Medicaid & Medicare

Remote Patient Monitoring

Remote patient monitoring (RPM) is the collection of a wide range of health data from the point of care, such as vital signs, weight, and blood pressure. The data is transmitted to health professionals in facilities such as monitoring centers in primary care settings, hospitals and intensive care units, and skilled nursing facilities. A little over half of state Medicaid programs reimburse for RPM, however there are a multitude of restrictions associated with its use. The most common include only offering reimbursement to home health agencies, restricting the clinical conditions for which symptoms can be monitored, and limiting the type of monitoring device and information that can be collected.

See overview of states with RPM reimbursement >

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Federal

Last updated 07/17/2024

POLICY

Although not considered to fall under the definition of …

POLICY

Although not considered to fall under the definition of telehealth, in 2018 CMS began making separate payment for the collection and interpretation of physiologic data. In 2019, they expanded their reimbursement to three remote physiologic monitoring codes, and an add-on code was added in 2020. Currently eligible codes include 99091, 99453, 99454, 99457, 99458. Each code has its own requirements in the code description.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 123-125 & CY 2020 Final Physician Fee Schedule, CMS, p. 429, (Accessed Jul. 2024).

Remote therapeutic monitoring codes are similar to remote physiologic monitoring codes, however the primary billers are meant to be psychiatrists, nurse practitioners, and physical therapists, and allows non-physiological data to be collected. Codes include 98975, 98976, 98977, 98980, and 98981. Each code has its own requirements in the code description.

SOURCE: CY 2022 Physician Fee Schedule, CMS, p. 214-215, (Accessed Jul. 2024).

Home Health Agencies (HHAs) can provide more services to beneficiaries using telecommunications technology within the 30-day period of care, as long as it’s part of the patient’s plan of care and does not replace needed in-person visits as ordered on the plan of care. We acknowledge that the use of such technology may result in changes to the frequency or types of in-person visits outlined on existing or new plans of care. Telecommunications technology can include, for example: remote patient monitoring; telephone calls (audio only and TTY); and two-way audio-video technology that allows for real-time interaction between the clinician and patient. This provision is permanent beyond the COVID-19 PHE. Home health services furnished using telecommunication systems are required to be included on the home health claim beginning July 1, 2023.

The required face-to-face encounter for home health can be conducted via telehealth (i.e., 2-way audio-video telecommunications technology that allows for real-time interaction between the physician/allowed practitioner and the patient) when the patient is at home. After the PHE ends, the Consolidated Appropriations Act, 2023 provides for an extension for the flexibility to allow the home to be an originating site through December 31, 2024.

SOURCE: Centers for Medicare and Medicaid Services, Home Health Agencies, CMS Flexibilities to Fight COVID-19, 5/10/23, (Accessed Jul. 2024).

Note that chronic care management, principle care management, and transitional care management may also have remote monitoring applications.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 126-128; CY 2020 Final Physician Fee Schedule. CMS, p. 390-421 & Medicare Learning Network Booklet, Chronic Care Management Services, September 2022 (Accessed Jul. 2024).

Practitioners may bill RPM or RTM, but not both, concurrently with the following services:

Chronic Care Management (CCM)
Transitional Care Management (TCM)
Behavioral Health Integration (BHI)
Principle Care Management (PCM)
Chronic Pain Management (CPM)

RTM and RPM cannot be billed together.

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Jul. 2024).

CONDITIONS

Note that specific condition requirements apply for chronic care management, principle care management, and transitional care management which may also have remote monitoring applications.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 123-125; CY 2020 Final Physician Fee Schedule, CMS, p. 429 & Medicare Learning Network Booklet, Chronic Care Management Services, September 2022, (Accessed Jul. 2024).

Cardiovascular System

The CPT codes 93731, 93734, 93741 and 93743 are used to report electronic analyses of single or dual chamber pacemakers and single or dual chamber implantable cardioverterdefibrillators. In the office, a physician uses a device called a programmer to obtain information about the status and performance of the device and to evaluate the patient’s cardiac rhythm and response to the implanted device.

Advances in information technology now enable physicians to evaluate patients with implanted cardiac devices without requiring the patient to be present in the physician’s office. Using a manufacturer’s specific monitor/transmitter, a patient can send complete device data and specific cardiac data to a distant receiving station or secure Internet server. The electronic analysis of cardiac device data that is remotely obtained provides immediate and long-term data on the device and clinical data on the patient’s cardiac functioning equivalent to that obtained during an in-office evaluation. Physicians should report the electronic analysis of an implanted cardiac device using remotely obtained data as described above with CPT code 93731, 93734, 93741 or 93743, depending on the type of cardiac device implanted in the patient.

SOURCE: Center for Medicare and Medicaid Services, Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysicians Practitioners (Jun. 6, 2024), p. 26. (Accessed July. 2024).

PROVIDER LIMITATIONS

For remote physiologic monitoring, 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.

SOURCE: CY 2019 Final Physician Fee Schedule. CMS, p. 123-125, (Accessed Jul. 2024).

CMS has designated RPM codes 99457 and 99458 as defined in Sec. 410.26(b)(5). See below for referenced definition:

In general, services and supplies must be furnished under the direct supervision of the physician (or other practitioner). Designated care management services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided incident to the services of a physician (or other practitioner). Behavioral health services can be furnished under general supervision of the physician (or other practitioner) when these services or supplies are provided by auxiliary personnel incident to the services of a physician (or other practitioner). The physician (or other practitioner) supervising the auxiliary personnel need not be the same physician (or other practitioner) who is treating the patient more broadly. However, only the supervising physician (or other practitioner) may bill Medicare for incident to services.

SOURCE: CY 2020 Final Physician Fee Schedule. CMS, p. 431 & 42 CFR 410.26, (Accessed Jul. 2024).

FQHCs/RHCs

Beginning CY 2022, RHCs and FQHCs can bill CCM and TCM services for the same patient during the same time period

SOURCE: Medicare Learning Network Booklet, Chronic Care Management Services, September 2022 , p. 9 (Accessed Jul. 2024).

Services such as RPM are not separately billable because they are already included in the RHC AIR or FQHC PPS payment.

SOURCE: CY 2020 Final Physician Fee Schedule. CMS, p. 432, (Accessed Jul. 2024).

Home Health Agencies

An individualized plan of care must be established and periodically reviewed by the certifying physician or allowed practitioner. The plan of care must include all of the following: … Any provision of remote patient monitoring or other services furnished via telecommunications technology (as defined in § 409.46(e)) or audio-only technology. Such services must be tied to the patient-specific needs as identified in the comprehensive assessment, cannot substitute for a home visit ordered as part of the plan of care, and cannot be considered a home visit for the purposes of patient eligibility or payment.

Telecommunications technology, as indicated on the plan of care, can include: remote patient monitoring, defined as the collection of physiologic data (for example, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient or caregiver or both to the home health agency; teletypewriter (TTY); and 2-way audio-video telecommunications technology that allows for real-time interaction between the patient and clinician. The costs of any equipment, set-up, and service related to the technology are allowable only as administrative costs. Visits to a beneficiary’s home for the sole purpose of supplying, connecting, or training the patient on the technology, without the provision of a skilled service, are not separately billable.

SOURCE: 42 CFR Sec. 409.43 & 409.46, (Accessed Jul. 2024).

Starting on or after January 1, 2023, they may voluntarily report the use of telecommunications technology in providing HH services on HH payment claims. CMS will require this information on HH claims starting on July 1, 2023. Home Health Agencies will submit the use of telecommunications technology on the HH claim using the following 3 G-codes:

G0320: Home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system
G0321: Home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system
G0322: The collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (for example, remote patient monitoring)

SOURCE: Telehealth Home Health Services: G-Codes, MLN Matters MM12805, (Effective Date: Jan. 1, 2023), (Accessed Jul. 2024).

Starting January 1, 2023, you may voluntarily report the use of telehealth technology in providing home health (HH) services on HH payment claims. See MLN Matters Article MM12805 for more information.

Starting July 1, 2023, you must include on HH claims:

G0320: Home health services you furnish using synchronous telehealth you render via real-time audio video telehealth
G0321: Home health services you furnish using synchronous telehealth you render via telephone or another real-time, interactive, audio-only telehealth
G0322: The collection of physiologic data the patient digitally stores or transmits to the HH agency

See fact sheet for additional details.

SOURCE: Centers for Medicare and Medicaid Services (CMS), Telehealth Services MLN Fact Sheet, Apr. 2024, (Accessed Jul. 2024).

Beginning on or after January 1, 2023, HHAs may voluntarily report the use of telecommunications technology in the provision of home health services on claims. This information is required on home health claims beginning on July 1, 2023. HHAs shall submit the use of telecommunications technology when furnishing home health services, on the home health claim via three G-codes.

G0320: home health services furnished using synchronous telemedicine rendered via a real-time two-way audio and video telecommunications system
G0321: home health services furnished using synchronous telemedicine rendered via telephone or other real-time interactive audio-only telecommunications system
G0322: the collection of physiologic data digitally stored and/or transmitted by the patient to the home health agency (i.e., remote patient monitoring).

HHAs shall submit services furnished via telecommunications technology in line item detail and each service must be reported as a separately dated line under the appropriate revenue code for each discipline furnishing the service. Two occurrences of G0320 or G0321 on the same day for the same revenue code shall be reported as separate line items.

The use of remote patient monitoring that spans a number of days shall be reported as a single G0322 line item reporting the beginning date of monitoring and the number of days of monitoring in the units field. If more than one discipline is using the remote monitoring information during the billing period, the HHA may choose which revenue code to report on the remote monitoring line item.

Claims with no billable visits are not submitted to Medicare, including claims for billing periods where only telehealth services are provided.

Telehealth services with HCPCS codes G0320 or G0321 are reported with units of 1.

SOURCE: Centers for Medicare and Medicaid Services, Medicare Claims Processing Manual, Ch. 10: Home Health Agency Billing, 10/19/23, pg. 61, (Accessed Jul. 2024).

CMS will include the CPT codes related to RPM and RTM in the general care management code HCPCS G0511 which will provide FQHCs/RHCs payment for RTM and RPM services. CMS noted that these services are similar to the nonface-to-face requirements for general care management services and reflect the additional resources needed to provide such services by an FQHC/RHC.

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Jul. 2024).

OTHER RESTRICTIONS

Using the waiver authority under section 1135 of the Act during the PHE, we have permitted clinicians to bill for remote physiologic monitoring (RPM) services furnished to both new and established patients, and to patients with both acute and chronic conditions. When the PHE ends, clinicians must once again have an established relationship with the patient prior to providing RPM services. However, we will continue to allow RPM services to be furnished to patients with both acute and chronic conditions (pre-PHE, an initiating visit was required before RPM services could be billed).

Current CPT coding guidance states that the RPM services described by CPT codes 99453 and 99454 cannot be reported when fewer than 16 days of data are collected. During the PHE, we used section 1135 waiver authority to allow clinicians to bill CPT codes 99453 and 99454 when as few as two days of data were collected if the patient was diagnosed with, or was suspected of having, COVID-19 and as long as all other billing requirements of the codes were met. When the PHE ends, clinicians must only bill for these services when at least 16 days of data have been collected.

SOURCE: Centers for Medicare and Medicaid Services, Physicians and Other Clinicians: CMS Flexibilities to Fight COVID-19, 11/6/23, (Accessed Jul. 2024).

Although multiple devices can be provided to a patient, the services associated with all of the medical devices “can be billed only once per patient per 30-day period and only when at least 16 days of data have been collected.” This applies even when multiple devices are used.

Regarding global payment and how RTM and RPM maybe used, CMS notes that when a beneficiary’s procedure/surgery and related services are covered by a global payment, RPM or RTM services may be furnished separately and the provider will be paid for them separately from the global payment. If the beneficiary is currently receiving services during a global period, the provider may also furnish RPM or RTM services and the provider will receive a separate payment if the RPM/RTM services are unrelated to the diagnosis for the global procedure and are separate and distinct from the global procedure. See the 2024 Final Rule for more details

SOURCE: Center for Medicare and Medicaid Services, CY 2024 Physician Fee Schedule, Final Rule, CMS 1784-F, (Accessed Jul. 2024).

Can patients who received Remote Monitoring or other Communication Technology-Based services through a waiver in place during the PHE be considered an “established patient” for purposes of continued receipt of such services, even without an initiating service?

Yes. A patient who received Remote Monitoring or other Communication Technology-Based services while the PHE Waiver (85 FR 19230, 19244, 19264) was in effect will be considered an “established patient” for continued receipt of remote monitoring and other communication technology-based services after the end of the COVID-19 PHE. This rule applies as long as the patient consented to receive subsequent remote monitoring and other communication technology-based services. This consideration would be the case even if the patient did not have an in-person or telehealth-eligible initiating service. The patient’s consent to receive subsequent services should be documented in the patient’s medical records and should be available to CMS upon request.

SOURCE: Centers for Medicare and Medicaid Services, Frequently Asked Questions: CMS Waivers, Flexibilities and the End of the COVID-19 Public health Emergency, 5/19/23, (Accessed Jul. 2024).

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Alabama

Last updated 11/20/2024

POLICY

Remote Patient Monitoring (RPM), also known as In-home Remote …

POLICY

Remote Patient Monitoring (RPM), also known as In-home Remote Patient Monitoring, is a program that allows medical providers to monitor and manage acute and chronic health conditions while the patient is home. The goal of the program is to decrease exacerbation episodes, emergent care visits, hospital admissions, and medical costs and increase self-management of the disease/chronic condition.

SOURCE: AL Medicaid Management Information System Provider Manual, Remote Patient Monitoring (Ch. 111, Pg. 1), Oct. 2024. (Accessed Nov. 2024).

RPM services include, but are not limited to:

Initial home assessment for RPM
Initial setup of RPM equipment
Instructions and education about the use of monitoring devices
Instructing the patient/care giver on data entry
Instructing patient on optimum symptom control
Direct patient contact, when necessary and as indicated
Evaluate threshold violations
Monitoring and follow up
Diet/nutrition education
Needs assessing/screening
Making referrals for care when appropriate

RPM providers must also develop a process for addressing patient noncompliance. This process should include the expected actions of the patient and the RPM provider related to initial and on-going noncompliance issues. Noncompliance and the specified actions must be documented in the patient’s chart.

SOURCE: AL Medicaid Management Information System Provider Manual, Remote Patient Monitoring (Ch. 111, Pg. 3-4), Oct. 2024. (Accessed Nov. 2024).

CONDITIONS

Remote Patient Monitoring (RPM) services are available to Medicaid eligible persons with a need for daily monitoring and with a diagnosis of one or more of the following conditions:

Diabetes
Gestational Diabetes (effective 10/1/2022)
Hypertension
Congestive Heart Failure
Pediatric Asthma (effective 10/1/2022)

An order from the recipient’s primary care physician (PCP) is required prior to the start of rendering RPM service. Orders for RPM, along with the specific parameters for daily monitoring, must be obtained from the patient’s PCP prior to evaluation and admission. The order must be documented in the medical record. Orders must be signed and dated by the ordering practitioner and must be obtained annually.

Referrals for RPM may be accepted from any source, including physicians, ACHN Care Coordinators, patient or caregiver, the Health Department, hospitals, home health agencies, or community-based organizations.

A practitioner must obtain patient consent before furnishing or billing RPM services (see informed consent section for details).

