Telehealth: Remote Patient Monitoring Services

POLICY NUMBER

L.2.04.439

DESCRIPTION

“Telehealth” is the overarching umbrella of real-time clinical healthcare diagnosis, consultation and treatment provided through interactive electronic and telecommunication technologies. Telehealth encompasses Store-and-Forward Telemedicine and Remote Patient Monitoring.

Remote Patient Monitoring Services

Remote patient monitoring is the delivery of services using telecommunications technology to enhance the delivery of medically necessary services provided in the home, including: 

1. Monitoring of a) clinical patient data such as weight, blood pressure, pulse, pulse oximetry and other condition-specific data, such as blood glucose; and/or, b) Medication adherence; and,

2. Interactive video conferencing with or without digital image upload as needed.

Remote patient monitoring aims to allow more people to remain at home or in other residential settings while improving the quality and cost of their care, including prevention of more costly care. Remote Patient Monitoring services via telehealth aim to coordinate primary, acute, behavioral and long-term social service needs for high-need, high-cost patients. Specific patient criteria must be met for reimbursement to occur. 

Medication adherence management services is the monitoring of a patient's conformance with the clinician's medication plan with respect to timing, dosing and frequency of medication-taking through electronic transmission of data in a home telemonitoring program.

Related medical policy -

• Telehealth: Store-and-Forward Telemedicine Services

• Ambulatory Event Monitors and Mobile Cardiac Outpatient Telemetry

• Automated Ambulatory Blood Pressure Monitoring for the Diagnosis of Hypertension in Patients with Elevated Office Blood Pressure

• Continuous or Intermittent Monitoring of Glucose in Interstitial Fluid

POLICY

Coverage Requirements for Remote Patient Monitoring Services 

All Remote Patient Monitoring Services must be prior authorized and are subject to the Care Management provisions of the member’s Benefit Plan. Remote Patient Monitoring Services will only be prior authorized for coverage if the following criteria are met: 

1. Must be ordered by a Physician; and, 

2. Must be performed by a Mississippi-licensed Provider affiliated with a Mississippi health care facility. 

3. Services must be provided using HIPAA-compliant equipment and protocols necessary for delivery of Remote Patient Monitoring services via Telemedicine; and,

4. Must meet all requirements in the “Prior Authorization Requirements for Remote Patient Monitoring Services” section below; and,

5. Must meet all requirements in the “Provider Requirements and Delivery of Remote Patient Monitoring Services” section below.

Episode of Care for Remote Patient Monitoring Services  

1. An initial episode of remote patient monitoring will be allowed for up to 31 days if all coverage criteria is met.

2. Coverage of additional monitoring beyond 31 days will only be allowed if an updated plan of care signed and dated by the prescribing physician and documentation to support that the medical data from the previous 31-day episode was used in the management of the patient’s care is submitted for re-authorization.

3. Coverage of Remote Patient Monitoring will not be provided beyond a six-month period.

4. Services will no longer be considered medically necessary if the patient is hospitalized or is receiving duplicative services while under a Remote Patient Monitoring plan of care.

Prior Authorization Requirements for Remote Patient Monitoring Services

A.   Request Initial for Remote Patient Monitoring

An initial remote patient monitoring prior authorization request must be submitted and must include ALL of the following: 

1. An order for Remote Patient Monitoring services, signed and dated by the prescribing Physician; and,

2. A plan of care, signed and dated by the prescribing Physician, that includes ALL of the following: 

   • Specific clinical patient data to be monitored, which includes but is not limited to weight, blood pressure, pulse, respirations, blood glucose, and pulse oximetry

   • Acceptable and unacceptable clinical parameters for the patient

   • Telemonitoring transmission frequency (a minimum of five (5) monitoring encounters per week is required for services to be considered medically necessary)

   • How the monitoring provider is to report and respond to abnormal parameters

   • Ordered medication regimen/plan if medication adherence management services are ordered

   • The medication adherence monitoring method to be used for timing, dosing, and frequency of medication/plan if medication adherence management services are ordered

   • Schedule of reporting data to the prescribing physician, even when there have been no readings outside established parameters

   • Duration of monitoring requested; and,

3. The patient's diagnosis and risk factors that qualify the patient for Remote Patient Monitoring services supported by records that document that the patient was diagnosed in the last 18 months with one or more of the chronic conditions, as defined by the Centers for Medicare and Medicaid Services, to include (anemia, acute myocardial infarction, asthma, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease and bronchiectasis, depression, diabetes, heart failure, hypertension, ischemic heart disease, stroke/transient and ischemic attack); and,

