Pediatric Coding Alert

New initiatives could increase your care management program options.

In the Medicare Physicians Fee Schedule (MPFS) proposed rule for 2022, Medicare introduced two new concepts that could impact the way your pediatrician implements care management for your sick patient population beginning next year.

The concepts — remote therapeutic monitoring (RTM) and principal care management (PCM) — are very similar to other types of care management programs that you are familiar with. But as they differ slightly, they are worth examining in depth, so you know what they are and how they are coded if or when your practice implements them.

Here’s what you need to know.

Enter the Brave New World of Remote Therapeutic Monitoring

Beginning January 1, you’ll be able to code various RTM services using the following codes:

• 98975 (Remote therapeutic monitoring (eg, respiratory system status, musculoskeletal system status, therapy adherence, therapy response); initial set-up and patient education on use of equipment)
• 98976 (… device(s) supply with scheduled (eg, daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days)
• 98977 (… device(s) supply with scheduled (eg, daily) recording(s) and/or programmed alert(s) transmission to monitor musculoskeletal system, each 30 days)
• 98980 (Remote therapeutic monitoring treatment management services, physician or other qualified health care professional time in a calendar month requiring at least one interactive communication with the patient or caregiver during the calendar month; first 20 minutes)
• +98981 (… each additional 20 minutes (List separately in addition to code for primary procedure))

Basically, the “RTM codes monitor health conditions, including musculoskeletal system status, respiratory system status, therapy (medication) adherence, and therapy (medication) response,” according to the 2022 MPFS proposed rule. In other words, RTM services go beyond data collection to measure the efficacy of a given treatment on a patient’s condition. Additionally, the RTM codes “allow non-physiologic data to be collected. Data also can also be self-reported as well as digitally uploaded,” says Jan Blanchard, CPC, CPEDC, CPMA, Pediatric Solutions Consultant at Vermont-based PCC.

To do that, the patient must use a device that meets the Food and Drug Administration (FDA) definition of a medical device as described in section 201(h) of the Federal Food, Drug and Cosmetic Act (FFDCA), the proposed rule notes. This does not mean that the device has to be approved by the FDA. But it does mean the device has to be “recognized in the official National Formulary, or the United States Pharmacopeia, or any supplement to them” (Source: www.fda.gov/regulatory-information/search-fda-guidance-documents/classification-products-drugs-and-devices-and-additional-product-classification-issues).

Important reminder: Medicare’s current thinking regarding the RTM services suggests they should only be performed incident to with direct physician supervision. Further, according to the proposed rule, CMS believes the current construct of the RTM codes disallows physical therapists and other practitioners who are not physicians or NPPs from reporting the RTM codes, because CMS views the codes as including “incident to” services, and only physicians and certain other practitioners are authorized to furnish and bill “incident to” services under Medicare rules.

This could change when the proposed rule becomes finalized later this year.

Peruse This Proposal for Principal Care Management

“Next year, Medicare is proposing to accept and pay for new CPT^® codes for PCM,” says Lori Carlin, CPC, COC, CPCO, CCS, director, Professional Coding Services, Pinnacle Enterprise Risk Consulting Services LLC, in Centennial, Colorado.

The codes in question are:

• 99424 (Principal care management services, for a single high-risk disease: with the following required elements: one complex chronic condition expected to last at least 3 months, and which places the patient at significant risk of hospitalization, acute exacerbation /decompensation, functional decline, or death, the condition requires development, monitoring, or revision of disease-specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities; ongoing communication and care coordination between relevant practitioners furnishing care; first 30 minutes provided personally by a physician or other qualified health care professional, per calendar month)
• +99425 (Principal care management services … additional 30 minutes provided personally by a physician or other qualified health care professional …)
• 99426 (Principal care management services … first 30 minutes of clinical staff time directed by physician or other qualified health care professional, per calendar month)
• +99427 (Principal care management services each additional 30 minutes of clinical staff time directed by a physician or other qualified health care professional …).

“A patient would be eligible for PCM if they have a chronic condition that is expected to last at least three months. It would be a condition which places the patient at significant risk of hospitalization, acute exacerbation/decompensation, functional decline, or death,” Carlin clarifies.

“I could see the PCM approach relating to services like ongoing asthma care depending upon how often medication adjustments must be made to match the definition of ‘frequent.’ Care for pediatric patients with comorbidities would qualify in any case. Practices whose payers follow CMS [Centers for Medicare & Medicaid Services] beneficiary rules — maybe the same payers who accepted or required HCPCS codes G2064 [Comprehensive care management services for a single high-risk disease, e.g., principal care management, at least 30 minutes of physician or other qualified health care professional time per calendar month …] and G2065 [… at least 30 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month …] — should pay particular attention to the part of this proposal, which places this type of care squarely in the primary care realm,” says Blanchard.