RPM Playbook Pillar Page

The US healthcare system has often been described as a sick care system vs a healthcare system. The initial scope of Medicare to cover hospitalizations was well-intentioned in helping elderly Americans cover their most expensive healthcare bills, but ultimately led to a system where healthcare doesn’t begin until after we are already sick. Historically, the system has not promoted wellness or disease prevention.

With an average patient visit lasting only 17.4 minutes and an ever-growing administrative burden, it’s difficult for practices like yours to provide proactive care and establish ongoing, trusted relationships with patients. 

Remote patient monitoring (RPM) makes a preventative medicine and stronger provider-patient relationships possible. With RPM, your practice can extend the capacity of your clinical staff for prevention-focused care and get reimbursed for your time.

RPM drives positive clinical outcomes, higher patient engagement, and increased practiced reimbursement. Since November of 2018, CMS has provided reimbursement specific for RPM. The codes have continued to evolve and expand remote care coverage, demonstrating CMS’ ongoing commitment to RPM. This reimbursement has helped fuel the growth of RPM to over 23 million patients. RPM is projected to grow to 30 million patients by 2024.

CMS’ expansion of the codes reflects the clear clinical benefits of proactive, preventive care. If you are considering starting an RPM program or have an RPM program that is not performing at the level you would like, this Playbook will be an invaluable resource. We will walk through each of the necessary stages to launch, relaunch, or improve your RPM program to achieve the clinical and financial outcomes your practice wants. 

The Complete Remote Patient Monitoring Playbook

What you need to know to launch and manage a successful RPM program includes 7 stages:

Stage 1
Understanding Remote Patient Monitoring

Stage 2
Choosing Conditions and Devices for RPM

Stage 3
Preparing to Launch a Successful RPM Program

Stage 4
Identifying and Onboarding Patients

Stage 5
Monitoring Patients

Stage 6
Billing for RPM Services

Stage 7
Managing and Growing Your RPM Program

Stage 1: Understanding Remote Patient Monitoring

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Before jumping into how to launch a remote patient monitoring program, it will helpful to understand some of the basics of RPM. This section covers:

  • What is RPM?
  • How RPM works
  • RPM eligibility requirements
  • Chronic care management (CCM) and how it differs from RPM
  • The growth of RPM
  • Benefits of RPM

What is Remote Patient Monitoring?

Remote patient monitoring, is the collection of Patient-Generated Health Data (PGHD) by a patient or caregiver outside of a traditional clinical setting that is digitally stored and transmitted to a physician, Qualified Healthcare Professional, or clinical staff for review, analysis, care management, and intervention by a Qualified Healthcare Provider (QHCP) or Clinical Staff as appropriate.

What exactly does that all mean? Let’s break down each part of that definition.

Patient-Generated Health Data (PGHD) – Patient or their caregiver uses a device, such as a blood pressure cuff or weight scale, to take their own readings.

Outside of a traditional clinical setting – Readings are taken at a patient’s home or other convenient location (but not at the physician’s office).

Digitally stored and transmitted – Data from the device automatically syncs with software at the physician’s office.

Review, analysis, care management, and intervention – The data is used to monitor the patient for out-of-threshold readings, analyze trends in readings, provide a patient-specific treatment plan, care interventions as needed, and ongoing patient education.

By a Qualified Healthcare Provider or Clinical Staff – Appropriate clinical staff, including nursing staff or medical assistants, are providing care to the patient.

Who is Eligible for Remote Patient Monitoring?

While RPM can be used for patients with chronic or acute conditions, no formal diagnosis is required.  Given the prevalence and cost of chronic conditions, most practices start RPM programs with these patients.  

CMS does have enrollment criteria, including:

  • The patient must consent to participation in the program
  • The devices must be defined as medical devices by the FDA and be ordered by a qualified medical professional
  • Data captured by a device must be wirelessly synced/connected

Data monitoring services must be performed by a physician, a Qualified Healthcare Professional, or clinical staff (including nurses and medical assistants), subject to state law.

What is Chronic Care Management (CCM)?

Chronic care management (CCM), introduced by CMS in 2015, enabled providers to be paid for care that was provided between office visits. CCM CPT® codes cover clinical staff time for establishing, implementing, revising, and monitoring comprehensive care plans for patients with two or more chronic conditions that put the patient at significant risk.

Patients in chronic care management programs are often great candidates for remote patient monitoring. Prevention plans are the heart of a CCM program. Daily vital sign monitoring can help ensure that prevention plan is working. RPM provides unique access to more patient data without putting the burden of manually tracking readings on the patients. RPM and CCM can be a great complement to each other, and patients can participate in both programs.

RPM vs. CCM Requirements

Unlike CCM, RPM does not require a specific diagnosis. CCM requires multiple conditions lasting at least 12 months for eligibility, so many patients that are not eligible for CCM, will still be eligible for RPM. RPM can also be used for acute applications, beyond chronic conditions, such as medication management, behavioral health, and more. CCM and RPM use different CPT® codes, so a practice can bill for both but cannot apply the same minutes of care team time to multiple CPT® codes.

Additional requirements exist for billing each potential CPT® code for remote patient monitoring and are covered in the billing stage of the playbook.

How RPM Works

RPM has 4 primary steps – all of which we will dive into more detail in subsequent stages of the playbook.

