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Timothy Dy Aungst Pharm.D.
Timothy Dy Aungst, Pharm.D.

THE ADVENT OF MULTIPLE DEVICES using Bluetooth technology to sync with a user’s smartphone has led to the widespread adoption of the internet of things (IoT) mentality to transform everyday objects into “smart” tools that can track use in real time. Data can be collected remotely, collated, and analyzed for a myriad of purposes. For some, this may lead to a smart home where the temperature is controlled by a smart thermometer to cut down on costs, or lights that can be programmed for different levels throughout the day, all based on a central hub (e.g., Amazon Alexa, Google Home). Needless to say, start-ups and larger companies have leveraged such technologies to increase services that can be offered to patients.

At this time, we have multiple patient tools, such as blood pressure cuffs or glucose monitors, used for self-monitoring in the home setting that have been “upgraded” to integrate IoT services. This allows patients to tether their device to their smartphone to create an electronic log and track patterns. Lately, there has been a push to share such data with their clinicians for clinical purposes, but due in part to a lack of reimbursable rates, the uptake has been slow. Now the Centers for Medicare & Medicaid Services (CMS) has made drastic changes to remote patient monitoring (RPM) that may shift this mentality.

NEW DEVICES, NEW CODES

Previously, there were provided codes from CMS on RPM, though they were found to be generally confusing, provided a minimal financial incentive for providers, and lacked the integration of use with newer tools that arrived on the market. To take these new technologies into consideration, and along with its push to expand billable technology services (e.g., telemedicine), CMS has released three new Current Procedural Terminology (CPT) codes and revised a previous one, as seen in the table. In essence, the new codes expand opportunities for reimbursement for providers, clinical staff, and qualified healthcare professionals to conduct RPM services. As seen in the table, these include a one-time setup and patient education fee, and 30-day cycle reimbursement for monitoring of physiological measurement devices and treatment management services.

 

It is self-evident that many in the tech industry have been preparing for this, with many new and novel devices now arriving on the market. Continuous glucose monitoring (CGM) has been making much headway, with new devices such as the FreeStyle Libre now available in many pharmacies. While CGM may have its own CPT codes, other devices will benefit under the expansion. One new example includes Omron‘s new HeartGuide, which is a wrist-mounted blood pressure device that can also track fitness, activity, and sleep. In essence, it is a new-model smartwatch that takes blood pressure monitoring beyond infrequent home measurements and into a semi-continuous model. This is also being seen with other new advancements, such as the Apple Watch Series 4 having an integrated electrocardiogram (ECG) sensor to detect atrial fibrillation in patients. While the costs of such devices are relatively high (over $400), the opportunity for payers to cover such devices in the near future and for providers to be able to bill for services may lead to increased adoption. The American Medical Association has recently released a digital health report that serves as a guide for physicians looking to use novel tools in clinical practice. The first item to be discussed in this guide (which will expand over time) was RPM services.

ADHERENCE FEEDBACK

For the pharmacy profession, one novel opportunity for RPM may be medication adherence tracking. New digital medicines are arriving in 2019, including Lilly and Novo Nordisk smart insulin pens, Teva ProAir Digihaler, and new drugs using Proteus Digital Health bioingestible sensors, such as Abilify MyCite. Tracking physiological data concurrently with medication adherence may prove to be a golden opportunity to give enhanced feedback to patients on their clinical status. An example could be a patient using a smart blood pressure cuff who does not take his or her medications tracked from a smart pillbox. As the patient’s blood pressure increases, the pharmacist can verify that medications have not been taken, and appropriate intervention can be made for the patient to help improve clinical outcomes.

THE VALUE OF PHARMACISTS‘ TIME

Needless to say, the issue then becomes, can pharmacists bill for such services? In the Federal Register document covering the new RPM CPT codes, there were several comments and responses noted dealing with what a “qualified health professional” is, and where pharmacists fall in the grand scheme. Two comments are worth mentioning here:

Comment 1: One commenter stated that there was direct time spent by pharmacists for each patient, and the commenter requested that CMS factor pharmacist time into the practice expense (PE) valuation for CPT codes 99453, 99454, 99091, and 99457.

Response: We typically do not consider time spent by a pharmacist to be a part of the clinical labor time for purposes of direct PE. For additional information, we direct readers to the practice expense portion of this final rule (section II.B. of this final rule).

Comment 2: A few commenters suggested that additional medical professionals, including pharmacists, paramedics, chiropractors, physical therapists, occupational therapists, and dentists, should be allowed to bill Medicare for these services. Other commenters requested that CMS clarify the practitioners referred to as ‘‘other qualified healthcare professionals’’ in the code descriptor.

Response: We note that all practitioners must practice in accordance with applicable state law and scope of practice laws, and that some of the practitioners identified by the commenters are not authorized to bill Medicare independently for their services. We note that the term ‘‘other qualified healthcare professionals’’ used in the code descriptor is defined by CPT, and that definition can be found in the CPT codebook.

As it stands, it does not appear that CMS has clarified outright what a qualified healthcare professional is, and instead is deferring to states’ laws and boards to set the standard. While pharmacists can bill currently under specific codes (e.g., medication therapy management (MTM) billing codes [99605, 99696, 99607], transitional care management [99405, 99496], diabetes self-management training [G0108, G0109]), RPM may not be available for all pharmacists just yet. Instead, those in a collaborative practice agreement, consultant pharmacist roles, or involved in ambulatory care settings may be best able to fall under this rule.

Future expansion of CPT codes is likely to be generated to account for the various amounts of technology coming to the market. The expectation that CMS will keep up with a vastly disrupted health tech space may not come to fruition for some time. However, digital medicines and the increased ability to track medication adherence and biological impact may lead to pharmacist code expansion soon to help push such services for patient care. CT

Timothy Aungst, Pharm.D., is an associate professor of Pharmacy Practice at the Massachusetts College of Pharmacy and Health Sciences, Worcester, Mass. He can be reached at timothy.aungst@mcphs.edu, and you can follow him on Twitter at @TDAungst.