SOURCE: AL Medicaid Management Information System Provider Manual, Remote Patient Monitoring (Ch. 111, Pg. 3), Oct. 2024, (Accessed Nov. 2024).

PROVIDER LIMITATIONS

Remote Patient Monitoring providers are assigned a provider type of 08 (Remote Patient Monitoring) and provider specialty 085 or 086.

Services rendered by non-physician practitioners, i.e., physician assistants, certified registered nurse practitioner, etc., must adhere to applicable guidelines, policies and procedures. Refer to Administrative Code chapters 6: Physicians and 49: Certified Register Nurse Practitioner (CRNP) for additional information.

A provider who contracts with Medicaid as an RPM provider is added to the Medicaid system with the National Provider Identifiers provided to the Agency at the time application is made. Appropriate provider specialty codes are assigned to enable the provider to submit requests and receive reimbursements for RPM related claims.

Any provider that can and is willing to pay the Alabama State Share may enroll as an RPM provider. A Memorandum of Understand (MOU) must be executed between the Medicaid Agency and the RPM provider. The MOU will outline the financial and medical responsibilities for the Medicaid Agency and the RPM provider.

SOURCE: AL Medicaid Management Information System Provider Manual, Remote Patient Monitoring (Ch. 111, Pg. 1-2), Oct. 2024. (Accessed Nov 2024).

OTHER RESTRICTIONS

Requirements for RPM include but not limited to:

Ability to provide services statewide.
Meet appropriate clinical staffing requirements.
Provides and allows the recipients to keep user friendly, interactive audio and video technology monitoring equipment.
Accepts electronic submissions of referrals.
Provides an in-home initial assessment.
Transmits recipient data automatically in real time (a Medicare requirement).
Reviews, intervenes and reports on the data promptly.
Provides 24-hour-a-day, 7-day-a-week (24/7) access to physicians or other qualified health care professionals or clinical staff, to address urgent needs of recipients.
Develops, monitors and updates a patient-centered care plan
Ongoing, compliance monitoring.
Program graduation, when appropriate.

Federal requirements mandate providers re-validate periodically with the Alabama Medicaid program. Providers will receive a notification when it is time to re-validate. Failure to re-validate and provide appropriate documentation to complete the enrollment process will result in an end-date being placed on the provider file. A new enrollment application must be submitted once a provider file has been closed due to failure to timely re-validate.

Medicaid will not separately reimburse for any direct care services, such as wound care, rendered by RPM providers. RPM services are restricted to the medical diagnosis outlined in section 111.2.

See manual for documentation and evaluation report requirements.

SOURCE: AL Medicaid Management Information System Provider Manual, Remote Patient Monitoring, Ch. 111, Oct. 2024. (Accessed Nov. 2024).

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Alaska

Last updated 11/22/2024

POLICY

Alaska Medicaid will pay for telemedicine services delivered in …

POLICY

Alaska Medicaid will pay for telemedicine services delivered in the following manner: …

Self-monitoring method: The patient is monitored in his or her home via a telemedicine application, with the provider indirectly involved from another location.

Note: Manual is under review.

SOURCE: State of AK Dept. of Health and Social Svcs., Alaska Medical Assistance Provider Billing Manuals for Physician, ARNP, PA Services (5/13), p. 31, (Accessed Nov. 2024).

* A provider has notified CCHP that Alaska Medicaid currently only pays for the RPM device and not the actual service. This has not been verified.

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

No Reference Found

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Arizona

Last updated 10/28/2024

POLICY

Remote Patient Monitoring: Personal health and medical data collection …

POLICY

Remote Patient Monitoring: Personal health and medical data collection from a member in one location via electronic communication technologies, which is transmitted to a provider in a different location for use in providing improved chronic disease management, care, and related support. Such monitoring shall be either synchronous (real-time) or asynchronous (store and forward).

SOURCE: AZ Health Cost Containment System, AHCCCS Contract and Policy Dictionary, 9/24, pg. 96, (Accessed Oct. 2024).

Remote patient monitoring enables the monitoring of members outside of conventional clinical settings, such as in the home. The Contractor and FFS Programs cover both synchronous and asynchronous remote patient monitoring.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Medical Policy for AHCCCS Covered Services, Ch. 300, (320-I pg. 4). Approved 8/29/23. (Accessed Oct. 2024).

Service delivery via telehealth can be done via teledentistry, remote patient monitoring, telemedicine, or asynchronous (store and forward).

Remote Patient Monitoring is “personal health and medical data collection from a member in one location via electronic communication technologies, which is transmitted to a provider in a different location for use in providing improved chronic disease management, care, and related support. Such monitoring may be either synchronous (real-time) or asynchronous (store-and-forward).

SOURCE: AZ Health Care Cost Containment System, AHCCCS Fee-For-Service Provider Billing Manual, Ch. 10: Individual Practitioner Services, (5/2/24), pg. 49-50 & IHS/Tribal Provider Billing Manual, (5/2/24), pg. 53. (Accessed Oct. 2024).

AHCCCS covers all major forms of telehealth services. Asynchronous (also called “store and forward”) occurs when services are not delivered in real-time, but are uploaded by providers and retrieved, perhaps to an online portal. Telephonic services (audio-only) use a traditional telephone to conduct health care appointments. Telemedicine involves interactive audio and video, in a real-time, synchronous conversation. AHCCCS also covers telehealth for remote patient monitoring and teledentistry.

See chart on webpage for code set.

SOURCE: AZ Health Care Cost Containment System. Telehealth Services, (Accessed Oct. 2024).

Remote monitoring

G2010 – Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.
G2012 – Brief communication technology-based service, e.g., virtual check-in, by a physician or other qualified health care professional who can report evaluation and management services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

SOURCE: AZ Administrative Code Title 20, Ch. 5, pg. 424-925. (Accessed Oct. 2024).

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

Coverage of equipment and/or supplies for remote patient monitoring is limited to when:

The service being provided is an AHCCCS covered service eligible for remote monitoring; and
The equipment and/or supplies are AHCCCS covered items. For additional information, refer to AMPM Policy 310-P.

The AHCCCS Telehealth code set defines which codes are billable as a remote patient monitoring service and the applicable modifier(s) and place of service providers must use when billing for a service provided through remote patient monitoring.

SOURCE: AZ Health Care Cost Containment System, AHCCCS Medical Policy for AHCCCS Covered Services, Ch. 300, (320-I pg. 4). Approved 8/29/23. (Accessed Oct. 2024).

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Arkansas

Last updated 10/21/2024

POLICY

Remote client monitoring means the use of electronic information …

POLICY

Remote client monitoring means the use of electronic information and communication technology to collect personal health information and medical data from a client at an originating site that is transmitted to a healthcare provider at a distant site for use in the treatment and management of medical conditions that require frequent monitoring.

SOURCE: AR Medicaid Provider Manual. Section I General Policy. Rule 105.190. Updated Jan. 1, 2022, (Accessed Oct. 2024).

Although remote patient monitoring is included in Medicaid’s definition of telemedicine, no information was found regarding reimbursement of store-and-forward.

Patient-Led Arkansas Shared Savings Entity (PASSE) Program
Virtual providers can use mobile telemonitoring technologies to remotely monitor and evaluate the patient’s functional and health status.

SOURCE: PASSE Program, p. II-8 (1/1/23). (Accessed Oct. 2024).

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

As previously communicated, Arkansas Medicaid is updating the billing processes for diabetic supplies including Continuous Glucose Monitors (CGMs), which will be changing to a pharmacy claim type submission by both pharmacies and DME providers. The official start date is 8/1/2024 for both DME providers and pharmacy providers.

Provider training available.

SOURCE: AR Medicaid, Official Notice: Health Care Providers – Prosthetics (Includes Durable Medical Equipment (DME) and Orthotics, June 27, 2024, (Accessed Oct. 2024).

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California

Last updated 06/29/2024

POLICY

Principal care management (PCM) services are provided when medical …

POLICY

Principal care management (PCM) services are provided when medical and/or psychological needs manifested by a single, complex chronic condition are expected to last at least three months. CPT codes 99424 and 99426 each have a frequency limit of once per calendar month, any provider and 99427 has a frequency limit of two per calendar month, any provider.

Remote physiologic monitoring (RPM) services for established patients ages 21 and older are reimbursable when ordered by and billed by physicians or other qualified health professionals (QHP). RPM services may be delivered by auxiliary personnel including contracted employees, when under the supervision of the billing physician or qualified health professional. See manual for codes.

Prior to or at the time RPM services are furnished, the patient must give consent to receive the services. Consent may be verbal (written consent is not required) but must be documented in the medical record, along with justification for the use of RPM services.

SOURCE: CA DHCS Evaluation and Management Manual (Dec. 2022), p. 39-42. (Accessed Jun. 2024).

The department may authorize the use of remote patient monitoring as an allowable telehealth modality for covered health care services and provider types it deems appropriate for dates of service on or after July 1, 2021. The department may establish a fee schedule for applicable health care services delivered via remote patient monitoring.

SOURCE: Sec. 14124.12 (f)(1)(B) of the Welfare and Institutions Code. (Accessed Jun. 2024).

Remote Physiologic Monitoring

Medi-Cal reimburses for 5 remote physiologic monitoring codes (99091, 99453, 99454, 99457, 99458), consistent with Medicare Communication Technology Based Services (CTBS) .

SOURCE: Medi-Cal Rates Information. (Accessed Jun. 2024).

Continuous Glucose Monitoring

Effective for dates of service on or after May 1, 2023, CPT^® codes 95250 (ambulatory continuous glucose monitoring [CGM] of interstitial fluid via a subcutaneous sensor for a minimum of 72 hours; physician or other qualified health care professional [office] provided equipment, sensor placement, hook-up, calibration of monitor, patient training, removal of a sensor, and printout of recording) and 95251 (ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours; analysis, interpretation and report) are added as Medi-Cal benefits.

SOURCE: Durable Medical Equipment (DME): Billing Codes Manual, Nov. 2023, p. 52. (Accessed Jun. 2024).

Continuous Glucose Monitoring (CGM) is a covered benefit for California Children’s Services (CCS) and the Genetically Handicapped Persons Program (GHPP). CGM systems are minimally invasive devices that measure subcutaneous interstitial fluid glucose. The availability of real-time CGM data allows the individual or caregiver to monitor glucose levels, receive alerts for dangerously high or low blood glucose levels, and adjust diet and medications to avert adverse hypoglycemic or hyperglycemic events.

Effective October 1, 2022, non-therapeutic CGMs are also processed through Medi-Cal Rx according to the Medi-Cal Rx integrated coverage policy. Prior Authorization is required on all CGM requests through Medi-Cal Rx.

Section 13.4 of the Medi-Cal Rx Provider Manual
Under Covered continuous Glucose Monitoring (CGM) Systems Medi-Cal Providers | Forms and Information

SOURCE: CA Dept. of Health Care Services. California Children’s Services Numbered Letter 15-1222. CGM as a CCS and GHPP Program Benefit. Dec. 23, 2022. (Accessed Jun. 2024).

CONDITIONS

Continuous Glucose Monitoring

The CCS Program or GHPP client must meet all of the following:

The client has a diagnosis of type 1 diabetes mellitus, cystic fibrosis (CF) related diabetes, insulin-dependent type 2 diabetes, or sequelae of a CCS Program-eligible condition that requires ongoing insulin use.
The client requires glucose testing by finger stick or CGM at least three times per day.
The client requires analog insulin injections at least three times per day or uses an insulin pump.
The client’s insulin regimen requires frequent adjustment on the basis of finger stick or CGM blood glucose readings.

SOURCE: CA Dept. of Health Care Services. California Children’s Services Numbered Letter 15-1222. CGM as a CCS and GHPP Program Benefit. Dec. 23, 2022. (Accessed Jun. 2024).

PROVIDER LIMITATIONS

Remote Physiologic Monitoring

SOURCE: Department of Health Care Services. Evaluation & Management Manual. Page 41. Dec. 2022. (Accessed Jun. 2024).

Continuous Glucose Monitoring

CCS/CHPP – Therapeutic and non-therapeutic CGMs may be prescribed by one of the following:

A CCS Program-paneled endocrinologist affiliated with an Endocrine Special Care Center (SCC) or SCC nurse practitioner if the physician has ordered CGM for the client, as documented in the medical record.
A CCS-paneled community pediatric endocrinologist if the client meets certain conditions.
For GHPP clients, an adult endocrinologist at an approved Endocrine SCC or an adult endocrinologist or internal medicine specialist with an active MediCal provider number treating the GHPP-eligible condition.

SOURCE: CA Dept. of Health Care Services. California Children’s Services Numbered Letter 15-1222. CGM as a CCS and GHPP Program Benefit. Dec. 23, 2022. (Accessed Jun. 2024).

OTHER RESTRICTIONS

Principle Care Management Services

CPT codes 99424 and 99426 each have a frequency limit of once per calendar month, any provider and 99427 has a frequency limit of two per calendar month, any provider.

Remote Physiologic Monitoring

Remote physiologic monitoring (RPM) services are reimbursable for established patients ages 21 and older.

CPT code 99453 is reimbursable once per episode of care but cannot be used for monitoring fewer than 16 days during a 30-day billing period. The interactive communication required for 99457 must be real-time synchronous with two-way audio with a minimum of 20 minutes per month and the patient must have a treatment plan for chronic care management. For additional information regarding minimum duration of service and definition of episode care, refer to the CPT book.

The frequency limit for 99453, 99454 and 99091 is one per 30 days, any provider. The frequency limit for 99457 is one per calendar month, any provider. The frequency limit for 99458 is three per interactive communication session.

SOURCE: CA Department of Health Care Services. Evaluation & Management Manual. Page 39-42. Dec. 2022. (Accessed Jun. 2024).

The department may establish separate fee schedules for applicable health care services delivered via remote patient monitoring or other permissible virtual communication modalities.

SOURCE: Welfare and Institutions Code 14132.725. (Accessed Jun. 2024).

Continuous Glucose Monitoring

CPT codes 95250 and 95251 cannot be reported more than once per month per patient, any provider, regardless of the duration of professional CGM or the number of times CGM is provided in a single month. CPT 95251 cannot be reported in conjunction with CPT 99091. For prior authorization requirements for CGM systems, see Medi-Cal Rx Provider Manual, Section 13.4.

SOURCE: CA Department of Health Care Services. Durable Medical Equipment (DME): Billing Codes Manual, Nov. 2023, p. 52. (Accessed Jun. 2024).

CCS/CHPP – Specific documentation containing certain information must be submitted by the Endocrine SCC or provider to Medi-Cal Rx. See notice for additional information and requirements.

SOURCE: CA Dept. of Health Care Services. California Children’s Services Numbered Letter 15-1222. CGM as a CCS and GHPP Program Benefit. Dec. 23, 2022. (Accessed Jun. 2024).

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Colorado

Last updated 08/13/2024

POLICY

Telehealth monitoring is available for members who are eligible …

POLICY

Telehealth monitoring is available for members who are eligible through the Home Health benefit and should not be billed as telemedicine. Providers rendering telehealth monitoring should refer to the Home Health Billing Manual located on the Billing Manuals web page under the CMS 1500 drop-down menu.

SOURCE: CO Department of Health Care Policy and Financing. “Telemedicine Billing Manual” 5/24. (Accessed Aug. 2024).