  1. Patient Onboarding: Key steps in the patient onboarding process include identifying an RPM-eligible patient, securing an order for RPM from the provider, collecting patient consent (written or verbal), and completing a patient onboarding appointment for device setup and education.
  2. Transmission and Collection of Physiological Data: Once the patient is educated on how to use their RPM-enabled device, it is their responsibility to take regular readings at home, which will be automatically transmitted to the provider. An important RPM distinction is that the monitoring is done at the patient’s home or long-term care facility. It is not the same as inpatient monitoring which is done in a hospital by clinical staff.

Ongoing Monitoring and Engagement: Clinical staff establish clinical goals, treatment plans, and escalation policies to improve patient conditions. They serve as health coaches and advocates, engaging with patients and developing trusted relationships.
Billing and Reimbursement: RPM requires dedicated clinical and support staff time (from your own staff or your RPM partner). CMS will reimburse clinics for their time and investment.  

What is Fueling the Growth in RPM?

Remote patient monitoring is expected to grow at an average annual rate of 23 percent to hit $85 billion in the United States by the end of 2026. The increasing age of the population as well as the prevalence of chronic diseases is driving healthcare expenditures and the need for more preventative measures to reduce costs.

More than 40 percent of Americans – 133 million – have a chronic condition and 81 million Americans have more than one chronic condition. 90 percent of the $3.8 trillion spent on healthcare in the U.S., or 17.7 percent of the total US economy, is for chronic and mental health conditions. This is creating a healthcare spending crisis in the United States, where on average, the US spends twice as much as other wealthy nations on healthcare.

With those statistics, it’s no surprise that CMS is shifting towards value-based care and preventative medicine. The New England Journal of Medicine defined the benefits of value-based care for each stakeholder in the healthcare landscape:

The shift to value-based care means looking holistically at the resources available and the best ways to deliver care that improves outcomes while lowering costs. In other words, reserving the most expensive resources – acute care hospital stays – for only the patients and procedures that absolutely require it and using less expensive resources, like home-based care, when possible.

Clinical studies have demonstrated that remote patient monitoring does reduce acute care use and hospitalizations. At-home, daily monitoring with connected devices provides continuous care, enabling providers to collect and analyze patient data between visits.

In addition, RPM is growing because patients see the benefits as well.

60 percent of people now report being very interested in remote care.
68 percent of physicians are using or plan to use remote patient monitoring.
25 percent of people report that they are willing to switch providers to access more remote care services.  

With technology breaking down barriers to remote care, we expect CMS will continue to expand reimbursement strategies that align with incentives for better outcomes at lower costs. And while many of these programs are voluntary now, practices should be prepared for potential mandatory value-based care programs in the future.

Benefits of Remote Patient Monitoring

RPM provides unique visibility into a patient’s health between office visits, enabling your care team to intervene when it matters most – before an adverse event outcome. This drives both clinical and financial benefits for your practice and your patients.

Clinical Benefits

Clinical studies demonstrate remote patient monitoring reduces hospital admissions, emergency room visits, and mortality rates. Research also shows that patients in RPM programs can significantly improve the physiological parameters that they are measuring, such as blood pressure or A1C.

RPM helps healthcare providers gain a greater understanding of their patients’ health outside of their routine appointments. With the ability to collect data over time, chronic conditions can be treated in the broader context of a person’s lifestyle, leading to more impactful education opportunities and interventions.

For more detailed information on clinical benefits by condition, see the Conditions section in Stage 2 of the playbook.

Patient Benefits

RPM programs empower your patients to take an active role in improving their health by literally putting measurement tools in their hands. Your monitoring staff serve as their coaches and educators, building rapport and trust with patients that strengthens the patient-provider relationship.

Many of your patients with chronic conditions only visit your office when their health starts to deteriorate or they have a routine office visit scheduled. With RPM, your patients can be checked on by clinical staff every day. With a proactive care plan that makes the right adjustments to medications and treatment based on daily feedback, RPM can prevent possible deterioration in health between office visits.

Many of your patients are already used to taking readings, such as blood pressure or blood sugar, at home. However, your patients are often writing down their readings with paper and pencil and not sharing the data with your office. Your patients are essentially on their own for figuring out how to interpret and act upon that information. RPM can not only reduce the burden of using paper and pencil with automatic transmissions, it also allows clinically-trained experts to be involved in the daily assessment of your patients’ data.

Financial Benefits

CMS has demonstrated a willingness to reimburse practices for time invested in RPM because RPM has been proven effective in lowering overall healthcare costs.

RPM will not replace your in-office revenue as it provides supplemental care between  visits. You can bill for RPM services in conjunction with CCM, where applicable.

While reimbursement varies by location, your practice can be reimbursed up to an average of $122 – 174* per patient per month depending on which CPT ® codes each of your patients are eligible for every month.  

In addition to Medicare patients, commercial and Medicaid reimbursement for RPM is also increasing.  As of 2022, 34 state Medicaid programs cover RPM. While commercial coverage for RPM still varies by plan, eligibility verification services can help you quickly identify which of your patients have RPM coverage.

For more detailed information on financial benefits, see the Billing for RPM stage of the playbook.

* Please note all information taken directly from the CMS CPT© Guidebook, Professional Edition 2022. Optimize Health does not interpret or define the CMS RPM codes. Refer to your billing specialist or MAC office for guidance – Local Reimbursements can be located at CMS.gov’s Physician Fee Schedule.