4. The Physician recommends disease management services via remote patient monitoring; and,

5. Records to support a documented history of poor adherence to ordered medication regimen if medication adherence management services are ordered; and,

6. Attestation that the patient is sufficiently cognitively intact and able to operate the equipment or has a willing and able person to assist in completing electronic transmission of data; and,

7. Attestation that the patient is not receiving duplicative services via disease management services.

B.   Request for Continued Remote Patient Monitoring

A continued remote patient monitoring prior authorization request must be submitted and must include ALL of the following:

1. An order for home telemonitoring services, signed and dated by the prescribing Physician; and, 

2. A plan of care, signed and dated by the prescribing Physician, that includes ALL of the following:

   • Specific clinical patient data to be monitored, which includes but is not limited to weight, blood pressure, pulse, respirations, blood glucose, and pulse oximetry

   • Acceptable and unacceptable clinical parameters for the patient

   • Telemonitoring transmission frequency (a minimum of five (5) monitoring encounters per week is required for services to be considered medically necessary)

   • How the monitoring provider is to report and respond to abnormal parameters

   • Ordered medication regimen when medication adherence management services are ordered

   • The medication adherence monitoring method to be used for timing, dosing, and frequency of medication if medication adherence management services are ordered

   • Schedule of reporting data to the prescribing physician, even when there have been no readings outside established parameters

   • Duration of monitoring requested; and,

3. The clinical patient data transmissions from the previous episode of monitoring services; and,

4. Monitoring provider reports and interventions from the previous episode of monitoring services; and, 

5. The Physician recommends disease management services via remote patient monitoring; and,

6. Attestation that the patient is sufficiently cognitively intact and able to operate the equipment or has a willing and able person to assist in completing electronic transmission of data; and,

7. Attestation that the patient is not receiving duplicative services via Disease Management services or other healthcare means.

Provider Requirements and Delivery of Remote Patient Monitoring Services

Providers rendering remote patient monitoring services must meet ALL of the following care and management protocols: 

1. An assessment, problem identification, and evaluation that includes: 

2. 1. Assessment and monitoring of clinical data including, but not limited to, appropriate vital signs, pain levels and other biometric measures specified in the plan of care, and also includes assessment of response to previous changes in the plan of care; and,

   2. Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care; and

3. Implementation of a management plan through one or more of the following: 

   1. Teaching regarding medication management as appropriate based on the telemedicine findings for that encounter;

   2. Teaching regarding other interventions as appropriate to both the patient and the caregiver;

   3. Management and evaluation of the plan of care including changes in visit frequency or addition of other skilled services;

   4. Coordination of care with the ordering physician regarding telemedicine findings;

   5. Coordination and referral to other medical providers as needed; and,

   6. Referral for an in-person visit or the emergency room as needed; and,

4. Have protocols in place to address all of the following:

   1. Authentication and authorization of users;

   2. A mechanism for monitoring, tracking and responding to changes in a patient's clinical condition;

   3. A standard of acceptable and unacceptable parameters for patient's clinical parameters, which can be adjusted based on the patient's condition;

   4. How monitoring staff will respond to abnormal parameters for patient's vital signs, symptoms and/or lab results;

   5. The monitoring, tracking and responding to changes in patient's clinical condition;

   6. The process for notifying the prescribing the Physician for significant changes in the patient's clinical signs and symptoms;

   7. The prevention of unauthorized access to the system or information;

   8. System security, including the integrity of information that is collected, program integrity and system integrity;

   9. Information storage, maintenance and transmission;

   10. Synchronization and verification of patient profile data; and,

   11. Notification of the patient's discharge from remote patient monitoring services or the de-installation of the remote patient monitoring unit; and,

5. Equipment must meet ALL of the following criteria:

   1. Comply with applicable standards of the United States Food and Drug Administration and the Health Insurance Portability and Accountability Act (HIPAA);

   2. Telehealth equipment be maintained in good repair and free from safety hazards;

   3. Telehealth equipment be new or sanitized before installation in the patient's home setting;

   4. Accommodate non-English language options;

   5. Have 24/7 technical and clinical support services available for the patient user;

   6. Be capable of monitoring any data parameters in the plan of care; and,

   7. Be, at least, an FDA Class II hospital-grade medical device.

POLICY EXCEPTIONS

Federal Employee Program (FEP) Members

BlueCard Host Members: Coverage of Telemedicine Services is subject to the Member’s individual Blue Cross and/or Blue Shield benefit plan.

