As COVID-19 presented an immediate need for novel therapies and treatments to combat the disease, diagnosing the virus and managing patient symptoms from afar drove the adoption of telemedicine, telehealth, and remote patient monitoring devices. Likewise, the halt of elective surgeries forced physicians to adapt and remotely manage patients’ symptoms as well until hospitals reopened operating rooms and surgery centers for non-virus-related surgeries. Broadly speaking, the digital health landscape encompasses many tools physicians were forced to adopt and are now further considering adopting to more effectively manage patients remotely. These tools include:

• Software as a medical device (SaMD), including mobile medical apps, artificial intelligence, and machine learning algorithms
• Wireless medical devices (RFID technology and medical telemetry)
• Clinical decision support software, including device software and non-device software
• Medical device data systems, including health analytics and insights
• Telemedicine and telehealth, including video conferencing, streaming media, and mobile health (mHealth) communication

This column focuses on telehealth, telemedicine, and remote patient monitoring devices. Telehealth refers to electronic and telecommunications technologies and services used to provide care and services at a distance. Telehealth can refer to remote non-clinical services such as health education or even e-prescription services. Telemedicine refers specifically to remote clinical services, where the provider is delivering patient care through remote technology. This includes remote diagnosis and treatment by means of telecommunications technology, including but not limited to videoconferencing for clinical consultations, transmission of photographs and imaging for remote review, diagnosis and Rx, and remote monitoring of symptoms, vital signs, and broader health conditions through mHealth devices (e.g., smart watches and smartphones). In short, telemedicine refers specifically to remote clinical services, while telehealth can refer to remote non-clinical services.

Three new areas that will be tracked given the increased interest and adoption of digital health technologies include telenursing, telepharmacy, and telerehabilitation. Telenursing refers to utilization of communicative technology to provide remote nursing services. Consultations can be arranged by phone to reach a diagnosis and monitor health conditions and symptoms. This is growing in favor due to the low cost and high accessibility of the services to patients, particularly for those in rural regions. It also has the potential to reduce hospitalizations because it is possible to address minor ailments earlier. Telepharmacy allows for providing pharmaceutical advice to patients when direct contact with a pharmacist is not possible. This allows for medications to be monitored and pharmaceutical management advice to be offered over the phone. Depending on regulations, refill authorization may be given to allow patients to receive regular medications when required. Telerehabilitation utilizes technology to communicate and perform clinical assessments and therapy for rehabilitation patients. This usually has a strong visual element with video conferences and webcams commonly used to assist in communicating symptoms and clinical progress. All three of these areas are growing in popularity in response to the COVID-19 pandemic. Providers and patients have had to become very creative in providing secure platforms for interaction, monitoring, and results tracking.

According to the American Telemedicine Association (ATA), the “telemedicine tipping point is here, and laws have changed to make it easier to access. The market is expected to grow at a 16.8 percent compound annual growth rate from 2017 to 2023.” Research conducted by Accenture in conjunction with the ATA shows that more than 50 percent of healthcare services will be consumed virtually by 2030, and 50 percent to 75 percent of those polled said they were willing to have digital/virtual interactions. An area that will further drive utilization of telemedicine, telehealth, and remote patient monitoring services is the payment for these services.

In 2018, the American Medical Association (AMA) created a Digital Medicine Payment Advisory Workgroup, comprised of a diverse cross-section of leading experts charged with identifying barriers to digital medicine adoption and proposing solutions for coding, payment, and coverage while also identifying clinical validation literature and evidence. The Centers for Medicare & Medicaid Services (CMS) and the AMA had started to implement policy to pay for telemedicine and digital health; however, the pandemic forced careful analysis of these policies and, at times, re-engineering of these policies in order to adequately encourage adoption of this method of care delivery this year by providers. The policies will continue to develop in favor of digital and telemedicine, opening opportunities for medical innovators and for providers looking to offer care through different communication methods and different channels.

Before COVID-19, for Medicare to cover telehealth, patients had to: 1) live in a rural area or HPSA (Healthcare Professional Shortage Area), 2) be an established patient and 3) have had one traditional face-to-face evaluation and management visit with the provider in the last three years. Codes that described the delivery of care through telehealth, telemedicine, and/or remote patient monitoring devices had been developed and released in 2019; however, payment was far less than the amount assigned to traditional E&M codes used to capture services rendered within office or hospital-based settings.

To expand access to these services, CMS lifted Medicare restrictions on the use of telehealth and telemedicine services during the COVID-19 emergency. Effective March 6 and throughout the national public health emergency, Medicare began paying physicians for telehealth and telemedicine services at the same rate as in-person visits for all diagnoses, not just services related to COVID-19. Patients were allowed to receive telehealth and telemedicine services in all areas of the country and in all settings, including at their home. CMS lifted the requirement that patients have an established relationship with the telehealth and/or telemedicine provider. Physicians licensed in one state can provide services to Medicare beneficiaries in another state. Although state licensure laws still apply, the lifting of geographic boundaries allowed for provider-patient communication to be performed across state lines and enabled physicians to continue to practice through these communication methods from their homes. HHS Office for Civil Rights (OCR) also offered flexibility for telehealth through popular video chat applications such as FaceTime or Skype during the pandemic. The device must be audio or visual and provide real-time communication abilities; this flexibility was key to fostering communication between providers and patients during the lockdown.

Table 1 details the most recent and pertinent telehealth and telemedicine codes currently available.

Table 1: CY 2020 Medicare Telehealth and Telemedicine Services
G0406	Inpt/tele follow up 15
G0407	Inpt/tele follow up 25
G0408	Inpt/tele follow up 35
G0425	Inpt/ed teleconsult30
G0426	Inpt/ed teleconsult50
G0427	Inpt/ed teleconsult70
G0459	Telehealth inpt pharm mgmt.
G0508	Crit care telehea consult 60
G0509	Crit care telehea consult 50
G0459	Inpatient telehealth pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy
G2010	Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment
G2012	Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related e/m service provided within the previous 7 days nor leading to an e/m service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion

Remote patient monitoring (RPM) codes were also being encouraged during the lockdown and still are. CMS’s 2018 and 2019 Final Rule approved and expanded coding options for RPM. In 2018, Medicare began coverage and payment for the first RPM code, CPT CODE 99091.

In 2019, Medicare began coverage and payment for additional chronic care remote physiologic monitoring codes. These codes are still applicable (detailed in Table 2).

Table 2: CY 2019 & 2020 MEDICARE Remote Patient Monitoring Services
99453	Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment
99454	Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
99457	Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; first 20 minutes

Prior to 2019, only physicians were allowed to practice, interpret, and monitor results through remote patient monitoring. But last year, “incident to billing” was approved and permits nurses and licensed care managers to bill incident to and manage patients through RPM devices and applications, freeing up physician time to focus on acute, immediate patient needs.

One of the positives to emerge from the COVID-19 pandemic is the seamless adoption of digital health tools, which has subsequently expanded the overall market. The largest market barrier has been eliminated and is further confirmed through a commitment by CMS to continue to expand telehealth service policy and address payment variances. The ease of use and integration of devices and platforms will be important and will continue to evolve the way care is delivered long after the virus has been defeated. 

---

Lauren Craig has more than 15 years of reimbursement experience, holding positions at Teva, Hologic, Shire Regenerative Medicine, Boston Scientific, and most recently, Intersect ENT. Her experience spans payer and policy analysis with coverage pull-through, internal and external reimbursement education, and high-performance sales with medical device products. She drives and creates market access opportunities for PMA-approved and FDA 510k-cleared treatments and devices and is a certified coder through the AAPC.