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MEDICARE AND TECHNOLOGYRemote Monitoring (from page 66)expensive but this is offset by lowermonthly fees.68Patient OnboardingPatient onboarding includes education about the parameters, the significance of monitoring it on a dailybasis and the mechanisms for makingadjustments when there is determination of what being monitored is out ofsorts. Onboarding can be done in thephysician’s office if the device is provided on-site; sometimes it’s done bythe device provider remotely if the device is shipped directly to the patient.Gaining patient trust to use RPMdepends largely on the provider’slevel of comfort with the technologyand his/her relationship with the patient. Providers need to understandhow to use the RPM device prior toencouraging its use. When patientssee providers struggling to use thetechnology, it can cause uncertaintyin patients about its value in the delivery of their care.The key to engaging patients withRPM is to make it easy. Devices workbest if they require little prior knowledge about technology, easily connectto patients’ smart phones or othercommunication devices, and seamlessly integrate into patients’ dailylives. Patients will be most receptiveto adopting RPM if the patient’s family members are included in the engagement/education process.Platform/DashboardThe RPM platform allows someone the physician employs, potentially off-site and possibly a contractedvendor, to manage patients througha single comprehensive dashboard.The dashboard should offer analytictools to report on and assess patientdata, and allow the physician to integrate reports into their EHR. Thedashboard should track the amountof time spent reviewing patient data,accessing other documents, and providing patient communication. HIPAAsecurity requires separate log-ins byindividuals accessing the platform.Communication StrategyNudge theory contends that indirect suggestions and positive re-inforcement can influence people’sactions. The simple act of being reminded, or “nudged,” to respond toreported measures on a consistent,unobtrusive basis can elicit positive health behaviors. While relevant patient-reported data captureand revenue enhancement are theprimary goals of an RPM program,an ancillary benefit is stronger pa-ers and business models to use thetechnology.CPT code 99453: Patient educationand set up“Remote monitoring of physiologic parameter(s) (e.g., weight, bloodpressure, pulse oximetry, respiratoryflow rate), initial; set-up and patienteducation on use of equipment.”The RPM platform allows someone thephysician employs, potentially off-site and possibly acontracted vendor, to manage patients througha single, comprehensive dashboard.tient engagement. Programs will bemost successful when patients havea single point of contact for technicaland clinical issues. It is through therelationship building that occurs withmonthly communication that patientsbecome willing to accept RPM as away to achieve better outcomes.Every RPM company must finetune its communication strategy tonot send too many alerts that arefalse positives nor miss significantfindings by creating false negatives.Too many warnings that are not trulyurgent risk patients becoming irritated and even worse, choosing to withdraw from the program. Too littlecommunication and patients mightfail to value the merit of their continued participation.Medicare Program OverviewRemote patient monitoring became covered by Medicare in January 2018. It’s significant that thenew CPT codes 99457 and 99458can be billed “incident to” andunder “general supervision” rather than “direct supervision”. General supervision means the servicecan be furnished under the billingpractitioner’s overall direction andcontrol, but the billing practitioneris not required to be physically present or even within the same officebuilding as the practice associateproviding the care. The “incident to”revision aims to expand RPM reimbursement by allowing more provid-OCTOBER 2020 PODIATRY MANAGEMENTCPT 99453 offers reimbursementfor the work associated with onboarding a new patient onto an RPMservice, setting up the equipment,and educating the patient on usingthe equipment. The 2020 nationalMedicare payment for these servicesis 18.77. Patient must opt-in for theservice Patient cannot be charged forthe device. Device must meet the FDA’sdefinition of medical device and capture physiological data. Physician must order the device. Anyone on staff can perform theset up and education. Monitoring must be for at least16 days. No RVUs, a technical code Documentation should be basedupon the provider’s clinical judgmentof the patient’s condition and include:– Nature and severity of condition– Detailed history of condition– Medical necessity and clear rationale for monitoring– Goals to be achieved by RPM CMS does not reference a faceto-face requirement associated withRPM, despite having previously imposed such a requirement for CPT99091. This omission supports theinterpretation that CMS does not intend to carry forward the consentand face-to face visit requirementsfor the new RPM codes.Continued on page 70www.podiatrym.com