POLICY GUIDELINES

Refer to the Blue Cross & Blue Shield of Mississippi Telehealth Coding Policy .

The coverage guidelines outlined in the Medical Policy should not be used in lieu of the Member's specific benefit plan language.

Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Member's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:

1. Consistent with the symptoms or diagnosis and treatment of the Member's condition, illness, or injury; and

2. Appropriate with regard to standards of good medical practice; and

3. Not solely for the convenience of the Member, his or her Provider; and

4. The most appropriate supply or level of care which can safely be provided to Member. When applied to the care of an Inpatient, it further means that services for the Member's medical symptoms or conditions require that the services cannot be safely provided to the Member as an Outpatient.

For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.

POLICY HISTORY

12/28/2017: New policy added.

05/17/2018: Medical and coding policy links updated.

09/21/2018: Code Reference section updated to add new ICD-10 diagnosis code I63.89, effective 10/01/2018.

12/21/2018: Code Reference section updated to add CPT codes 99091, 99453, 99454, 99457 and HCPCS codes G0071, G2010, and G2012, effective 01/01/2019.

09/18/2019: Code Reference section updated to add new ICD-10 diagnosis codes D75.A, I48.11, I48.19, I48.20, and I48.21, effective 10/01/2019.

12/19/2019: Code Reference section updated to add new CPT code 99458. Revised code description for CPT code 99457. Effective 01/01/2020.

09/24/2020: Code Reference section updated to add new ICD-10 diagnosis codes D59.10, D59.11, D59.12, D59.13, and D59.19, effective 10/01/2020.

06/01/2021: Policy statement revised to remove the requirement of documentation to support that the patient has a recent history of costly service use due to one or more of the chronic conditions (anemia, acute myocardial infarction, asthma, atrial fibrillation, chronic kidney disease, chronic obstructive pulmonary disease and bronchiectasis, depression, diabetes, heart failure, hypertension, ischemic heart disease, stroke/transient and ischemic attack), as evidenced by two (2) or more hospitalizations, including emergency room visits, in the last twelve (12) months. Minor wording change of "medication regimen/plan."

06/18/2021: Code Reference section updated to add new CPT code 0650T, effective 07/01/2021. Removed deleted ICD-10 diagnosis codes I48.1 and I48.2.

12/16/2021: Code Reference section updated to add new CPT codes 98975, 98976, 98977, 98980, 98981, effective 01/01/2022.

07/01/2022: Policy description updated regarding telehealth and related medical policies. Policy statements revised to update terminology: "Blue Cross & Blue Shield of Mississippi Network Blue Primary Care Provider" changed to "Physician." Revised policy statements to state that the services must be performed by a Mississippi-licensed Provider affiliated with a Mississippi health care facility and that they must be provided using HIPAA-compliant equipment. Policy Exceptions updated to remove State Health Plan (State and School Employees) Members.

12/21/2022: Code Reference section updated to revise the description for CPT codes 98975, 98976, and 98977, effective 01/01/2023.

08/07/2023: Policy reviewed; no changes.

09/29/2023: Code Reference section updated to add new ICD-10 diagnosis codes I24.81, I24.89, and I25.85, effective 10/01/2023.

08/28/2024: Policy reviewed; no changes.

12/20/2024: Code Reference section updated to revise descriptions for CPT codes 98975, 98976, and 98977 effective 01/01/2025.

SOURCE(S)

1. Miss. Code Ann. §83-9-353

2. Centers for Medicare & Medicaid Services Medicare Learning Network Telehealth Services Fact sheet

3. The American Telemedicine Association, Core Standards for Telemedicine Operations

4. The American Telemedicine Association, Remote Patient Monitoring and Home Video Visits

CODE REFERENCE

This may not be a comprehensive list of procedure codes applicable to this policy.

The code(s) listed below are ONLY medically necessary if the procedure is performed according to the "Policy" section of this document.

Medically Necessary Diagnosis Codes

Medically Necessary Procedure Codes

Not Medically Necessary Codes   

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