Remote Patient Monitoring as a Foundation for Effective Chronic Care Management

Effective management of chronic conditions is undoubtedly one of the most time-intensive tasks on any physician’s caseload. Over the last several years, Medicare and many commercial payers have expanded reimbursement options for the growing patient population that desperately needs chronic care management (CCM) interventions.

In this article, the Medek team describes how remote patient monitoring (RPM) is being utilized as a treatment intervention for multiple chronic diseases. In addition to improving clinical outcomes and patient engagement, RPM allows medical practices to maximize revenue while still sustaining manageable patient caseloads.

A Description and Brief History of Remote Patient Monitoring

Also called remote physiologic monitoring, RPM is a telehealth intervention in which patients, family members, or other caregivers take biometric measurements in the home setting. Data is transmitted electronically through HIPAA-secured connections that are then analyzed by the patient’s physician, nurse, or other designated healthcare provider. Devices include weight scales, blood pressure cuffs, glucose meters, and oximeters.

The evidence base supporting the use of home monitoring devices has been solid for almost three decades. Case in point is a systematic review that analyzed 65 empirical studies between 1990 and 2006. The researchers from that review emphasized the following:

“Dramatic increases in the numbers of chronically ill patients in the face of shrinking provider numbers and significant cost pressures mean that a fundamental change is required in the process of care.”¹(p. 270)

The clinical benefits of RPM became more apparent during the COVID-19 pandemic, when healthcare providers had no choice but to deliver patient care from a distance. The declaration of this public health emergency (PHE) led to the expansion of fee-for-service reimbursements for RPM by Medicare and multiple commercial payers.^2,3

The result? Patients were able to remain safe at home while medical practices maintained, or increased, financial solvency.⁴

ADDITIONAL RESOURCE: How the 2023 CMS Fee Schedule Could Affect Remote Patient Monitoring in Your Practice

How do Patients Qualify for Chronic Care Management (CCM) Services?⁵

In order for CCM to be reimbursed under Medicare, patients must be diagnosed with at least 2 chronic conditions that:

⇒are expected to last at least 1 year or until death, and

⇒place the patient at significant risk of death, acute decompensation, or functional decline.

CCM communications are typically not face-to-face and outside of the regular office visit.

How Does RPM Harmonize with Chronic Care Management?

Because Medicare CCM allows doctors to capture and document non-face-to-face events of care and actually be paid for it,⁶ remote patient monitoring becomes an indispensable support mechanism that provides specific insight on patient status between office visits, such as: ^7,8

1. Deterioration and improvement of patient status.
2. Detection of exacerbations.
3. Need for medication adjustments.
4. Potential need for in-office visit, urgent/emergency care, hospitalization.

Not only is RPM billable under Medicare CPT® codes, it can reduce massive expenses that overwhelmed the US healthcare system by supporting high-quality preventive care.

ADDITIONAL RESOURCES: RPM for Chronic Conditions

RPM Revenue Calculator

Connectivity and Simplicity

Particularly when transitioning between the hospital and the home setting, patients and their caregivers need to feel like they are not alone. Indeed, the non-face-to-face interaction that your patients receive from you and your clinical team in the comfort of familiar surroundings is invaluable.⁹

RPM devices are among the simplest telemedicine tools for patients to use. Therefore, they become the ideal treatment intervention for those who must deal with the complexities of chronic disease. What makes it extremely convenient for patients is that, as soon as they step on the scale, measure blood sugars, take their blood pressure, etc., the data is automatically collected. This drastically reduces the error-rate of all measurements.

A Key to Self-Management of Chronic Conditions

As healthcare practitioners, we’ve all been frustrated with helping certain patients to manage their chronic conditions. We know that increasing patients’  knowledge and engagement is critical in  keeping exacerbations, hospitalizations, and further disability at bay. Participation in RPM helps improve the potential for positive outcomes in the following ways:¹⁰

• Understanding the importance of adhering to the care plan.
• Comprehension of their condition over time.
• Improving self-confidence.
• Knowing when their situation may warrant a call to the doctor or an ER visit.

ADDITIONAL RESOURCE: Chronic Care Management Gets Better Outcomes with Remote Patient Monitoring.