MEDICARE AND TECHNOLOGYRemote Monitoring (from page 68)70CPT code 99454: Device and transmission of data“Device(s) supply with daily recording(s) or programmed alert(s)transmission, each 30 days.”CPT 99454 offers reimbursement for providing the patient withan RPM device for a 30-day period.99454 can be billed each 30 days.The 2020 national Medicare paymentis 64.15. Device must be supplied for atleast 16 days to be applied to a billing period. The service must be ordered bya physician or other qualified healthcare professional. Data must be wirelessly syncedwhere it can be evaluated No RVUs May be used with either CPT99091 or 99457. There is no minimum numberof measurements that must be collected each day.CPT code 99457: Interpretation andManagement“Remote physiologic monitoring treatment management services,clinical staff/physician/other qualified health care professional time ina calendar month requiring interactive communication with the patient/caregiver during the month, first 20minutes.”CMS will reimburse for clinicalstaff time that contributes towardmonitoring and interactive communication which includes phone,text, and email. It’s significant thatin January 2020, Medicare changedthe rules to allow RPM services tobe delivered by auxiliary personnel who are not under direct supervision of the physician. Auxiliarypersonnel can be in a different location from the supervising physician.These changes permit technologyvendors and other third parties whohave not historically been involvedin the delivery of direct patient careto engage in RPM arrangements thatsupport physicians and other careproviders. The 2020 national Medicare payment for these services is 51.61. Report once each 30 days. Do not report in conjunctionwith CPT99091. Do not count any time on a daywhen the physician reports an evaluation/management service. May be billed as an “incidentto” service. Does not require live face-toface or voice communication.Services billed as “incident to”must be an integral, though incidental, part of the billing practitioner’s service in the course of thepatient’s diagnosis or treatment.This means the practitioner submitting the bill must furnish an initialservice (e.g., an E/M visit) to whichthe subsequent RPM services areintegral and incidental, establishingthe patient relationship prior to furnishing RPM. During the COVID-19Continued on page 71Table 1:Annual Revenue per Patient1st MonthMonth 2-12AnnualTotalSetup (99453) 19 19Equipment Data Transmission (99454) 62 62 744Viewing Data, Communicating with Patient—Initial 20 Minutes (99457) 52 52 624Viewing Data, Communicating with Patient—Additional 20 Minutes (99458) 42 42 252* 175 156 1,639Annual revenue opportunity of approximately 1,500 per year per patient, or higher***Assumes spending additional 20 minutes for 50% of monthly communication**Does not include cost of equipment or softwareOCTOBER 2020 PODIATRY MANAGEMENTwww.podiatrym.com

MEDICARE AND TECHNOLOGYRemote Monitoring (from page 70)crisis, E&M visits can be performedvia telehealth.CPT code 99458: Interpretation andManagement, additional 20 minutes“Add-on code for patients whoreceive an additional 20 minutes ofRPM services in a given month (i.e.,40 minutes of RPM services).”CPT 99458 allows for the physician or clinical staff, under generalsupervision, to provide, when thecomplexity of the patient’s conditionwarrants it, additional interactivecommunication beyond the initial 20minutes. The 2020 national Medicarepayment for these services is 42.22(each calendar month per patient).CPT code 99091: Collection and interpretation of physiologic data“Collection and interpretation ofphysiologic data (e.g., ECG, bloodpressure, glucose monitoring) digital-www.podiatrym.comly stored and/or transmitted by thepatient and/or caregiver to the physician or other qualified healthcareprofessional, qualified by education,training, licensure/regulation (whenapplicable) requiring a minimum of30 minutes of time, each 30 days.”When patients with chronic conditions are remotely monitored andthe physiological data indicates nothing abnormal and thus no modification of the care plan needed, it wouldbe appropriate to bill using chroniccare management code CPT 99091,“Data collection and interpretation”.CMS will reimburse for professional time dedicated to monitoringservices and does not require interactive communication like CPT 99457to bill. However, it requires the physician to perform these services, andrequires 30 minutes of time every 30days to bill. CPT 99457 and 99091cannot be billed concurrently. Theaverage 2020 Medicare payment forthese services is 59.19.How Podiatrists Can Implement RPMSelect ParameterPhysicians should focus on chronic conditions that they commonly seein their practice and that a plan ofcare would fall under their scope ofpractice. For most podiatrists, diabeticfoot ulceration is the chronic condition most frequently seen that can beimproved via on-going monitoring.The parameters that have been validated and that device manufacturers addressing DFUs have thus far focused on are foot temperature, plantarpressure, and patient adherence.Identify PatientsAs every state has a different Medicare carrier and because the programis so new, there are instances of somepayors not recognizing these newcodes. It’s expected that Medicare Advantage plans and private payors willbe soon coming on board and payingContinued on page 72OCTOBER 2020 PODIATRY MANAGEMENT71