The CO Medical Assistance Program will reimburse for home health care or home and community-based services through telemedicine at a flat fee set by the state board.

SOURCE: CO Revised Statutes 25.5-5-321. (Accessed Aug. 2024)

Home care agencies and home care placement agencies rules must allow for supervision in person or by telemedicine or telehealth. Any rules adopted by the board shall be in conformity with applicable federal law and must take into consideration the appropriateness, suitability and necessity of the method of supervision permitted.

SOURCE: CO Revised Statutes 25-27.5-104. (Accessed Aug. 2024).

Home Health Telehealth means the remote monitoring of clinical data transmitted through electronic information processing technologies, from the client to the home health provider which meet HIPAA compliance standards.

SOURCE: 10 CO Code of Regulation 2505-10 8.520.1.L. (Accessed Aug. 2024).

The Home Health Agency shall create policies and procedures for the use and maintenance of the monitoring equipment and the process of telehealth monitoring. The Home Health Agency shall provide monitoring equipment that possesses the capability to measure any changes in the monitored diagnoses and meets all the safety requirements in the regulation. Home Health Telehealth services are covered for clients receiving Home Health Services for telehealth monitoring.

SOURCE: 10 CO Code of Regulation 2505-10 8.520.5.D. (Accessed Aug. 2024).

CO Medicaid reimburses telehealth remote monitoring services including installation and on-going remote monitoring of clinical data through technologic equipment in order to detect minute changes in the member’s clinical status that will allow Home Health agencies to intercede before a chronic illness exacerbates requiring emergency intervention or inpatient hospitalization.

SOURCE: CO Medical Assistance Program, Home Health Billing Manual, (7/24), (Accessed Aug. 2024).

CO Medicaid covers home health telehealth, which includes frequent and ongoing self-monitoring of members through equipment left in the member’s home which is designed to measure the common signs and symptoms of disease exacerbation before a crisis occurs allowing for timely intervention and symptom management.

SOURCE: CO Department of Health Care Policy and Financing. “Home Health Telehealth”. (Accessed Aug. 2024).

Recently Passed Legislation – Telehealth Remote Monitoring Services for Outpatient Clinical Services

Telehealth remote monitoring means the ongoing remote assessment and monitoring of clinical data through technological equipment in order to detect changes in a member’s clinical status, which allows health-care providers to intervene before a health condition exacerbates and requires emergency intervention or inpatient hospitalization.

On or before September 1, 2024, the state department shall initiate a stakeholder process to determine the billing structure for telehealth remote monitoring for outpatient clinical services. See legislation and Telemedicine Provider Information website for more information on the stakeholder process and requirements.

On or before June 30, 2025, the state board shall promulgate rules regarding the billing structure based on feedback from the stakeholder process.

SOURCE: CO Revised Statutes 25.5-5-337 as proposed to be added by SB 24-168 (2024 Session). (Accessed Aug. 2024).

Recently Passed Legislation – Continuous Glucose Monitors Coverage

Continuous glucose monitor means an instrument or a device designed for the purpose of aiding in the treatment of diabetes by measuring glucose levels on demand or at set intervals through a small, electronic sensor that slightly penetrates an individual’s skin when applied and that is designed to remain in place and active for a least seven days. Beginning November 1, 2025, the state department shall provide coverage for a continuous glucose monitor and related supplies to members under the Medicaid Medical and Pharmacy benefit.

SOURCE: CO Revised Statutes 25.5-5-338 as proposed to be added by SB 24-168 (2024 Session). (Accessed Aug. 2024).

Continuous Glucose Monitor (CGM) Coverage – Refer to the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Billing Manual for CGM criteria with adherence to the member’s regimen and treatment plan.

SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin. May 2024. (Accessed Aug. 2024).

TCM Monitoring Visits

Rural travel add-ons may be billed for members residing in counties designated as rural or frontier. Rural add-on may not be billed in conjunction with telephone/virtual monitoring. This work includes monitoring the effective and efficient provision of services across multiple funding sources.

SOURCE: CO Dep. of Health Care Policy and Financing, Home and Community-Based Services for Persons with Intellectual and/or Developmental Disabilities Waiver Programs & Targeted Case Management for Home and Community-Based Services Waiver Programs, Last revised 6/23/24, (Accessed Aug. 2024).

CONDITIONS

A member is eligible only if they meet the following criteria:

Member must receive Home Health services from provider who has opted to provide telehealth services
Member must require frequent and on-going monitoring/management of their disease or condition
Member’s home environment must be compatible with the use of the equipment
Member or caregiver must be willing and able to comply with vital sign self-monitoring
Member must have one or more of the following diagnoses:
1. Congestive Heart Failure
2. Chronic Obstructive Pulmonary Disease
3. Asthma
4. Diabetes
5. Other diagnosis or condition deemed appropriate by the Department or its designee

SOURCE: CO Department of Health Care Policy and Financing. “Home Health Telehealth”. (Accessed Aug. 2024).

The following requirements must be met:

Client is receiving services from a home health provider for at least one of the following: congestive heart failure, chronic obstructive pulmonary disease, asthma, or diabetes, pneumonia; or other diagnosis or medical condition deemed eligible by the Department or its Designee.
Client requires ongoing and frequent, minimum of 5 times weekly, monitoring to manage their qualifying diagnosis, as defined and ordered by a physician or podiatrist;
Client has demonstrated a need for ongoing monitoring as evidenced by having been hospitalized two or more times in the last twelve months for conditions related to the qualifying diagnosis; or, if the client has received home health services for less than six months, the client was hospitalized at least once in the last three months, an acute exacerbation of a qualifying diagnosis that requires telehealth monitoring, or new onset of a qualifying disease that requires ongoing monitoring to manage the client in their residence;
Client or caregiver misses no more than 5 transmissions of the provider and agency prescribed monitoring events in a thirty-day period; and
Client’s home environment has the necessary connections to transmit the telehealth data to the agency and has space to set up and use the equipment as prescribed.

SOURCE: 10 CO Code of Regulation 2505-10 8.520.5.D. (Accessed Aug. 2024).

Recently Passed Legislation – Telehealth Remote Monitoring Services for Outpatient Clinical Services

Beginning July 1, 2025, the state department shall provide reimbursement for the use of telehealth remote monitoring for outpatient clinical services if:

The member’s health-care provider determines that telehealth remote monitoring is medically necessary based on the member’s medical condition or status;
The member’s health care provider determines that telehealth remote monitoring would likely prevent the member’s admission or readmission to a hospital, emergency department, nursing facility, or other clinical setting;
The member is cognitively and physically capable of operating the telehealth remote monitoring devices or equipment or the member has a caregiver who is able and willing to assist with the telehealth remote monitoring device or equipment; and
The member resides in a setting that is suitable for telehealth remote monitoring and does not have health-care staff on site.

The state board shall promulgate rules regarding additional eligibility requirements. The eligibility requirements must prioritize members who are pregnant and carrying a high-risk pregnancy.

SOURCE: CO Revised Statutes 25.5-5-337 as proposed to be added by SB 24-168 (2024 Session). (Accessed Aug. 2024).

Recently Passed Legislation – Continuous Glucose Monitors Coverage

Beginning November 1, 2025, the state department shall provide coverage for a continuous glucose monitor and related supplies to members under the Medicaid Medical and Pharmacy benefit. Coverage criteria must align with the current glucose monitor local coverage determination standards issued by the Centers for Medicare and Medicaid that are used to determine coverage for Medicare-eligible individuals, including individuals with gestational diabetes not being treated with insulin. Coverage pursuant to this section includes the cost of any necessary repairs or replacement parts for the continuous glucose monitor.

SOURCE: CO Revised Statutes 25.5-5-338 as proposed to be added by SB 24-168 (2024 Session). (Accessed Aug. 2024).

PROVIDER LIMITATIONS

Any home health agency is eligible to provide services. A specific list of agencies providing these services via telehealth is listed.

SOURCE: CO Department of Health Care Policy and Financing. “Home Health Telehealth”. (Accessed Aug. 2024).

Acute home health agencies and long-term home health agencies are reimbursed for the initial installation and education of telehealth monitoring equipment and can be billed once per client per agency. The agency can also bill for every day they receive and review the client’s clinical information.

No prior authorization needed, but agencies should notify the Department or its designee when a client is enrolled in the service.

SOURCE: CO Medical Assistance Program, Home Health Billing Manual, (7/24), (Accessed Aug. 2024).

A home health-care or home- and community-based services provider who delivers services through telemedicine shall provide to each patient, before treating that patient through telemedicine for the first time, the following written statements:

That the patient retains the option to refuse the delivery of home health care or home- and community-based services via telemedicine at any time without affecting the patient’s right to future care or treatment and without risking the loss or withdrawal of any program benefits to which the patient would otherwise be entitled;
That all applicable confidentiality protections shall apply to the services; and
That the patient shall have access to all medical information resulting from the telemedicine services as provided by applicable law for patient access to his or her medical records.

The provisions of paragraph (a) of this subsection (4) shall not apply in an emergency.

SOURCE: CO Revised Statutes 25.5-5-321. (Accessed Aug. 2024).

Recently Passed Legislation – Telehealth Remote Monitoring Services for Outpatient Clinical Services

The assessment and monitoring of the health data transmitted by telehealth remote monitoring must be performed by one of the following licensed health-care professionals:

Physician
Podiatrist
Advanced Practice Registered Nurse
Physician Assistant
Respiratory Therapist
Pharmacist; or
Licensed health-care professional working under the supervision of a medical director

SOURCE: CO Revised Statutes 25.5-5-337 as proposed to be added by SB 24-168 (2024 Session). (Accessed Aug. 2024).

OTHER RESTRICTIONS

Home Health services are covered under Medicaid only when all of the following are met:

Services are medically necessary.
Services are provided under a plan of care as defined at Section 8.520.1 DEFINITIONS.
Services are provided on an intermittent basis, as defined at Section 8.520.1, DEFINITIONS.
The client meets one of the following:
1. The only alternative to Home Health services is hospitalization or emergency room care; or
2. Client’s medical records indicate that medically necessary services should be provided in the client’s home instead of other out-patient setting, according to one or more of the following guidelines:
  1. The client, due to illness, injury or disability, is unable to travel to an outpatient setting for the needed service;
  2. Based on the client’s illness, injury, or disability, travel to an outpatient setting for the needed service would create a medical hardship for the client;
  3. Travel to an outpatient setting for the needed service is contraindicated by a documented medical diagnosis;
  4. Travel to an outpatient setting for the needed service would interfere with the effectiveness of the service; or
  5. The client’s medical diagnosis requires teaching which is most effectively accomplished in the client’s place of residence on a short-term basis.
The client is unable to perform the health care tasks for him or herself, and no unpaid family/caregiver is able and willing to perform the tasks; and
Covered service types are those listed in Service Types, Section 8.520.5.

SOURCE: 10 CO Code of Regulation 2505-10 8.520.4.A. (Accessed Aug. 2024).

Reimbursement shall not be provided for purchase or lease of telemedicine equipment.

SOURCE: CO Revised Statutes 25.5-5-321. (Accessed Aug. 2024).

Continuous Glucose Monitor (CGM) Coverage

Refer to the Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Billing Manual for CGM criteria with adherence to the member’s regimen and treatment plan. Providers must adhere to the following criteria:

The treating practitioner must have an in-person or telehealth visit with the member to assess adherence to their CGM regimen and diabetes treatment plan every six (6) months following the initial prescription of the CGM.
Providers must document what education and counseling occurred with the member to improve adherence for the next six (6) months in cases where adherence has not been optimal.

SOURCE: CO Department of Health Care Policy and Financing. Provider Bulletin. May 2024. (Accessed Aug. 2024).

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Connecticut

Last updated 07/17/2024

POLICY

Telehealth includes (1) telemedicine (synchronized audio-visual two-way communication services) …

POLICY

Telehealth includes (1) telemedicine (synchronized audio-visual two-way communication services) and, where specified by DSS, (2) audio-only two-way synchronized communication services delivered via telephone.

SOURCE: CT Policy – Provider Bulletin 2023-38. May 2023. (Accessed Jul. 2024).

“Telehealth” means the mode of delivering health care or other health services via information and communication technologies to facilitate the diagnosis, consultation and treatment, education, care management and self-management of a patient’s physical, oral and mental health, and includes (A) interaction between the patient at the originating site and the telehealth provider at a distant site, and (B) synchronous interactions, asynchronous store and forward transfers or remote patient monitoring. “Telehealth” does not include the use of facsimile, texting or electronic mail.

SOURCE: CT General Statute 17b, Sec. 245g. (Accessed Jul. 2024).

Telehealth FAQs

Is there a difference between Telehealth and Telemedicine under the Connecticut Medical Assistance Program (CMAP)?

Yes, DSS is using the term telehealth as a broad umbrella term for remote health services currently including either telemedicine or audio only. Telemedicine is defined as synchronized audio-visual two-way communication services. Audio only is defined as a two-way synchronized communication services delivered via telephone.

SOURCE: CT Medical Assistance Program (CMAP) Telehealth FAQs (May 11, 2023). (Accessed Jul. 2024).

TRANSMISSION FEE

OTHER RESTRICTIONS

Before RPM services can be provided, the distant telehealth practitioner must ensure that:

The recipient is cognitively and physically capable of operating the RPM equipment or that the recipient has a caregiver willing and able to assist with the equipment;
The recipient’s residence is suitable for RPM Services; and
The recipient or caregiver, as appropriate, receives education and training on the use, maintenance, and safety of the RPM equipment.

SOURCE: DE Medical Assistance Program. Practitioner Provider Specific Manual, 1/12/24. Ch. 16.2.9, pg. 74. (Accessed Jul. 2024).

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District of Columbia

Last updated 06/05/2024

POLICY

There is no reimbursement for remote patient monitoring.

The recipient has been diagnosed by his or her primary care physician, or another licensed health care practitioner authorized to make such diagnosis, with Type 1 diabetes, Type 2 diabetes, gestational diabetes, or any other type of diabetes that may be treated with insulin; and
A health care practitioner with the applicable prescribing authority has prescribed insulin to treat the recipient’s diabetes and a continuous glucose monitor to assist the recipient and practitioner in managing the recipient’s diabetes.

SOURCE: FL Statute Sec. 409.9063, (Accessed Nov. 2024).

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

Coverage under this section includes the cost of any necessary repairs or replacement parts for the continuous glucose monitor.

To qualify for continued coverage under this section, the Medicaid recipient must participate in follow-up care with his or her treating health care practitioner, in person or through telehealth, at least once every 6 months during the first 18 months after the first prescription of the continuous glucose monitor for the recipient has been issued under this section, to assess the efficacy of using the monitor for treatment of his or her diabetes. After the first 18 months, such follow-up care must occur at least once every 12 months.

SOURCE: FL Statute Sec. 409.9063, (Accessed Nov. 2024).

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Georgia

Last updated 05/23/2024

POLICY

Pilot Program to Reduce Infant and Maternal Mortality

The

…

POLICY

Pilot Program to Reduce Infant and Maternal Mortality

The Department of Public Health shall conduct a pilot program to provide home visiting in at-risk and underserved rural communities during pregnancy and early childhood to improve birth outcomes, reduce preterm deliveries, and decrease infant and maternal mortality.

Source: SB 106. (Accessed May 2024).

