Does your cutting-edge mHealth app make the cut for ICD-10-CM?

The market for home health providers received a boost in early July when Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma spoke about promoting reimbursement for remote patient monitoring, one of many telehealth services aimed to improve patient access and care.

In a July 2 statement, Verma said a proposal to pay for increased use of remote patient monitoring would “allow home health agency payment to reflect their use of innovative technology” and remove “incentives to provide unnecessary care” in the shift from volume to value.

The fact that government payers are encouraging increased use of mobile health (mHealth) and related digital patient health technologies should only accelerate the growth of the medical device industry, which topped $180 billion in revenue in the United States alone in 2017.

But as startups and other device makers look to capitalize on a healthcare landscape that’s hungry for solutions to address the “silver tsunami” and a crunch on primary care providers, there are still some basics that any cutting-edge innovation needs to get right.

Documentation

For starters, all services provided must be documented properly in the medical record and must be medically necessary. Medical necessity is conveyed by the diagnosis (ICD-10-CM) code and must be backed up by the documentation. An mHealth or remote patient monitoring device should be easily integrated with a practice’s EHR.

Just because the service is properly documented and coded, however, doesn’t mean it will be paid. Reimbursement rules vary by payer, so be sure to know if and how your commercial insurers will pay for this service.

Many consumer-centered health apps and wearable devices focus on a few key measures, such as pulse rate. Generally speaking, vital signs are one of the elements of an exam and will not be paid separately.

For CMS purposes, vital signs must include three of the following seven:

1. Sitting or standing blood pressure
2. Supine blood pressure
3. Pulse rate and regularity
4. Respiration
5. Temperature
6. Height
7. Weight

Proper coding

Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) is reported with code 99091 when the data is stored or transmitted by the patient or caregiver to the provider. Time required is a minimum of 30 minutes.

Fifty professional societies and healthcare providers recently banded together and requested that CMS reimburse three new remote monitoring codes:

• 990X0: 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
• 990X1: Device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days
• 994X9: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month

Telephone services and online medical evaluation (non-face-to-face services) codes are 99441 to 99444, while the codes for these services performed by a nonphysician provider are 98966 to 98969. However, the coding guidelines for the above codes are extensive, so apps or devices that will ultimately be used in services billable by these codes would do well to incorporate checkboxes for use by the provider or coder on the receiving end.

There are a few codes available for billing vital signs as stand-alone procedures:

• 93799 (Unlisted cardiovascular service or procedure)
• 94799 (Unlisted pulmonary service or procedure)
• 99199 (Unlisted special service, procedure or report)

Unlisted services are often not paid, but if they become part of the generally accepted landscape — usually via medical record documentation submitted with the claim — they can be paid as stand-alone services.

HCPCS codes, which are usually for supplies or equipment but can also be used for services in certain instances, may also apply. There are also some HCPCS G codes that may apply in quality-based payment situations, but they are likely too complex to be integrated into a first-generation device or app that still must achieve accurate readings and basic interoperability to become widely used and received by providers.

While so much of the mHealth and wearable device and app market has been driven by consumers’ embrace of popular Apple and Fitbit products, the next stage in its evolution will be properly integrating with the electronic records systems of the nation’s healthcare providers. Making sure practices get paid for embracing innovative patient care technologies will likely set certain developers apart from the pack.