MEDICARE AND TECHNOLOGYRemote Monitoring (from page 71)for RPM as well. Patients have to optin to remote patient monitoring programs and are responsible for applicableco-payments. It makes sense to workwith patients who are capable of working with new, easy-to-use technology,and who will be receptive to frequentreminders. It doesn’t pay to spend muchtime trying to convince patients to participate if they are not enthusiastic abouta program of self-care and demonstratea likelihood of dropping out.72Select DeviceCompanies will be competingbased on how easily they make it forpractices to onboard their patientsand how easy their devices are forpatients to use. The best devices willeasily integrate into patients’ routines, will be easy to keep charged,and will work with minimal hassle. Anumber of companies have recentlylaunched that offer a complimentaryapproach for improving diabetic footcare. They feature: Sensor impregnated socks thattrack foot temperature as a means ofdetecting impending ulceration, An innovative, adjustable bootthat tracks patient activity and patient compliance for healing plantarwounds, and Custom diabetic inserts thatincorporate sensors that measure foottemperature, pressure, and patientadherence.Develop Office ProtocolsPractices will potentially havehundreds of patients that they canenroll in remote patient monitoring.Focusing on the people implementingand using the technology, rather thanthe technology itself, will make all thedifference in developing a successfulprogram that incorporates a sustainable, new model of care.Your EHR should be used to flagpatients with the selected parameterand qualified payer. There should bea mechanism to remind clinicians topromote RPM to qualified patients, toeducate them about its benefits andobligations, and to get their consentto participate. Some devices can bestocked and dispensed that same day,some devices need to be individuallyordered. Some devices can be shippedto patients with patients on-boardedremotely; some programs require thepatients to return to the office.The practice must spend a minimum of 20 minutes communicatingwith each patient every 30 days in orderto bill Medicare. Twenty and sometimesforty minutes spent, per patient, permonth will become a substantial time Improved patient self-management Improved access to care Improved use of clinical resources Increased practice revenueImplementation is unfortunatelyfar more complicated than simplyproviding devices, collecting patientfoot information, and creating practice revenue. RPM success will beA successful RPM program has the potentialto improve the health of hundreds of patients ineach practice and creates an opportunityfor most offices to earn 100,000 or more.requirement for practices once hundreds of patients are enrolled. WhileMedicare reimbursement can easilycover the cost of office personnel doingthe monthly follow-up, many officeswill recognize the benefit of delegatingthis responsibility to an outside vendor.Develop MetricsYou cannot manage a program ifyou cannot measure it. A successfulRPM program has the potential toimprove the health of hundreds ofpatients in each practice and createsan opportunity for most offices toearn 100,000 or more (Table 1). Thephysician overseeing the programshould, on an ongoing basis, track: # Patients enrolled # Patients monitored # Patients dropping out Revenue collected Average time to heal ulceration Average time of re-ulcerationIt would also be valuable to doperiodic surveys to assess patient satisfaction and audits to ensure thatproper billing and documentationpractices are being followed.SummaryRemote patient monitoring is rapidly evolving and stands to become anincreasingly vital part of how podiatrists practice. Opportunities include: Reduction of diabetic footulceration Reduction of overall cost of careOCTOBER 2020 PODIATRY MANAGEMENTachieved by practices planning andstarting in a limited fashion, making adjustments along the way, andslowly and steadily enrolling patients. It would not be unrealistic tostart with a test group as small as5-10 patients to get a good understanding of issues that will be encountered. Once issues are identified and addressed, practices will bemuch better able to streamline protocols, improve patient outcomes andmake more money. PMReferencesPritzger, P, Gallagher P, 65 in theUnited States: 2010, U.S. Department ofCommerce issued 2014, pp 23-2014.2The Triple Aim: Care, Health, andCost. Berwick DM, Nolan TW, Whittington J, Health Aff (Millwood). 2008 MayJun; nationalhealthexpenddata/nhe-fact-sheet4American Diabetes Association, Boulton, Armstrong, D., ‘Diagnosis and Management of Diabetic Foot Complications’,2018.1Josh White, DPM,CPed is VP of OrthoFeetand the founder of SafeStep. He is a member ofthe American PodiatricMedical Association’sDME workgroup and aCodingline Expert Panelist. (Contact info: joshwhitedpm@gmail.com)www.podiatrym.com

OCTOBER 2020 PODIATRY MANAGEMENT www.podiatrym.com 68 MEDICARE AND teChNoLoGy ers and business models to use the technology. CPT code 99453: Patient education and set up "Remote monitoring of physiolog-ic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of .