CONDITIONS

On and after July 1, 2023, the department shall include coverage for continuous glucose monitors as a benefit under Medicaid via the most cost-effective benefit delivery channel. The criteria for such coverage shall be updated to align with current standards of

care and shall include, but shall not be limited to, requirements that:

The recipient has been diagnosed with diabetes mellitus by a treating practitioner;
The recipient’s treating practitioner has concluded that the recipient or the recipient’s caregiver has had sufficient training in using a continuous glucose monitor as evidenced by the provision of a prescription therefor; and
The recipient:
- Is treated with at least one daily administration of insulin; or
- Has a history of problematic hypoglycemia with documentation of at least one of the following:
  - Recurrent level 2 hypoglycemic events (glucose less than 54 mg/dL (3.0 mmol/L)) that persist despite two or more attempts to adjust medication, modify the diabetes treatment plan, or both; or
  - A history of a level 3 hypoglycemic event (glucose less than 54 mg/dL (3.0 mmol/L)) characterized by altered mental or physical state requiring third-party assistance for treatment for hypoglycemia.

IL Medicaid will cover home uterine monitoring with prior approval and when patient meets specific criteria. Payment is only for the items and not for the service.

SOURCE: IL Dept. of Healthcare and Family Services, Handbook for Durable Medical Equipment, Chapter M-200, Policy and Procedures for Medical Equipment and Supplies, p. 56 (Sept. 2015). (Accessed Jul. 2024).

Continuous Glucose Monitoring (For Enrolled Pharmacies)

The Department of Healthcare and Family Services’ (HFS) will cover for continuous glucose monitors (CGMs) as required under Public Act 102-1093. Coverage is provided under both Medicaid fee-for-service (FFS) and the HealthChoice Illinois (HCI) managed care plans (MCOs).

The Act requires medically necessary CGMs be provided for individuals diagnosed with type 1 or type 2 diabetes who require insulin for the management of their diabetes. HFS already provides coverage for medically necessary CGMs and insulin, and no program coverage changes are necessary. The criteria for CGM coverage can be found at Criteria and Forms | HFS (illinois.gov) under the Criteria heading.

SOURCE: IL Dept of Healthcare and FamilyServices Provider Notice 7/25/22 Confirmation of Coverage for Continuous Glucose Monitors. (Accessed Jul. 2024).

The Department shall adopt rules to implement the changes made to Section 356z.59 of the Illinois Insurance Code, as applied to the medical assistance program. The rules
shall, at a minimum, provide that:

the ordering provider must be a physician licensed under the Medical Practice Act of 1987 or a certified nurse practitioner or physician assistant with a collaborative agreement with the physician; the ordering provider is not required to obtain continuing medical education in order to prescribe a continuous glucose monitor;
continuous glucose monitors are not required to have an alarm when glucose levels are outside the pre-determined range; the capacity to generate predictive alerts in case of impending hypoglycemia; or the ability to transmit real-time glucose values and alerts to the patient and designated other persons;
the beneficiary is not required to need intensive insulin therapy;
the beneficiary is not required to have a recent history of emergency room visits or hospitalizations related to hypoglycemia, hyperglycemia, or ketoacidosis;
if the beneficiary has gestational diabetes, the beneficiary is not required to have suboptimal glycemic control that is likely to harm the beneficiary or the fetus;
if a beneficiary has diabetes mellitus and the beneficiary does not meet the coverage requirements or if the beneficiary is in a population in which continuous glucose monitor usage has not been well-studied, requests shall be reviewed, on a case-by-case basis, for medical necessity and approved if appropriate; and
prior authorization is required for a prescription of a continuous glucose monitor; once a continuous glucose monitor is prescribed, the prior authorization shall be approved for a 12-month period.

SOURCE: Senate Bill 3414, (2024 Session), (Accessed Jul. 2024).

Community-Integrated Living Arrangements (CILA)

“Remote Monitoring and Supports.” The use of electronic interactive technology (e.g., a device, a product, or system) to provide supports and services, absent of direct care staff, in accordance with the Health Care Affordability Act [305 ILCS 5/12-21.21]. Remote monitoring and supports are meant to increase independence and daily living skills of individuals.

SOURCE: IL Admin. Code, Title 59, Chapter 1, Part 115, Sec. 115.120. (Accessed Jul. 2024).

CILA agencies may provide remote monitoring and support services in community-integrated living arrangements pursuant to 305 ILCS 5/12-21.21, as determined by DDD. Remote monitoring and supports (i.e., video, web-cameras, or other interactive technology) may be provided to increase independence and daily living skills of an individual and address an individual’s needs and outcomes identified in their personal plan. Remote supports and services must be based on an assessment which shall, at a minimum, identify risks important in considering whether remote monitoring and supports are appropriate for the individual.

SOURCE: IL Admin Code, Title 59; Chapter 1, Part 115, Sec. 115.320(C)(7). (Accessed Jul. 2024).

CONDITIONS

Only for home uterine monitoring.

Home uterine monitoring
Must be at least 24 weeks gestation; gestation of less than 24 weeks may require additional information
Hospitalized for preterm labor at 24-36 weeks
Cessation of labor accomplished by administration of tocolytics (terbutaline, procardia, etc.)
Discharged to home on oral or subcutaneous tocolytics
Multiple gestation pregnancy
History of preterm labor and delivery
Cervical status change (lengthening or dilation)
Cervical effacement
Contraction threshold
Gravida/para

Pregnancy-Induced Hypertension Monitor

Covered for diagnosis of pregnancy-induced hypertension, previous pregnancy induced hypertension or pre-eclampsia
Hospitalizations for symptoms related to pregnancy induced; i.e., hypertension, headaches, edema in face, hands and feet
Blurred vision
Right upper quadrant pain
24-hour urine results greater than 300 mg of total protein
Antihypertensive medications
Pre-pregnancy and current blood pressure readings.

Will not be covered for patients with a diagnosis of chronic hypertension.

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

No Reference Found

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Indiana

Last updated 08/07/2024

POLICY

The Indiana Health Coverage Programs (IHCP) covers select medical, …

POLICY

The Indiana Health Coverage Programs (IHCP) covers select medical, dental and remote patient monitoring services delivered via telehealth.

Remote patient monitoring (RPM) is the scheduled monitoring of clinical data transmitted through technologic equipment in the member’s home. Data is transmitted from the member’s home to the provider location to be read and interpreted by a qualified practitioner. The technologic equipment enables the provider to detect minute changes in the member’s clinical status, which allows providers to intercede before the member’s condition advances and requires emergency intervention or inpatient hospitalization.

The IHCP has implemented a single RPM coverage and prior authorization policy to be used for fee-forservice (FFS) and managed care delivery systems. This coverage and PA policy applies to all IHCP programs that offer such services – including but not limited to Healthy Indiana Plan (HIP), Hoosier Care Connect, Hoosier Healthwise and Traditional Medicaid.

The IHCP covers the RPM services listed in the Procedure Codes Covered for Remote Patient Monitoring table on Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers. The service must be billed with POS code 02 or 10 and with modifier 95, as described in the Billing and Reimbursement for Telehealth Services section.

Prior authorization is required for specified RPM services, as indicated in the Procedure Codes for Remote Patient Monitoring Services table, in Telehealth and Virtual Services Codes, accessible from the Code Sets page at in.gov/medicaid/providers.

See manual for further details.

SOURCE: Indiana Health Coverage Programs, Provider Reference Module, Telehealth and Virtual Services (Feb. 29, 2024), p. 1, 9. (Accessed Mar. 2024).

Effective for dates of service on or after July 21, 2022, procedure codes 99091, 99453, 99454, 99457 and 99458 will be covered RPM services. RPM or “remote patient monitoring technology” is listed under the definition of telehealth services per Indiana Code IC 25-1-9.5-6.

The IHCP is implementing a single RPM coverage and prior authorization (PA) policy to be used for fee-for service (FFS) and managed care delivery systems. This coverage and PA policy apply to all IHCP programs that offer such services – including but not limited to Healthy Indiana Plan (HIP), Hoosier Care Connect, Hoosier Healthwise and Traditional Medicaid.

See Bulletin for more information.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202238 (May 17, 2022). (Accessed Aug 2024).

Indiana Code requires Medicaid to reimburse providers who are licensed as a home health agency for telehealth services.

SOURCE: IN Code, 12-15-5-11(b)(5). (Accessed Aug. 2024).

Medicaid will reimburse Home Health Agencies for telehealth services.

SOURCE: IN Admin Code Title 405, 1-4.2-3 & 5-16-2 & IHCP Home Health Services (Oct. 3, 2023), p. 2. (Accessed Aug. 2024).

CONDITIONS

The member must meet one or more of the following criteria to receive prior authorization for an RPM service:

Received an organ transplantation within one year following the date of surgery
Had a surgical procedure (three-month service authorization following the date of surgery)
Had one or more uncontrolled chronic conditions that significantly impaired the patient’s health or resulted in two or more related hospitalizations or emergency department visits in the previous 12 months
Had been readmitted within 30 days for the same or similar diagnosis or condition
Identified as having a high-risk pregnancy (up to three-month service authorization postpartum); see the Obstetrical and Gynecological Services provider reference module for more information about high-risk pregnancy

The duration of initial service authorization is six months, unless otherwise indicated. Reauthorizations will be permitted for select services as appropriate.

SOURCE: Indiana Health Coverage Programs, Provider Reference Module, Telehealth and Virtual Services (Feb. 29, 2024, p. 9-10. (Accessed Aug. 2024).

The member must be receiving services from a home health agency. Member must initially have two or more of the following events related to one of the conditions listed below within the previous twelve months:

Emergency room visit
Inpatient hospital stay

An emergency room visit that results in an inpatient hospital admission does not constitute two separate events.

The two qualifying events must be for the treatment of one of the following diagnoses:

Chronic obstructive pulmonary disease
Congestive heart failure
Diabetes

SOURCE: IN Admin Code, “Article 5” Title 405, 5-16-3.1(d), p. 48-29 (Accessed Aug. 2024).

Personal Emergency Response System

The following activities are allowed under the PERS service:

Device installation
Ongoing monthly maintenance of the device
Electronic service that is usually a portal help button; however, it can also be an electronic device that includes, but is not limited to GPS or video monitoring service (Note: Remote monitoring will not be placed in participant bedrooms or bathrooms.)

SOURCE: IHCP Office of Medicaid Policy and Planning, Home and Community Based Services: Indiana PathWays for Aging Waiver, p. 80 (Jul. 1, 2024). (Accessed Aug. 2024).

PROVIDER LIMITATIONS

Reimbursement for home health agencies under certain conditions. A licensed registered nurse must perform the reading of transmitted health information provided from the member in accordance with the written order of the physician.

SOURCE: IN Admin Code, “Article 5” Title 405, 5-16-3.1(d)(5), p. 49. (Accessed Aug. 2024).

OTHER RESTRICTIONS

See Bulletin for more information.

SOURCE: Indiana Health Coverage Programs IHCP Bulletin BT 202238 (May 17, 2022). (Accessed Aug. 2024).

Treating physician must certify the need for home health services and document that there was a face-to-face encounter with the individual.

SOURCE: IN Admin Code, “Article 5” Title 405, 5-16-3.1(e), p. 49 (Accessed Aug. 2024).

Approved telehealth services are reimbursed separately from other home health services. The unit of reimbursement for telehealth services provided by an HHA is one (1) calendar day.

Reimbursement is available for telehealth services as follows:

One-time amount per client of fourteen dollars and forty-five cents ($14.45) related to an initial face-to-face visit necessary to train the member to appropriately operate the telehealth equipment.
One (1) payment of nine dollars and eighty-four cents ($9.84) for each day the telehealth equipment is used by a registered nurse (RN) to monitor and manage the client’s care in accordance with the written order from a physician.

POLICY

Telehealth visits must use face-to-face, real-time, interactive video contact to monitor members in the home setting as opposed to a nurse visiting the home. This technology can be used to monitor a member’s health status and to provide timely assessment of chronic conditions and other skilled nursing services.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, p. AIII-8 (Oct. 2024) (Accessed Nov. 2024).

Home and Community Based Services for the Frail Elderly

Home Telehealth is a remote monitoring system that enables the member to effectively manage one or more diseases and catch early signs of trouble so intervention can occur before the member’s health declines. The provision of Home Telehealth involves member education specific to one or more diseases (e.g. COPD, CHF, hypertension, and diabetes), counseling, and nursing supervision.

SOURCE: Kansas Medical Assistance Program, Provider Manual, HCBS Frail Elderly, p. 8-25. (Sept. 2024). (Accessed Nov. 2024).

CONDITIONS

Codes T1030 and T1031 are per visit for home telehealth visits. Bill T1030 and T1031 with place of service 02 and modifier GY for telehealth skilled nursing visits for Medicare-eligible members with a Medicaid-covered benefit plan.

Providers use codes T1030 and T1031 for the provision of telehealth visits under the Long-Term Care Home Health Service Plan. See specific provider requirements for the provision of telehealth services.

Providers may use codes T1030 and T1031 for the provision of telehealth visits to assist members in managing their diabetes. See specific provider requirements for the provision of telehealth services.

PRN visits can be requested at the time they occur or within five working days after a visit has been made. Calls made to the PA department during nonworking hours are considered to be notification of the request. Agencies have 15 working days from the time of the call to submit a physician’s order and completed, appropriate home health services PA request form to the PA department. If the required documentation is not submitted within the timeframe, the request will be denied. PRN telehealth visits are noncovered

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, (Oct. 2024). (Accessed Nov. 2024).

Home and Community Based Services for the Frail Elderly

Telehealth services are provided on an individualized basis for members who have an identified need in their ISPOC. Member options and information are provided and discussed during the development of the ISPOC.

A participant can qualify if either of the following apply:

The participant is in need of disease management consultation and education AND has had two or more hospitalizations, including emergency room (ER) visits, within the previous year related to one or more diseases.
The participant is using MFP to move from a nursing facility back into the community.

SOURCE: Kansas Medical Assistance Program, Provider Manual, HCBS Frail Elderly, p. 8-25, 8-26. (Sept. 2024). (Accessed Nov. 2024).

Effective with dates of service on and after August 1, 2024, the Home and Community Based Services (HCBS)/Frail Elderly (FE) Telemonitoring installation claims must be submitted with code S0315 with a U1 modifier appended. The current HCBS/FE Telemonitoring installation coverage criteria, limitations, and prior authorization requirements will remain the same. The HCBS/FE Telemonitoring installation is not subject to Electronic Visit Verification (EVV) requirements.

SOURCE: KMAP General Bulletin 24113. Jul. 2024. (Accessed Nov. 2024).

PROVIDER LIMITATIONS

Telehealth visits must be provided by a RN or LPN.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, (Oct. 2024). (Accessed Nov. 2024).

Home and Community Based Services for the Frail Elderly

A registered nurse (RN) or licensed practical nurse (LPN) with RN supervision must set up, supervise, and provide participant counseling.

Providers can include home health agencies or county health departments with system equipment capable of monitoring participant vital signs daily. This includes (at a minimum) heart rate, blood pressure, mean arterial pressure, weight, oxygen saturation, and temperature. Also, the provider must have the capability to ask the participant questions which are tailored to his or her diagnosis.

The provider and equipment must have needed language options such as English, Spanish, Russian, and Vietnamese.

