Remote Patient Monitoring: COVID-19 Applications and Policy Challenges

Updated to reflect changes issued by CMS in the “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency” interim final rule.

Remote patient monitoring (RPM) offers tools for disease monitoring and patient-provider communications that reduce infection risks for patients, communities and providers. RPM can be an especially safe and useful method of care as our healthcare system works to combat COVID-19.

What is Remote Patient Monitoring?

Remote patient monitoring allows health providers to monitor disease and symptom progression remotely and then engage with patients virtually to modify care plans and to provide education on self-care, based on changes in the patient’s condition.

This connected care technology is uniquely helpful for treatment and care during a pandemic such as COVID-19 since it allows clinicians to monitor temperature and pulmonary function, blood pressure and other appropriate physiology for changes in a patient’s disease and symptom progression, using digitally connected, non-invasive devices (e.g. sensors for body temperature or thermometers, pulse-oximeters and home blood pressure monitors).

Clinicians and clinical staff can communicate modifications in medication and other self-care to the patient and provide answers to patient questions. If symptoms and the disease progress to the point that hospital services are needed, providers will be able to arrange for care and transport that will ensure safety of the patient and health personnel.

Why is Remote Patient Monitoring Necessary?

For patients who test positive for COVID-19, home-based monitoring for symptom escalation can help reduce the risk of transmission and can target the provision of hospital-based care on a timely basis, should the need arise. As we face a growing hospital bed shortage, allowing for this type of remote monitoring can free up valuable and critical hospital resources to treat the most critical cases.

Current Centers for Disease Control and Prevention (CDC) guidance says most patients with a positive COVID-19 diagnosis can recover at home, but they should monitor themselves for difficulty breathing. In addition to the qualitative “emergency warning signs,” periodic monitoring of SpO₂ via pulse-oximetry can provide a quantitative checkpoint to ease patient anxiety over the progression of their disease.

Clinical guidance from the World Health Organization (WHO) indicates the onset of severe pneumonia in adolescents or adults when the SpO₂ is less than or equal to 93 percent. Patients able to monitor their SpO₂ at home can better watch for that approaching target, rather than trying to decide what “difficulty breathing” entails. Physicians monitoring these numbers remotely can arrange for inpatient care if necessary without asking an infected patient to triage through crowded public spaces based on the physiologic readings.

How is Remote Patient Monitoring Conducted?

Remote monitoring is ordered by a patient’s clinician. The order can generate a home delivery and set up of equipment, or equipment may be provided to a patient at an in-person visit, along with instructions on set up. The clinician conducts a short, remote course on how to use the equipment and communications. The clinician and clinical staff then monitor the physiologic data, are pinged with alerts when there are concerning changes in the physiologic data and conduct communications with the patient based on care need changes.

Demand for RPM equipment is leading to supply shortages, at least through traditional, consumer sources, but many companies stand ready to provide turn-key service to clinicians, including equipment management, home delivery and a monitoring application. Some electronic health record vendors include such integrations within their software packages. To address these shortages, the FDA, on March 20, issued updated guidance that allows for quicker entry into the market for digital remote monitoring equipment. While this should help consumers looking to build their own RPM kits, most companies offering full-service RPM solutions should have sufficient stock available to help clinics looking to start RPM programs today.

What does the government need to do to ensure patients can receive this service and mitigate potential device shortages?

Clinicians are rapidly adopting and using RPM for COVID-19 in the United States and around the world, particularly as many payers are encouraging use of any connected care as a substitute for in-person care.

Before the COVID-19 public health emergency, Medicare coverage of RPM services was limited to patients with one or more chronic conditions. However, as patients were being encouraged (and in some places ordered) to stay at home, the need for RPM to treat patients with acute, time-limited conditions became all the more critical.

In response to pressure from Congress and calls from HIMSS and other groups to utilize RPM to treat these patients, CMS issued specific guidance around RPM as part of their “Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency” interim final rule with comment period.

In the rule, CMS made a number of changes to how they cover RPM, both for the duration of the public health emergency as well as permanent fixes. Specifically, CMS clarified that going forward, RPM could be used for patients with both acute and/or chronic conditions, not just limited to patients with only chronic conditions.

Additionally, for the duration of the COVID-19 pandemic, CMS has clarified that RPM could be provided to new patients as well as established patients, and that consent could be obtained once annually. These changes by CMS to how providers can utilize RPM will have profound benefits going forward, both in our immediate response to the unique COVID-19 challenges as well Medicare’s long-term ability to provide the best care to patients.

CPT codes exist for all components necessary for the provision of RPM , they include:

CPT Code 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. (Initial set-up and patient education of monitoring equipment)

CPT Code 99454: Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. (Initial collection, transmission, and report/summary services to the clinician managing the patient)

CPT Code 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

CPT Code 99458: Each additional 20 minutes (List separately in addition to code for primary procedure)

CPT Code 99091: Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/ regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days.

As we continue the global response to the COVID-19 crisis, we are witnessing all sectors of our healthcare system come together in extraordinary and innovative ways to deal with this unique challenge. Remote patient monitoring is a critical tool in the healthcare arsenal. It will serve as a complement to telehealth and other tools, giving healthcare professionals across the country access to all the information they need to make the best-informed decisions to treat their patients.

Originally published March 30, 2020.