Coordination Across Providers

When patient biometrics are collected through remote patient monitoring, all applicable practitioners in your medical practice can access the data by way of a HIPAA-secured portal. Furthermore, data is easily accessed on a 24/7/365 basis. This lays a strong foundation for the group collaborations necessary for well-coordinated chronic care management. Instead of being the sole provider to patients, the physician becomes a team leader, which is the recommendation of public health experts when managing and preventing chronic disease.¹¹

What Medek RPM Offers Your Medical Practice

Medek RPM is a premier provider of remote patient monitoring as well as chronic care management (CCM) programming. Our core features include the following

1. Comprehensive onboarding processes.
2. Precision data collection.
3. Extensive support in patient compliance.
4. Expedient insurance billing.

Medek’s patient care team is second to none in ensuring that patients are completely knowledgeable of the RPM process. The patients aren’t bogged down with the struggles of device set-up or connecting to Wi-Fi. This means that your medical practice isn’t bogged down either. It gives you the time to provide high-quality patient care with maximum financial solvency.

Do you have questions about concurrent billing for CCM and RPM? We invite you to learn more about our resources, expertise, and services. Start a conversation with a Medek Representative today. 

Contact us for a Demo!

1. Paré, G., Jaana, M., & Sicotte, C. (2007). Systematic review of home telemonitoring for chronic diseases: the evidence base. Journal of the American Medical Informatics Association : JAMIA, 14(3), 269–277. https://doi.org/10.1197/jamia.M2270
2. Donohue D. (2020). A Primary Care Answer to a Pandemic: Keeping a Population of Patients Safe at Home through Chronic Care Management and Remote Patient Monitoring. American journal of lifestyle medicine, 14(6), 595–601. https://doi.org/10.1177/1559827620935382
3. Centers for Medicare and Medicaid Services. (2020, December 1). Final Policy, Payment, and Quality Provisions Changes to the Medicare Physician Fee Schedule for Calendar Year 2021. https://www.cms.gov/newsroom/fact-sheets/final-policy-payment-and-quality-provisions-changes-medicare-physician-fee-schedule-calendar-year-1
4. Donohue D. (2020). A Primary Care Answer to a Pandemic: Keeping a Population of Patients Safe at Home through Chronic Care Management and Remote Patient Monitoring. American journal of lifestyle medicine, 14(6), 595–601. https://doi.org/10.1177/1559827620935382
5. Centers for Medicare and Medicaid Services [CMS] (2022, September 23). Chronic care management and connected care. https://www.cms.gov/about-cms/agency-information/omh/health-equity-programs/c2c/ccm
6. Centers for Medicare and Medicaid Services [CMS](n.d.)Connected care: Physician testimonial about chronic care management (CCM) [Video]. https://www.youtube.com/watch?v=_EATHNIyCRg
7. LeadingAge (n.d.) [updates a 2013 paper] Telehealth and Remote Patient Monitoring for Long-Term and Post-Acute Care: A Primer and Provider Selection Guide. https://leadingage.org/white-papers/telehealth-and-remote-patient-monitoring-long-term-and-post-acute-care-primer-and
8. Telehealth, Health and Human Services (HHS).gov. (2022, August 26). Telehealth and remote patient monitoring. https://telehealth.hhs.gov/providers/preparing-patients-for-telehealth/telehealth-and-remote-patient-monitoring/
9. Centers for Medicare and Medicaid Services [CMS] (n.d.)Connected care: Physician testimonial about chronic care management (CCM) [Video]. https://www.youtube.com/watch?v=_EATHNIyCRg
10. Guzman, V. (2021, October 21). https://www.ncqa.org/digital-measures/resources/blogs/de22efbe-094f-41e9-bbc3-910e6678ae5e/#:~:text=LOGIN%20%26%20GET%20ACCESS%20Health%20care%20organizations%20should,and%20communication%2C%20understanding%20a%20patient%E2%80%99s%20beliefs%20is%20essential.
11. Yarnall KSH, Østbye T, Krause KM, Pollak KI, Gradison M, Michener JL. Family physicians as team leaders: “time” to share the care. Prev Chronic Dis 2009;6(2). http://www.cdc.gov/pcd/issues/2009/apr/08_0023.htm

ADDITIONAL SOURCES: 1) Medek website and the Medek team.