SOURCE: Kansas Medical Assistance Program, Provider Manual, HCBS Frail Elderly, p. 8-26, 8-27. (Sept. 2024). (Accessed Nov. 2024).

OTHER RESTRICTIONS

Home Telehealth Limitations

Providers must bill T1030 and T1031 with place of service 02 for home telehealth skilled nursing visits. These codes are per visit.
PAs are entered for no more than 60 days. Home telehealth services cannot be approved for durations of more than 60 days. Additional documentation may be required to support continuation of home telehealth service requests that exceed 60 days.
Telehealth visits must be provided by a RN or LPN.
Telehealth visits must use face-to-face, real-time, interactive video contact to monitor members in the home setting as opposed to a nurse visiting the home. This technology can be used to monitor a member’s health status and to provide timely assessment of chronic conditions and other skilled nursing services.
HCBS members eligible for face-to-face skilled nursing visits provided by a home health agency (05-050) may also receive home telehealth visits with documentation of medical necessity and PA. The PA request must include units to cover the duration and frequency of home telehealth visits.
Oral medication administration or monitoring is not considered skilled care.

Providers must be able to demonstrate that the equipment used to render home telehealth services meets program specifications (real-time, interactive, audio and video telecommunication) and is HIPAA compliant.

Providers must be able to obtain and maintain telecommunication devices to render home telehealth visits.

When the provider has satisfied all the enrollment/demonstration requirements and a site visit is performed by the state program manager, KMAP will approve enrollment of PT/PS 05-051.

Providers are eligible for reimbursement of home telehealth services that meet the following criteria:

Prescribed by a physician or allowed nonphysician practitioner
Considered medically necessary
Signed member consent for telehealth services
Skilled nursing service
Does not exceed program limitations (limited to two visits per week for non-HCBS members)

Upon completion of the enrollment process and approval of the telehealth demonstration, home health agencies should refer to home telehealth prior authorization criteria as noted in this appendix for further guidance.

SOURCE: Dept. of Health and Environment, Kansas Medical Assistance Program, Provider Manual, Home Health, (Oct. 2024). (Accessed Nov. 2024).

Home and Community Based Services for the Frail Elderly

See HCBS Frail Elderly provider manual for documentation requirements.

SOURCE: Kansas Medical Assistance Program, Provider Manual, HCBS Frail Elderly, p. 8-28. (Sept. 2024). (Accessed Nov. 2024).

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Kentucky

Last updated 11/28/2024

POLICY

Pursuant to Section 7 of this administrative regulation, remote …

POLICY

Pursuant to Section 7 of this administrative regulation, remote patient monitoring shall be an eligible telehealth service within the fee-for-service and managed care Medicaid programs.

A recipient participating in a remote patient monitoring service shall:

Have the capability to utilize any monitoring tools involved with the ordered remote patient monitoring service. For the purposes of this paragraph, capability shall include the regular presence of an individual in the home who can utilize the involved monitoring tools; and
Have the internet or cellular internet connection necessary to accommodate any needed remote patient monitoring equipment in the home.

The department may restrict the remote patient monitoring benefit by excluding:

Remote patient monitoring equipment;
Upgrades to remote patient monitoring equipment; or
An internet connection necessary to transmit the results of the services.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Nov. 2024).

Health care providers performing a telehealth or digital health service shall, as appropriate for the service, provider, and recipient, utilize the following modalities of communication delivered over a secure communications connection that complies with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA):

Live or real-time audio and video synchronous telehealth technology;
Asynchronous store-and-forward telehealth technology;
Remote patient monitoring using wireless devices, wearable sensors, or implanted health monitors;
Audio-only telecommunications systems; or
Clinical text chat technology when:
- Utilized within a secure, HIPAA compliant application or electronic health record system; and

- Meeting:
  - The scope of the provider’s professional licensure; and
  - The scope of practice of the provider; and
  - Comply with the following federal laws to prevent waste, fraud, and abuse relating to telehealth:
    - False Claims Act, 31 U.S.C. § 3729-3733;
    - Anti-Kickback Statute, 42 U.S.C. § 1320a-7b(b); and
    - Physician Self-Referral, Section 1877 of the Social Security Act

SOURCE: KY 900 KAR 12:005 (Accessed Nov. 2024).

CONDITIONS

Pursuant to Section 7 of this administrative regulation, remote patient monitoring shall be an eligible telehealth service within the fee-for-service and managed care Medicaid programs.

Conditions for which remote patient monitoring shall be covered include:

Pregnancy;
Diabetes;
Heart disease;
Cancer;
Chronic obstructive pulmonary disease;
Hypertension;
Congestive heart failure;
Mental illness or serious emotional disturbance;
Myocardial infarction;
Stroke; or
Any condition that the department determines would be appropriate and effective for remote patient monitoring.

Except for a recipient participating due to a pregnancy, a recipient receiving remote patient monitoring services shall have two (2) or more of the following risk factors:

Two (2) or more inpatient hospital stays during the prior twelve (12) month period;
Two (2) or more emergency department admissions during the prior twelve (12) month period;
An inpatient hospital stay and a separate emergency department visit during the prior twelve (12) month period;
A documented history of poor adherence to ordered medication regimens;
A documented history of falls in the prior six (6) month period;
Limited or absent informal support systems;
Living alone or being home alone for extended periods of time;
A documented history of care access challenges; or
A documented history of consistently missed appointments with health care providers.

A recipient may participate in a remote patient monitoring program as the result of a pregnancy if the provider documents that the recipient has a condition that would be improved by a remote patient monitoring service.

A recipient participating in a remote patient monitoring service shall:

Have the capability to utilize any monitoring tools involved with the ordered remote patient monitoring service. For the purposes of this paragraph, capability shall include the regular presence of an individual in the home who can utilize the involved monitoring tools; and
Have the internet or cellular internet connection necessary to accommodate[host] any needed remote patient monitoring equipment in the home.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Nov. 2024).

PROVIDER LIMITATIONS

Remote patient monitoring shall be ordered by:

A physician;
An advanced practice registered nurse;
A physician assistant; or
When operating within their scope of practice and licensure, the following behavioral health practitioners:
- A psychiatrist;
- A licensed psychologist;
- A licensed psychological practitioner;
- A certified psychologist with autonomous functioning;
- A licensed clinical social worker;
- A licensed marriage and family therapist;
- A licensed professional art therapist;
- A licensed clinical alcohol and drug counselor; or
- A licensed behavior analyst.

Providers who may provide remote patient monitoring services include:

A home health agency;
A hospital;
A federally qualified health center;
A rural health center;
A primary care center;
A physician;
An advanced practice registered nurse;
A physician assistant;
A behavioral health multi-specialty group participating in the Medicaid Program pursuant to 907 KAR 15:010;
A behavioral health services organization participating in the Medicaid Program pursuant to 907 KAR 15:020 or 907 KAR 15:022;
A residential crisis stabilization unit participating in the Medicaid Program pursuant to 907 KAR 15:070;
A chemical dependency treatment center participating in the Medicaid Program pursuant to 907 KAR 15:080;
A community mental health center that is participating in the Medicaid Program in compliance with 907 KAR 1:044, 907 KAR 1:045, or 907 KAR 1:047; or
A certified community behavioral health clinic that is participating in the Medicaid Program.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Nov. 2024).

OTHER RESTRICTIONS

The department may restrict the remote patient monitoring benefit by excluding:

Remote patient monitoring equipment;
Upgrades to remote patient monitoring equipment; or
An internet connection necessary to transmit the results of the services.

SOURCE: KY Admin. Regs. Title, 907, 3:170. (Accessed Nov. 2024).

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Louisiana

Last updated 11/06/2024

POLICY

Remote patient monitoring services as provided for in the …

POLICY

Remote patient monitoring services as provided for in the Louisiana Remote Patient Monitoring Program Law, R.S. 40:1227.1 et seq., shall be a covered service in the medical assistance program.

SOURCE: House Bill 896 (2024 Session), & LA Statute Title 40, Sec. 1221.1 (Accessed Nov. 2024).

“Remote patient monitoring services” means the delivery of in-home healthcare services using telecommunications technology to enhance the delivery of in-home health care, including but not limited to all of the following:

Monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, and other condition-specific data, such as blood glucose and activity trackers.
Medication adherence monitoring.
Interactive video conferencing with or without digital image upload.

“Telehealth” has the same meaning as defined in R.S. 40:1223.3.

SOURCE: House Bill 896 (2024 Session), & LA Statute Title 40, Sec. 1227.3 (Accessed Nov. 2024).

Remote patient monitoring services through telehealth may consist of all of the following:

An assessment, problem identification, and evaluation which includes all of the following:
- Assessment and monitoring of clinical data, including but not limited to appropriate vital signs, pain levels, and other biometric measures specified in the plan of care and an assessment of responses to previous changes in the plan of care.
- Detection of condition changes based on the telehealth encounter that may indicate the need for a change in the plan of care.
Implementation of a management plan through one or more of the following:
- Teaching regarding medication management as appropriate based on the telemedicine findings for that encounter.
- Teaching regarding other interventions as appropriate to both the patient and the caregiver.
- Management and evaluation of the plan of care including changes in visit frequency or addition of other skilled services.
- Coordination of care with the ordering healthcare provider regarding telehealth findings.
- Coordination and referral to other healthcare providers as needed.
- Referral for an in-person visit or the emergency room as needed.

SOURCE: House Bill 896 (2024 Session), & LA Statute Title 40, Sec. 1227.6 (Accessed Nov. 2024).

Personal Emergency Response System (PERS)

PERS is an electronic device that enables the beneficiary to secure help in an emergency. See manual for details.

Community Choices Waiver

Telecare is a delivery of care services to beneficiaries in their home by means of telecommunications and/or computerized devices to improve outcomes and quality of life, increase independence and access to health care, and reduce health care costs. Telecare services include the following:

Activity and Sensor Monitoring,
Health status monitoring, and
Medication dispensing and monitoring.

Monthly telecare services consist of:

Delivering, furnishing, maintaining and repairing/replacing equipment on an ongoing basis. This may be done remotely as long as all routine requests are resolved within three business days;
Monitoring of recipient-specific service activities by qualified staff;
Training the recipient and/or the recipient’s responsible representative in the use of the equipment;
Cleaning and storing equipment;
Providing remote teaching and coaching as necessary to the recipient and/or caregiver(s); and
Analyzing data, developing and documenting interventions by qualified staff based on information/data reported.

Activity and Sensor Monitoring

This service is a computerized system that monitors the beneficiary’s in-home movement and activity for health, welfare, and safety purposes. The system is individually calibrated based on the beneficiary’s typical in-home movements and activities. The provider agency is responsible for monitoring electronically generated information, for responding as needed, and for equipment maintenance. At a minimum, the system shall include the following:

Monitor the home’s points of egress;
Detect falls;
Detect movement or lack of movement;
Detect whether doors are opened or closed; and
Provide a push button emergency alert system.

Some systems also monitor the home’s temperature.

Health Status Monitoring

The health status monitoring service collects health-related data to assist the health care provider in assessing the beneficiary’s health condition and in providing beneficiary education and consultation. The data is collected electronically from the beneficiary using wireless technology or a phone line and assists the healthcare provider in assessing the beneficiary’s health. Health status monitoring may be beneficial to beneficiaries with chronic medical conditions such as congestive heart failure, diabetes, or pulmonary disease in monitoring the beneficiary’s:

Weight;
Oxygen saturation measurements (pulse oximetry); and
Vital signs (pulse, blood pressure, etc.).

Peripheral equipment used must be capable of interfacing with the telecare health status monitoring equipment.

Medication Dispensing and Monitoring

The medication dispensing and monitoring service assists the beneficiary by dispensing medication and monitoring medication compliance. A remote monitoring system is individually pre-programed to dispense and monitor the beneficiary’s compliance with medication therapy. The provider or family caregiver is notified when there are missed doses or non-compliance with medication therapy.

Dispensing and monitoring devices must have the ability to send text or e-mail messages to the beneficiary’s caregiver should the medication not be taken or there is a problem with the equipment.

Dispensing and monitoring systems may include a web-based component for dosage programming, monitoring, and/or communication.

SOURCE: LA Dept. of Health, Community Choices Waiver Provider Manual, Chapter Seven of the Medicaid Svcs. Manual, Section 7.1, p. 23-25 (as issued on 3/11/24). (Accessed Nov. 2024).

Standards

Assistive Devices and Medical Supplies Provided by a Durable Medical Equipment (DME) provider that:

Is enrolled to provide DME; and
Has enrolled in Medicaid as an OAAS Waivers – assistive devices provider (provider type 17);

Provided by a home health agency provider that:

Is licensed to provide home health services;
Is Medicare certified; and
Has enrolled in Medicaid as an OAAS Waivers – assistive devices provider (provider type 17).

For personal emergency response systems (PERS), these services are provided by a provider that:

Is enrolled in Medicaid as a PERS provider (provider type 16); and
Has furnished verification (copy of letter from the manufacturer written on the manufacturer’s letterhead stationary) that the provider is an authorized dealer, supplier or manufacturer of a PERS product.

The PERS provider must install and support PERS equipment in compliance with all of the applicable federal, state, parish, and local laws and regulations, as well as meet manufacturer’s specifications, response requirements, maintenance records, and beneficiary education.

SOURCE: LA Dept. of Health, Community Choices Waiver Provider Manual, Chapter Seven of the Medicaid Svcs. Manual, Section 7.6, p. 78 and 89 (As issued 3/11/24). (Accessed Nov. 2024).

Technology Supports with Remote Features:

Mobile Emergency Response System- an on-the-go mobile medical alert system, used in and outside the home. This system will cellular/GPS technology, two-way speakers and no base station required;
Medication Reminder System- an electronic device programmed to remind individual to take medications by a ring, automated recording or other alarm. The electronic device may dispense controlled dosages of mediation and may include a message back to the center if a medication has not been removed from the dispenser. Requires ability to self administer medication with reminder and services face-to-face once per month;
Monitoring Device, stand alone or intergraded, include all accessories, components and electronics not otherwise classified. Monitoring Feature device may be interactive audio and video;
Assessment of home, physical and family environment, to determine suitability to meet patient’s medical needs;
Purchase of emergency response system; and
Other equipment used to support someone remotely may include but not limited to: electronic motion door sensor devices, door alarms, web-cams, telephones with modifications (large buttons, flashing lights), devices affixed to wheelchair or walker to send alert when fall occurs, text-to-speech software, intercom systems, tablets with features to promote communication or smart device speakers.

Remote Technology Service Delivery: covers monthly response center/remote support monitoring fee and tech upkeep (no internet cost coverage)

Remote Technology Consultation: evaluation of tech support needs for an individual, including functional evaluation of technology available to address the person’s assess needs and support person to achieve outcomes identified in the POC.

SOURCE: LA Dept. of Health, Residential Options Waiver, Section 38.1, p. 47-48 (As issued 5/9/24). (Accessed Nov. 2024).

CONDITIONS

Remote patient monitoring services provided through telehealth may be used by patients who meet the requirements of this Section and are capable and willing to use home telehealth and can maintain performance of needed tasks, or have the availability of informal caregivers to help with remote patient monitoring through telehealth.

