback to the doctor or patient in real time.

QPP Rule No: 2 - Unbundling of the CPT Code 99091

According to the 2018 PFS Final Rule, the CMS ‘bundled’ CPT code 99091 became ‘unbundled’, with effect from January 1, 2018. This CPT code was tagged by CMS for the ‘analysis of clinical data stored in a computer’.

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Bundling meant that the code had to be used in concurrence with a standard evaluation and management service code. But this meant that the patient was required to make an in-person visit to his physician/other healthcare providers.

The unbundling of the CPT code 99091 is great news for all concerned as this means the providers can be reimbursed separately for the time, (30 mins at a time) they spend on collecting and analyzing any remote Patient-Generated Health Data. The best part about the unbundling of this code is that physicians are not dependent on in-person patient visits for getting reimbursements for the time they spend on remote care. This is a relief for both the patient who does not have to make the costly trip as well as for the treating physician who will not have to worry about his reimbursements.

The Code Guidelines for Reimbursement of Remote Care

As per the new CMS QPP final rules, the CPT code 99091 cannot be used more than once in a 30-day period for a specific patient. The reimbursement will include

  • Time spent on accessing, reviewing and analyzing PGHD data

  • Time spent on communication with the patient

  • Time spent on documentation as a result of the analysis

To bill for the service, the physician has to get the beneficiary consent for the service in advance and this has to be documented in the patient’s medical record. The physician also has to spend a minimum of 30 minutes per month reviewing and analyzing the data for the given patient. The time taken to make changes to the existing care plan as a result of reviewing the patient data can also be included in the reimbursement charges. This is also inclusive of the time spent on associated documentation and to communicate the changes to the patient as well as their caregiver, if any.

The good news is that CMS does not restrict the reimbursement with more structured telehealth or in-person guidelines for care. This provides some space for flexibility in the remote patient monitoring software or technology used as well as the way in which the technology is used for generating and transmitting the Patient-Generated Health Data. This flexibility within the guidelines take into consideration the innumerable apps and devices available in today's markets for producing and relaying health data thus enabling patients to choose their preferred platforms for transmitting data to their physicians.

This move from CMS gives many incentives to physicians to spend their time collecting and interpreting patient data and to provide better value care based on this data. They are willing to set aside their precious time to look into patient records as they are now more assured of being reimbursed for this activity. This looks promising as healthcare is shifting from costly and burdensome in-person visits to more comprehensive and long-term remote care programs that appropriately assimilate PGHD to enhance patient results.


CMS seems to be definitely embracing telemedicine and remote healthcare with all these new policy updates. They are taking into consideration various social determinants of health, especially the ones that make it difficult for patients to visit the physicians personally. These may vary from the lack of knowledge about medical provisions to financial issues or the unavailability of transport in a certain locality. The unbundling of the CPT code 99091 makes in-patients visits unnecessary, which is otherwise an expensive burden for both the physician as well as the patient.

The upgrade of PGHD use to a “high” rating allows physicians to get better scores for engaging patients by using technology, in the Clinical Practice Improvement Activity (CPIA) category. The purpose of the CPIA category is to encourage the physicians to be more involved in projects that lead to improvements in patient engagement, customer service and so on, which in turn ensures more value-based care.

For a successful changeover to value-based care from the traditional pay per service system, it is important that healthcare providers are rewarded for implementing new programs like telemedicine and remote healthcare software, which in turn help to streamline the care practices by reducing costs and improving patient outcomes. The recent changes made in the QPP codes makes it evident that CMS acknowledges the value of such recognition and is indeed playing a major role in promoting remote patient monitoring software. Now it's up to the physicians to take advantage of these policy changes to update their healthcare technology to capitalize on programs that offer better efficiency, savings as well as patient outcomes.