To qualify for participation in remote patient monitoring services, a patient shall meet any two of the following criteria:

Be diagnosed with one or more chronic conditions, as defined by the Centers for Medicare and Medicaid Services, which include but are not limited to sickle cell disease, mental illness, asthma, diabetes, cancer, and heart disease.
Have a recent history of costly service use due to one or more chronic conditions as evidenced by two or more hospitalizations, including emergency room visits, in the last twelve months.
Have a recommendation from the patient’s healthcare provider for disease management services through remote patient monitoring

SOURCE: House Bill 896 (2024 Session), & LA Statute Title 40, Sec. 1227.5 (Accessed Nov. 2024).

Health status monitoring:

Health status monitoring may be beneficial to beneficiaries with chronic medical conditions such as congestive heart failure, diabetes, or pulmonary disease in monitoring the beneficiary’s:

Weight;
Oxygen saturation measurements (pulse oximetry); and
Vital signs (pulse, blood pressure, etc.).

Services must be based on a verified need of the beneficiary and the service must have a direct or remedial benefit with specific goals and outcomes.

SOURCE: LA Dept. of Health, Community Choices Waiver Provider Manual, Chapter Seven of the Medicaid Svcs. Manual, Section 7.1, p. 34-35 (as issued on 3/11/24). (Accessed Nov. 2024).

PROVIDER LIMITATIONS

Remote patient monitoring services as provided for in the Louisiana Remote Patient Monitoring Program Law, R.S. 40:1227.1 et seq., shall be a covered service in the medical assistance program.

A one-time telehealth installation and training reimbursement to the telehealth provider from Medicaid for remote patient monitoring services may also be reimbursed at a maximum of two installation and training reimbursements per calendar year.

No geographic restrictions shall be placed on the delivery of remote patient monitoring services in the home setting other than requiring the patient reside within this state.

SOURCE: House Bill 896 (2024 Session), & LA Statute Title 40, Sec. 1221.1 (Accessed Nov. 2024).

Assistive devices and providers that provide telecare services under ADMS, must meet the following system requirements:

Be UL listed/certified or have 501(k) clearance;
Be web-based;
Be compliant with the requirements of the Health Insurance Portability and Accountability Act (HIPAA);
Have beneficiary specific reporting capabilities for tracking and trending;
Have a professional call center for technical support based in the United States; and
Have on-going provision of web-based data collection for each beneficiary, as appropriate. This includes response to beneficiary self-testing, manufacturer’s specific testing, self-auditing, and quality control.

SOURCE: LA Dept. of Health, Community Choices Waiver Provider Manual, Chapter Seven of the Medicaid Svcs. Manual, Section 7.6, p. 89 (As issued 3/11/24). (Accessed Nov. 2024).

OTHER RESTRICTIONS

In any reimbursement claim for the remote monitoring services provided, the appropriate procedure code as established by the Louisiana Department of Health for the covered healthcare service shall be included with the appropriate modifier indicating telehealth services were used.

Nothing in this Section shall prohibit any health benefit plan offered by a health insurer, managed care organization, or other health payor from establishing its own policy and payment structure for in lieu of service agreements with providers.

SOURCE: House Bill 896 (2024 Session), & LA Statute Title 40, Sec. 1227.8 (Accessed Nov. 2024).

Any telehealth equipment and network used for remote patient monitoring services shall meet all of the following requirements:

Compliance with applicable standards of the United States Food and Drug Administration.
Maintenance of telehealth equipment in good repair and free from safety hazards.
Installation of only new or sanitized equipment in the patient’s home setting.

SOURCE: House Bill 896 (2024 Session), & LA Statute Title 40, Sec. 1227.7 (Accessed Nov. 2024).

Where applicable, beneficiaries must use Medicaid state plan services, Medicare, or other available payers first. The beneficiary’s preference for a certain brand or supplier is not grounds for declining another payer in order to access waiver services.

Limitations

Services must be based on a verified need of the beneficiary and the service must have a direct or remedial benefit with specific goals and outcomes.
The benefit must be determined by an independent assessment on any item that costs over $500 and on all communication devices, mobility devices, and environmental controls.
Independent assessments must be performed by individuals who have no fiduciary relationship with the manufacturer, supplier, or vendor of the item.
All items must reduce reliance on other Medicaid State Plan or waiver services.
All items must meet applicable standards of manufacture, design, and installation.
The items must be on the POC developed by the support coordinator and are subject to approval by OAAS Regional office or its designee.
A beneficiary will not be able to simultaneously receive telecare activity and sensor monitoring services and traditional PERS services.

Reimbursement for Telecare services includes a one-time installation fee that covers the cost of equipment installation and removal. A monthly maintenance fee includes a face-to-face visit by a qualified professional should the collected data warrant a visit. Should the beneficiary require additional visits during the month, those visits must be conducted by a nurse, authorized by the support coordinator, and provided under Nursing Service. If the data indicates a potential emergency, the provider may dispatch a qualified professional without consultation for approval with the support coordinator; however, the support coordinator must be contacted by the next business day to request retroactive approval.

Billing for PERS or Telecare services involves an installation fee and a monthly maintenance fee. Only one claim for each month is allowed. Claims for the monthly maintenance fee may be span-dated at the discretion of the provider. Partial months shall not be billed.

If a beneficiary who receives PERS or Telecare service moves to a different location or changes providers, reimbursement for a second installment is permissible.

Assistive devices/equipment and/or medical supplies (up to $500) are reimbursed in the amount authorized in the POC or POC revision. The PA is released upon completion and submission of the Assistive Devices and Medical Supplies form and the approved POC or POC revision by the support coordinator.

SOURCE: LA Dept. of Health, Community Choices Waiver Provider Manual, Chapter Seven of the Medicaid Svcs. Manual, Section 7.1, p. 32 & 35, 107, (As issued on 3/11/24). (Accessed Nov. 2024).

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Maine

Last updated 10/23/2024

POLICY

Telemonitoring Services are the use of information technology to …

POLICY

Telemonitoring Services are the use of information technology to remotely monitor a member’s health status through the use of clinical data while the member remains in the residential setting. Telemonitoring may or may not take place in real time.

SOURCE: MaineCare Benefits Manual. Ch. II. Home Health Services. Sec. 40.01, p. 5 (Aug. 11, 2019). (Accessed Oct. 2024).

“Telemonitoring,” as it pertains to the delivery of MaineCare services, means the use of information technology to remotely monitor a patient’s health status via electronic means, allowing the provider to track the patient’s health data over time. Telemonitoring may be synchronous or asynchronous.

SOURCE: ME Statute Sec. 22:855.3173-H(E), (Accessed Oct. 2024).

Telemonitoring Services: The use of information technology to remotely monitor a Member’s health status via electronic means, allowing the provider to track the enrollee’s health data over time. Telemonitoring may be synchronous or asynchronous.

Telemonitoring Services are intended to collect a Member’s health related data, such as pulse and blood pressure readings, that assist Health Care Providers in monitoring and assessing the Member’s medical conditions. The following activities qualify as Telemonitoring Services:

Evaluation of the Member to determine if Telemonitoring Services are medically necessary for the Member. Prior to conducting an evaluation, the Home Health Agency must assure that a Health Care Provider’s order
or note demonstrating the necessity of Telemonitoring Services, is included in the Member’s Plan of Care.
Evaluation of the Member to assure that the Member is cognitively and physically capable of operating the Telemonitoring equipment or assurance that the Member has a caregiver willing and able to assist with the equipment;
Evaluation of the Member’s residence to determine suitability for Telemonitoring Services. If the residence appears unable to support Telemonitoring Services, the Home Health Agency may not implement Telemonitoring Services in the Member’s residence unless necessary adaptations are made. Adaptations are not reimbursable by MaineCare;
Education and training of the Member and/or caregiver on the use, maintenance and safety of the Telemonitoring equipment, the cost of which is included in the monthly flat rate paid by MaineCare to the Home Health Agency;
Remote monitoring and tracking of the Member’s health data by a registered nurse, nurse practitioner, physician’s assistant, or physician, and response with appropriate clinical interventions. The Home Health Agency and Health Care Provider utilizing the data shall maintain a written protocol that indicates the manner in which data shall be shared in the event of emergencies or other medical complications;
At least monthly Interactive Telehealth Services or Telephonic Services with the Member;
Maintenance of equipment, the cost of which is included in the monthly flat rate paid by MaineCare to the Home Health Agency; and
Removal/disconnection of equipment from the Member’s home when Telemonitoring Services are no longer necessary or authorized.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4. (Nov. 6, 2023). Adopted 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services. (Nov. 6, 2023). (Accessed Oct. 2024).

Home and Community Benefits for the Elderly and for Adults with Disabilities

Assistive Technology-Remote Monitoring means real time remote support monitoring of the member with electronic devices to assist them to remain safely in their homes. Remote monitoring services may include a range of technological options including in-home computers, sensors, and video camera linked to a provider that enables 24/7 monitoring and/or contact as necessary.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19.04-2, p. 2 (May 2, 2021). (Accessed Oct. 2024).

CONDITIONS

In order to be eligible for telemonitoring a member must:

Be eligible for home health services;
Have a current diagnosis of a health condition requiring monitoring of clinical data at a minimum of five times per week, for at least one week;
Have documentation in the patient’s medical record that the patient is at risk of hospitalization or admission to an emergency room OR have continuously received Telemonitoring Services during the past calendar year and have a continuing need for such services, as documented by an annual note from a health care provider;
Have telemonitoring services included in the Member’s plan of care. A notation from a Health Care Provider, dated prior to the beginning of service delivery, must be included in the Member’s Plan of Care. MaineCare shall not
reimburse for Telemonitoring Services if they began prior to the date recorded in the Provider’s note.
Reside in a setting suitable to support telemonitoring equipment; and
Have the physical and cognitive capacity to effectively utilize the telemonitoring equipment or have a caregiver willing and able to assist with the equipment.
Have telemonitoring services included in the member’s plan of care. A notation from a Health Care Provider, dated prior to the beginning of service delivery, must be included in the member’s plan of care. If telemonitoring Services begin prior to the date recorded in the provider’s note, services shall not be reimbursed. [last bullet only in Home Health Services Manual].

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.02-2. p.3 (Nov. 6, 2023). Adoption 10-144 C.M.R. Chapter 101, Chapter I, Section 4, Telehealth Services (Nov 6, 2023) & MaineCare Benefits Manual. Ch. II. Home Health Services. Sec. 40.05. p. 10-11. (Aug. 11, 2019). (Accessed Oct. 2024).

Home and Community Benefits for the Elderly and for Adults with Disabilities Final approval must be obtained from the Department, Office of Aging and Disability Services upon a recommendation by the ASA or SCA. In making such a recommendation the ASA or the SCA must consider and document the following information:

Number of hospitalizations in the past year;
Use of emergency room in the past year;
History of falls in the last six months resulting from injury;
Member lives alone or is home alone for significant periods of time;
Service access challenges and reasons for those challenges;
History of behavior indicating that a member’s cognitive abilities put them at a significant risk of wandering; and
Other relevant information.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19.04-2, p. 23 (May 2, 2021). (Accessed Oct. 2024).

PROVIDER LIMITATIONS

Telemonitoring will be reimbursed only when provided by a certified Home Health Agency. See regulations for specific requirements of Home Health Agencies utilizing telemonitoring services.

SOURCE: MaineCare Benefits Manual. Ch. II. Home Health Services. Sec. 40.05. p. 16. (Aug. 11, 2019). (Accessed Oct. 2024).

In order to be eligible for reimbursement for Telemonitoring Services, a Health Care Provider must be a certified Home Health Agency pursuant to the MBM Chapter II, Section 40, Home Health Services. Compliance with all applicable requirements listed in Chapter II, Section 40, Home Health Services, is required.

The Health Care Provider ordering the service must be a Health Care Provider with prescribing privileges (physician, nurse practitioner or physician’s assistant).

Health Care Providers must document that they have had a face-to-face encounter with the Member before a physician may certify eligibility for services under the home health benefit. This may be accomplished through interactive telehealth services, but not by telephone or e-mail.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.03. p. 4 (Nov. 6, 2023). (Accessed Oct. 2024).

OTHER RESTRICTIONS

Telemonitoring services are intended to collect a member’s health-related data, such as pulse and blood pressure readings, that assist healthcare providers in monitoring and assessing the member’s medical conditions.

A note, dated prior to the beginning of service delivery, and demonstrating the necessity of home telemonitoring services, must be included in the member’s file. In the event that services begin prior to the date recorded on the provider’s note, services delivered in that month will not be covered.

Telemonitoring services must be included in the member’s plan of care. See page 16-17 for responsibilities of home health agencies utilizing telemonitoring.

SOURCE: Mainecare Benefits Manual. Ch. II. Home Health Services. Sec. 40.05. p. 16. (Aug. 11, 2019). (Accessed Oct 2024).

Services shall not be duplicate of any other services. See regulation for examples of duplication.

SOURCE: Mainecare Benefits Manual. Ch. II. Home Health Services. Sec. 40.06.p. 17-18. (Aug. 11, 2019). (Accessed Oct. 2024).

See home health manual for list of non-covered services.

SOURCE: Mainecare Benefits Manual. Ch. II. Home Health Services. Sec. 40.07. p. 18-19. (Aug. 11, 2019). (Accessed Oct. 2024).

Department required to adopt regulations that comply with the following:

May not include any requirement that a patient have a certain number of ER visits or hospitalizations related to the patient’s diagnosis in the criteria for a patient’s eligibility for telemonitoring services;
Except as provided in the last bullet point (see below), must include qualifying criteria for a patient’s eligibility of telemonitoring services that include documentation in a patient’s medical record that the patient is at risk of hospitalization or admission to an ER
Must provide that group therapy for behavioral health or addiction services covered by the MaineCare program may be delivered through telehealth;
Must include requirements for providers providing telehealth and telemonitoring services; and
Must allow at least some portion of case management services covered by the MaineCare program to be delivered through telehealth, without requiring qualifying criteria regarding a patient’s risk of hospitalization or admission to an emergency room.

SOURCE: ME Statute Sec. 3173-H, (Accessed Oct. 2024).

Home and Community Benefits for the Elderly and for Adults with Disabilities

Use of remote monitoring requires sufficient Back Up Plans and the SCA will be responsible for ensuring that the member has at least two adequate back-up plans prior to making a referral for this service.

SOURCE: MaineCare Benefits Manual, Home and Community Benefits for the Elderly and for Adults with Disabilities, 10-144 Ch. II, Sec. 19, p. 23 (May 2, 2021). (Accessed Oct. 2024).

Telemonitoring Services

Only the Health Care Provider at the Receiving (Provider) Site will be reimbursed for Telemonitoring Services.

No Originating Facility Fee will be paid for Telemonitoring Services.

Only a Home Health Agency may receive reimbursement for Telemonitoring Services.

Telemonitoring Services shall be billed using code S9110, which provides for a flat monthly fee for services, which is inclusive of all Telemonitoring Services, including, but not limited to:

Equipment installation;
Training the Member on the equipment’s use and care;
Monitoring of data;
Consultations with the primary care physician; and
Equipment removal when the Telemonitoring Service is no longer medically necessary.

Except as described in this policy, no additional reimbursement beyond the flat fee is available for Telemonitoring Services.

MaineCare will not reimburse separately for Telemonitoring equipment purchase, installation, or maintenance.

If in-person visits are required, these visits must be billed separately from the Telemonitoring Service in accordance with Chapters II and III, Section 40, Home Health Services, of the MBM.

If an interpreter is required, the Home Health Agency may bill for interpreter services in accordance with another billable service and the requirements of Chapter I, Section 1, of the MBM.

SOURCE: MaineCare Benefits Manual, Telehealth, 10-144 Ch. 101, Ch. 1, Sec. 4.07-3. p.12, (Nov. 6, 2023). (Accessed Oct. 2024).

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Maryland

Last updated 11/29/2024

POLICY

Remote patient monitoring services means the use of synchronous …

POLICY

Remote patient monitoring services means the use of synchronous or asynchronous digital technologies that collect or monitor medical, patient–reported, and other forms of health care data for Program recipients at an originating site and electronically transmit that data to a distant site provider to enable the distant site provider to assess, diagnose, consult, treat, educate, provide care management, suggest self–management, or make recommendations regarding the Program recipient’s health care.

SOURCE: MD Health General Code 15-141.2; Code of Maryland Admin. Regs., Sec. 10.09.96.02(B)(14). (Accessed Nov. 2024).

RPM is a service which uses digital technologies to collect medical and other forms of health data from individuals and electronically transmits that information securely to health care providers for assessment, recommendations, and interventions.

Existing MD Medicaid guidance and regulation limits reimbursement for remote patient monitoring to certain chronic conditions. Preauthorization requirements also apply.

SOURCE: Remote Patient Monitoring. MD Department of Health. (Accessed Nov. 2024).

Effective January 1, 2018, Maryland Medicaid covers remote patient monitoring. Please refer to COMAR 10.09.96 Remote Patient Monitoring for more information and resources for Remote Patient Monitoring: https://health.maryland.gov/mmcp/Pages/RPM.aspx.

SOURCE: MD Medicaid Synchronous Telehealth Policy Guide, p. 5. Updated Aug. 2023. (Accessed Nov. 2024).

Covered Services

Remote patient monitoring services include:

Installation;
Education for the participant in the use of the equipment; and
Daily monitoring of vital signs and other medical statistics.

The remote patient monitoring provider shall establish an intervention process to address abnormal data measurements in an effort to prevent avoidable hospital utilization.

Physician, nurse practitioner, and physician assistant providers who establish remote patient monitoring programs shall be responsible for:

Establishing criteria for reporting abnormal measurements;
Informing the participant of abnormal results; and
Monitoring results and improvements in patient’s ability to self-manage chronic conditions.

Medical interventions by a physician, nurse practitioner, or physician assistant based on abnormal results shall be reimbursed according to COMAR 10.09.02.07.

A home health agency shall:

Have an order by a physician, physician assistant, certified nurse midwife, or certified nurse practitioner who has examined the patient and with whom the patient has an established, documented and ongoing relationship;
Report abnormal measurements to the participant and to the ordering provider; and
Send the ordering provider a weekly summary of monitoring results, including improvement in patient’s ability to self-manage chronic conditions.

SOURCE: Code of Maryland Admin Regs, Sec. 10.09.96.06. (Accessed Nov. 2024).

Remote Ultrasound Procedures and Remote Fetal Nonstress Tests – Effective October 1, 2024

The Maryland Medical Assistance Program shall provide, subject to the limitations of the State budget, comprehensive medical, dental, and other health care services, including services provided in accordance with § 15–141.5 regarding remote ultrasound procedures and remote fetal non stress tests using Current Procedural Terminology codes, for all eligible pregnant women whose family income is at or below 250 percent of the poverty level for the duration of the pregnancy and for 1 year immediately following the end of the woman’s pregnancy, as permitted by the federal law.

The program shall provide reimbursement for a remote fetal non stress test in the same manner as an on-site fetal non stress test.

The Program shall issue guidance for program providers to carry out this section.

SOURCE: MD General Health Code 15-103, 15.141.5 as proposed to be amended and added by HB 1078 (2024 Legislative Session). (Accessed Nov. 2024).

CONDITIONS

Telehealth definition includes remote patient monitoring. The Program is required to reimburse a health care provider for the diagnosis, consultation, and treatment of a Program recipient for a health care service covered by the Program that can be appropriately provided through telehealth regardless of patient and provider location.

From July 1, 2021, to June 30, 2025, when appropriately provided through telehealth, the Program shall provide reimbursement in accordance on the same basis and the same rate as if the health care service were delivered by the health care provider in person. Reimbursement does not include:

Clinic facility fees unless the health care service is provided by a health care provider not authorized to bill a professional fee separately for the health care service; or
Any room and board fees.

The Department may adopt regulations to carry out this section.

SOURCE: MD Health General Code 15-141.2 (a-b, h), as amended by HB 1148/SB 582/SB 534 (2023 Legislative Session). (Accessed Nov. 2024).

Existing guidance states Medicaid recipients diagnosed with one of the following conditions qualify:

Chronic Obstructive Pulmonary Disease
Congestive Heart Failure
Diabetes (Type 1 or 2)

The participant must be enrolled in Medicaid, consent to RPM, have an internet connection and capability to use monitoring tools and have one of the following scenarios within the most recent 12-month period:

Two hospital admissions with the same qualifying medical condition as the primary diagnosis
Two emergency room department visits with the same qualifying medical condition as the primary diagnosis
One hospital admission and one emergency department visit with the same qualifying medical condition as the primary diagnosis.

SOURCE: MD Home Health Transmittal No. 64. Jan. 10, 2018. MD General Provider Transmittal No. 85. Feb. 12, 2018, MD Remote Patient Monitoring Transmittal No. 1, Jan 10, 2018. (Accessed Nov. 2024).

A participant is eligible to receive remote patient monitoring services if:

The participant is enrolled in the Maryland Medical Assistance Program on the date the service is rendered;
The participant consents to remote patient monitoring services and has the capability to utilize the monitoring tools and take actions to improve self-management of the chronic disease;
The participant has the internet connections necessary to host the equipment in the home;
The participant is at risk for avoidable hospital utilization due to a poorly controlled chronic disease capable of being monitored via remote patient monitoring; and
The provision of remote patient monitoring may reduce the risk of preventable hospital utilization and promote improvement in control of the chronic condition.

SOURCE: Code of Maryland Admin Regs., Sec. 10.09.96.05. (Accessed Nov. 2024).

An MCO shall provide its enrollees medically necessary remote patient monitoring services as described in COMAR 10.09.96.

SOURCE: Code of Maryland Admin Regs., Sec. 10.67.06.26-5. (Accessed Nov. 2024).

Remote Ultrasound Procedures and Remote Fetal Nonstress Tests – Effective October 1, 2024

The Maryland Medical Assistance Program shall provide remote ultrasound procedures and remote fetal non stress tests coverage using Current Procedural Terminology codes, for all eligible pregnant women whose family income is at or below 250 percent of the poverty level for the duration of the pregnancy and for 1 year immediately following the end of the woman’s pregnancy, as permitted by the federal law, if the patient is in a residence or a location other than the office of the patient’s provider.

SOURCE: MD General Health Code 15-103, 15.141.5 as proposed to be amended and added by HB 1078 (2024 Legislative Session). (Accessed Nov. 2024).

PROVIDER LIMITATIONS

The Department may specify in regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients via telehealth. If the Department specifies by regulation the types of health care providers eligible to receive reimbursement for health care services provided to Program recipients under this subsection, the regulations shall include all types of health care providers that appropriately provide telehealth services.

The Program is not required to reimburse a health care provider for a health care service delivered in person or through telehealth that is:

Not a covered health care service under the Program; or
Delivered by an out–of–network provider unless the health care service is a self–referred service authorized under the Program.

SOURCE: MD General Health Code 15-141.2(g-h). (Accessed Nov. 2024).

Eligible Providers:

Home Health Agencies
Hospitals
Clinics
Federally Qualified Health Centers
Managed Care Organizations
Health Professionals (Physicians, Nurses, Physician Assistants)

SOURCE: Remote Patient Monitoring. MD Department of Health. (Accessed Nov. 2024).

Remote patient monitoring is not a substitute for delivery of care. Provider shall see patients in person periodically for follow-up care. To provide remote patient monitoring, the provider shall be enrolled with an active status as a Maryland Medical Assistance Program provider on the date the service is rendered and be a:

Physician;
Physician assistant;
Certified nurse practitioner; or
Home health agency when remote patient monitoring services are prescribed by a physician; and
Meet the requirements for participation in the Medical Assistance Program as set forth in COMAR 10.09.36.03.

Medical Record Documentation. A remote patient monitoring provider shall:

Maintain documentation using either electronic or paper medical records;
Retain remote patient monitoring records according to the provisions of Health-General Article, §4-403, Annotated Code of Maryland;
Submit the preauthorization on a form developed by the Department; and
Include the participant’s consent to participate in remote patient monitoring.

SOURCE: Code of Maryland Admin Regs, Sec. 10.09.96.04. (Accessed Nov. 2024).

Home health agencies may only be reimbursed for remote patient monitoring when the service is ordered by a physician.

SOURCE: Code of Maryland Admin Regs, Sec. 10.09.96.07. (Accessed Nov. 2024).

Remote Ultrasound Procedures and Remote Fetal Nonstress Tests – Effective October 1, 2024

The provider shall the same standard of care that the provider would follow when providing services on-site.

The program shall require that a provider offering a remote ultrasound procedure or remote fetal non stress test use digital technology to collect any health data from the patient and electronically transmit the information in a secure manner to a health care provider in a different location for interpretation and recommendations that is compliant with the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) and approved by the Federal Food and Drug Administration.

SOURCE: MD General Health Code 15-103, 15.141.5 as proposed to be amended and added by HB 1078 (2024 Legislative Session). (Accessed Nov. 2024).

OTHER RESTRICTIONS

The Department may preauthorize services when the provider submits to the Department adequate documentation demonstrating the:

Participant’s condition meets the criteria listed in Regulation .05 of this chapter; and
Participant has not already been preauthorized for two episodes during the past rolling calendar year.

The RPM reimbursement rate is an all-inclusive rate of $125 per 30 days of monitoring which covers equipment installation, participant education for using the equipment, and daily monitoring of the information transmitted for abnormal data measurements.

Reimbursement does not include RPM equipment, upgrades to RPM equipment or internet service for participants.

The Program does not cover more than:

2 months of remote patient monitoring services per episode; and
Two episodes per year per participant.

SOURCE: MD Home Health Transmittal No. 64. Jan. 10, 2018, Code of Maryland Admin Regs, Sec. 10.09.96.06, Sec. 10.09.96.07, Sec. 10.09.96.08. (Accessed Nov. 2024).

Remote Ultrasound Procedures and Remote Fetal Nonstress Tests – Effective October 1, 2024

A remote fetal non stress test for which reimbursement is provided shall require the use of remote monitoring solutions that are cleared by the Federal Food and Drug Administration for on-label use for monitoring:

Fetal Heart Rate
Maternal Heart Rate
Uterine Activity

SOURCE: MD General Health Code 15-103, 15.141.5 as proposed to be amended and added by HB 1078 (2024 Legislative Session). (Accessed Nov. 2024).

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Massachusetts

Last updated 12/21/2024

POLICY

MassHealth expects to introduce coverage for remote patient monitoring

…

POLICY

MassHealth expects to introduce coverage for remote patient monitoring for chronic disease management in the future. Subject to the availability of federal financial participation, MassHealth plans to publish transmittal letters that will include applicable service limitations and add appropriate codes to the relevant provider manuals.

SOURCE: MassHealth All Provider Bulletin 379, Oct. 2023. (Accessed Dec. 2024).

Managed Care Entities:

This bulletin, which supersedes Managed Care Entity Bulletin 95 and will remain in effect until superseding guidance is issued, requires managed care entities to maintain a telehealth policy consistent with All Provider Bulletin 379, including but not limited to maintaining policies for coverage of telehealth services no more restrictive than those described in All Provider Bulletin 379.

SOURCE: MassHealth Managed Care Entity Bulletin 115 [replaced Bulletin 95], Apr. 2024, (Accessed Dec. 2024).

An allowable fee is listed for Remote Patient Monitoring Bundled Services. However, the manual notes that its used for COVID-19 remote patient monitoring bundled services provided through any appropriate technology or modality, including up to seven days of daily check-ins for evaluation and monitoring; multidisciplinary clinical team reviews of a member’s status and needs; appropriate physician oversight; necessary care coordination; and provision of a thermometer and pulse oximeter for remote monitoring.

SOURCE: MA Regulations, Sec. 446.03, (Accessed Dec. 2024).

CONDITIONS

Medicine Coding Updates

Remote therapeutic monitoring

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- Remote therapeutic monitoring (eg, respiratory system status, musculoskeletal system status, therapy adherence, therapy response); device(s) supply with scheduled (eg, daily) recording(s) and/or programmed alert(s) transmission to monitor respiratory system, each 30 days

98977- Remote therapeutic monitoring (eg, respiratory system status, musculoskeletal system status, therapy adherence, therapy response); 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; each additional 20 minutes (List separately in addition to code for primary procedure)

SOURCE: The Commonwealth of Massachusetts Executive Office of Health and Human Services Administrative Bulletin 22-09, (Jan. 2022), (Accessed Dec. 2024).

PROVIDER LIMITATIONS

No reference found.

OTHER RESTRICTIONS

No Reference Found

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Michigan

Last updated 12/22/2024

POLICY

“Remote patient monitoring” means digital technology to collect medical …

POLICY

“Remote patient monitoring” means digital technology to collect medical and other forms of health data from an individual in 1 location and electronically transmit that information via a health insurance portability and accountability act of 1996, Public Law 104-191 compliant, secure system to a health care provider in a different location for assessment and recommendations.

SOURCE: MI Compiled Laws Sec. 400.105g (Accessed Dec. 2024).

Remote Patient Monitoring (RPM) is a covered service under Michigan Compiled Law (MCL) 400.105g. RPM means using digital technology to collect medical and other forms of health data from an individual in one location and electronically transmit that information via a secure, HIPAA-compliant system to a provider in a different location for assessment and recommendations. RPM is covered for both acute and chronic conditions.

SOURCE: Medical Services Administration (MSA) Bulletin 21-24 Aug. 2021, & MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2152, Oct. 1, 2024, (Accessed Dec. 2024).

The department must provide coverage for remote patient monitoring services through the medical assistance program and Healthy Michigan program under this act.

SOURCE: MI Compiled Laws Sec. 400.105g (Accessed Sept. 2024).

Continuous Glucose Monitoring

CGMS may be non-adjunctive/therapeutic (CGMS can be used to make treatment decisions without the need to confirm test results using a blood glucose monitor [BGM]); or adjunctive/non-therapeutic (beneficiary must use a BGM to test the results displayed on the CGMS prior to making a treatment decision).

SOURCE: MI Bulletin 23-31, Revisions to Continuous Glucose Monitoring Systems Policy, June 1, 2023, & MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1237 Oct. 1, 2024, (Accessed Dec. 2024).

CONDITIONS

RPM is covered for both acute and chronic conditions.

SOURCE: Medicaid Provider Manual, p. 2126 Jul. 1, 2024, (Accessed Dec. 2024).

RPM devices include (1) non-invasive remote monitoring devices that measure or detect common physiological parameters, and (2) non-invasive monitoring devices that wirelessly transmit the beneficiary’s medical information to their health care provider or other monitoring entity. The device must be reliable and valid, and the beneficiary must be trained or sufficiently knowledgeable in the proper use/wearing of the device to ensure appropriate recording of medical information. Medical information may include, but is not limited to, blood pressure and heart rate and rhythm monitoring.

SOURCE: Medical Services Administration (MSA) Bulletin 21-24 Aug. 2021 & MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2152 Oct. 1, 2024, (Accessed Dec. 2024).

Continuous Glucose Monitoring

A personal use CGMS and supplies are covered for persons with diabetes when all the following are met (see manual).

PROVIDER LIMITATIONS

Continuous Glucose Monitoring

Personal use CGMS are covered for beneficiaries with diabetes when all the following are met:

The beneficiary is under the care of one of the following:
- An endocrinologist; or
- A physician or non-physician practitioner (nurse practitioner, physician assistant or clinical nurse specialist) who is managing the beneficiary’s diabetes.
The beneficiary has diabetes requiring the administering of insulin or is currently using an insulin pump.
The beneficiary or their caregiver is educated on the use of the device and is willing and able to use the CGMS.

Note: CGMS reduce the frequency of fingerstick blood glucose testing but do not eliminate the need to fingerstick test entirely. Glucometers and testing supplies must be made available. These supplies are billed separately (following frequency rules) for adjunctive/non-therapeutic CGMS. Glucometers and testing supplies are included in the monthly supply HCPCS code for non-adjunctive/therapeutic CGMS. Refer to the Payment Rules section of this policy.

Although not required for coverage consideration, physicians/non-physician practitioners are encouraged to refer patients who are willing and able to attend a certified diabetes self-management education training program. A map identifying Medicaid enrolled diabetes self-management education and support (DSME) providers can be found on the MDHHS website. (Refer to the Directory Appendix for website information.)

OTHER RESTRICTIONS

All RPM devices, including mobile medical applications, must meet the U.S. Food & Drug Administration (FDA) definition of a medical device. Personal tablets, computers, cell phones, software intended for administrative support or support of healthy lifestyles/general wellness, and electronic health records are not medical devices or durable medical equipment and are not covered as part of RPM services.

Reimbursement for the device used for remote monitoring, and programming of the device, is generally included in the reimbursement of RPM services and not separately reimbursable. For items or devices separately reimbursed to a medical supplier, such as personal use continuous glucose monitoring systems (CGMs), refer to the Medical Supplier chapter of the MDHHS Medicaid Provider Manual.

SOURCE: Medical Services Administration (MSA) Bulletin 21-24 Aug. 2021 & MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 2152 Oct. 1, 2024, (Accessed Dec. 2024).

See bulletin/manual for documentation, prior authorization and eligible CGM codes.

SOURCE: MI Bulletin 23-31, Revisions to Continuous Glucose Monitoring Systems Policy, June 1, 2023, & MI Dept. of Health and Human Services, Medicaid Provider Manual, p. 1236-1238 Oct. 1, 2024, (Accessed Dec. 2024).

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Minnesota

Last updated 11/22/2024

POLICY

Telemonitoring (Remote Physiological Monitoring Services)

Medical assistance covers telemonitoring …

POLICY

Telemonitoring (Remote Physiological Monitoring Services)

Medical assistance covers telemonitoring services if:

The telemonitoring service is medically appropriate based on the recipient’s medical condition or status;
The recipient’s health care provider has identified that telemonitoring services would likely prevent the recipient’s admission or readmission to a hospital, emergency room, or nursing facility;
The recipient is cognitively and physically capable of operating the monitoring device or equipment, or the recipient has a caregiver who is willing and able to assist with the monitoring device or equipment; and
The recipient resides in a setting that is suitable for telemonitoring and not in a setting that has health care staff on site.

“Telemonitoring services” means the remote monitoring of data related to a recipient’s vital signs or biometric data by a monitoring device or equipment that transmits the data electronically to a provider for analysis. The assessment and monitoring of the health data transmitted by telemonitoring must be performed by one of the following licensed health care professionals: physician, podiatrist, registered nurse, advanced practice registered nurse, physician assistant, respiratory therapist, or licensed professional working under the supervision of a medical director.

SOURCE: MN Statute Sec. 256B.0625 Subd. 3(h). (Accessed Nov. 2024).

Telemonitoring services are the remote monitoring of data related to a member’s vital signs or biometric data by a monitoring device or equipment that transmits the data electronically to a provider for analysis. Telemonitoring is a tool that can assist the provider in managing a member’s complex health needs.

MHCP covers telemonitoring services for MHCP members in fee-for-service programs.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Apr. 4, 2024. (Accessed Nov. 2024).

There is reimbursement for “tele-homecare” under Elderly Waiver (EW) and Alternative Care (AC) programs.

SOURCE: MN Dept. of Human Svcs., Provider Manual, Elderly Waiver (EW) and Alternative Care (AC) Program, As revised Aug. 29, 2024, (Accessed Nov. 2024).

A face-to-face visit can occur through telehealth.

Prior authorization for home care services is required for: …

All telehomecare skilled nurse visits

SOURCE: MN Dept. of Human Svcs., Provider Manual, Home Care Svcs., As revised Jan. 31, 2024, (Accessed Nov. 2024).

CONDITIONS

MHCP covers telemonitoring services for members in high-risk, medically complex patient populations. These members have medical conditions like congestive heart failure, chronic obstructive pulmonary disease (COPD) or diabetes.

MHCP covers telemonitoring services based on the following medical necessity criteria:

The telemonitoring service is medically appropriate based on the member’s medical condition or status.
The member is cognitively and physically capable of operating the monitoring device or equipment, or the member has a caregiver who is willing and able to assist with the monitoring device or equipment.
The member resides in a setting that is suitable for telemonitoring and not in a setting that has health care staff on site.
The prescribing provider has identified and documented how telemonitoring services would likely prevent the member’s admission or readmission to a hospital, emergency room or nursing facility.
The results of the telemonitoring services are directly used to impact the plan of care.

Any service that does not meet medical necessity criteria will not be covered.

Bill on 837P claim format. Refer to the MN–ITS 837P Professional User Guides.

Submit claims for telemonitoring services using the CPT or HCPC code that describes the services rendered. Prior-authorization is not needed.

Provider must bill for at least 16 days of data collection within a 30 day period.

The data must be collected and transmitted rather than self-reported to the provider. The device must be defined by the FDA as a medical device.

Only MDs and practitioners may bill for remote patient monitoring (RPM) services.

Independent diagnostic testing facilities are not able to bill for RPM services.

SOURCE: Provider Manual, Physician and Professional Services (Telehealth), As revised Apr. 4, 2024. (Accessed Nov. 2024).

Medical assistance covers telemonitoring services if:

the telemonitoring service is medically appropriate based on the recipient’s medical condition or status;
the recipient’s health care provider has identified that telemonitoring services would likely prevent the recipient’s admission or readmission to a hospital, emergency room, or nursing facility;
the recipient is cognitively and physically capable of operating the monitoring device or equipment, or the recipient has a caregiver who is willing and able to assist with the monitoring device or equipment; and
the recipient resides in a setting that is suitable for telemonitoring and not in a setting that has health care staff on site.

SOURCE: MN Statute Sec. 256B.0625 Subd. 3(h), (Accessed Nov. 2024).

Seizure Detection Devices

The following codes and seizure detection devices are covered by MHCP:

A9279: Monitoring feature/device, stand-alone or integrated, any type, includes all accessories, components, and electronics, not otherwise classified. MHCP covers one device every five years. Bill using U2 modifier.
99454: Remote monitoring of physiologic parameters, initial supply of devices with daily recordings or programmed alerts transmission, each 30 days. Refer to Telemonitoring Policy for more information. Bill using U2 modifier. MHCP only covers the standard plan subscription.

SOURCE: MN Dept of Human Services, Seizure Detection Devices, Apr. 17, 2024, (Accessed Nov. 2024).

PROVIDER LIMITATIONS

The assessment and monitoring of the health data transmitted by telemonitoring must be performed by the following licensed health care professionals:

Advanced practice registered nurse
Physician
Physician assistant
Podiatrist
Registered nurse
Respiratory therapist
a licensed professional working under the supervision of a medical director (for example, an LPN)

Only MDs and practitioners may bill for remote patient monitoring (RPM) services.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Apr. 4, 2024. (Accessed Nov. 2024).

For purposes of this subdivision, “telemonitoring services” means the remote monitoring of data related to a recipient’s vital signs or biometric data by a monitoring device or equipment that transmits the data electronically to a provider for analysis. The assessment and monitoring of the health data transmitted by telemonitoring must be performed by one of the following licensed health care professionals: physician, podiatrist, registered nurse, advanced practice registered nurse, physician assistant, respiratory therapist, or licensed professional working under the supervision of a medical director.

SOURCE: MN Statute Sec. 256B.0625 Subd. 3(h), (Accessed Nov. 2024).

OTHER RESTRICTIONS

Bill on 837P claim format. Refer to the MN–ITS 837P Professional User Guides.

Submit claims for telemonitoring services using the CPT or HCPC code that describes the services rendered. Prior authorization is not needed.

You must bill for at least 16 days of data collection within a 30-day period.

The data must be collected and transmitted rather than self-reported to the provider. The device must be defined by the FDA as a medical device.

Only MDs and practitioners may bill for remote patient monitoring (RPM) services.

Independent diagnostic testing facilities are not able to bill for RPM services.

SOURCE: MN Dept. of Human Services, Provider Manual, Physician and Professional Services (Telehealth), As revised Apr. 4, 2024. (Accessed Nov. 2024).

Telehomecare visits. Coverage of telehomecare is limited to two visits per day and all of the visits must be prior authorized.

SOURCE: MN Dept. of Human Services, Skilled Nursing Visit Services, Oct. 5, 2018, (Accessed Nov. 2024).

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Mississippi

Last updated 12/13/2024

POLICY

Policy applies to Private payers, MS Medicaid and employee …

POLICY

Policy applies to Private payers, MS Medicaid and employee benefit plans

“Remote patient monitoring services” means the delivery of home health services using telecommunications technology to enhance the delivery of home health care, including:

Monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry and other condition-specific data, such as blood glucose;
Medication adherence monitoring; and
Interactive video conferencing with or without digital image upload as needed.

Remote patient monitoring services aim to allow more people to remain at home or in other residential settings and to improve the quality and cost of their care, including prevention of more costly care. Remote patient monitoring services via telehealth aim to coordinate primary, acute, behavioral and long-term social service needs for high-need, high-cost patients. Specific patient criteria must be met in order for reimbursement to occur.

Remote patient monitoring services shall include reimbursement for a daily monitoring rate at a minimum of Ten Dollars ($10.00) per day each month and Sixteen Dollars ($16.00) per day when medication adherence management services are included, not to exceed thirty-one (31) days per month. These reimbursement rates are only eligible to Mississippi-based telehealth programs affiliated with a Mississippi health care facility.

A one-time telehealth installation/training fee for remote patient monitoring services will also be reimbursed at a minimum rate of Fifty Dollars ($50.00) per patient, with a maximum of two (2) installation/training fees/calendar year. These reimbursement rates are only eligible to Mississippi-based telehealth programs affiliated with a Mississippi health care facility.

To receive payment for the delivery of remote patient monitoring services via telehealth, the service must involve:

An assessment, problem identification, and evaluation that includes:
- Assessment and monitoring of clinical data including, but not limited to, appropriate vital signs, pain levels and other biometric measures specified in the plan of care, and also includes assessment of response to previous changes in the plan of care; and
- Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care.
Implementation of a management plan through one or more of the following:
- Teaching regarding medication management as appropriate based on the telemedicine findings for that encounter;
- Teaching regarding other interventions as appropriate to both the patient and the caregiver;
- Management and evaluation of the plan of care including changes in visit frequency or addition of other skilled services;
- Coordination of care with the ordering health care provider regarding telemedicine findings;
- Coordination and referral to other medical providers as needed; and
- Referral for an in-person visit or the emergency room as needed.

SOURCE: MS Code Sec. 83-9-353. (Accessed Dec. 2024).

The Division of Medicaid defines remote patient monitoring as using digital technologies to collect medical and other forms of health data from individuals in one location and electronically transmit that information securely to healthcare providers in a different location for interpretation and recommendation.

The Division of Medicaid reimburses for remote patient monitoring:

Of devices when billed with the appropriate code, and
For disease management:
- A daily monitoring rate for days the beneficiary’s information is reviewed.
- Only one (1) unit per day is allowed, not to exceed thirty-one (31) days per month.
- An initial visit to install the equipment and train the beneficiary may be billed as a set-up visit.
- Only one set-up is allowed per episode even if monitoring parameters are added after the initial set-up and installation.
- Only one (1) daily rate will be reimbursed regardless of the number of diseases/chronic conditions being monitored.

The Division of Medicaid does not reimburse for the duplicate transmission or interpretation of remote patient monitoring data.

The Division of Medicaid does not cover remote patient monitoring for disease management as outlined in Miss. Admin. Code Part 225, Rule 2.3.B. for a beneficiary who is a resident of an institution that meets the basic definition of a hospital or long-term care facility.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 2.1 & 2.4 & 2.5. (Accessed Dec. 2024).

Continuous Glucose Monitoring

A continuous glucose monitoring (CGM) service when medically necessary, prior authorized by the UM/QIO, Division of Medicaid or designee, ordered by the physician who is actively managing the beneficiary’s diabetes and the beneficiary meets specific criteria. See admin code.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 4.3. (Accessed Dec. 2024).

“Remote Monitoring” is defined as the use of technology to remotely track health care data for a patient released to his or her home or a care facility, usually for the intended purpose of reducing readmission rates.

SOURCE: MS Code Title 30 Part 2635, Ch. 5 Rule 5.1. (Accessed Dec. 2024).

CONDITIONS

The Division of Medicaid covers remote patient monitoring, for disease management when medically necessary, prior authorized by the Utilization Management/Quality Improvement Organization (UM/QIO), Division of Medicaid or designee, ordered by a physician, physician assistant, or nurse practitioner for a beneficiary who meets the following criteria:

Has been diagnosed with one (1) or more of the chronic conditions as defined by the Centers of Medicare and Medicaid Services (CMS) which include, but are not limited to:
- Diabetes,
- Congestive Heart Failure (CHF),
- Chronic Obstructive Pulmonary Disease (COPD),
- Heart disease,
- Mental health, and
- Sickle cell.
Is capable of using the remote patient monitoring equipment and transmitting the necessary data or has a willing and able person to assist in completing electronic transmission of data.

The Division of Medicaid covers remote patient monitoring of devices when medically necessary, ordered by a physician, physician assistant or nurse practitioner which includes, but not limited to:

Implantable pacemakers,
Defibrillators,
Cardiac monitors,
Loop recorders,
External mobile cardiovascular telemetry, and
Continuous glucose monitors.

SOURCE: MS Admin. Code 23, Part 225, Rule. 2.3. (Accessed Dec. 2024).

Qualifying patients for remote patient monitoring services must meet all the following criteria:

Be diagnosed, in the last eighteen (18) months, with one or more chronic conditions, as defined by the Centers for Medicare and Medicaid Services (CMS), which include, but are not limited to, sickle cell, mental health, asthma, diabetes, and heart disease; and
The patient’s health care provider recommends disease management services via remote patient monitoring.

SOURCE: MS Code Sec. 83-9-353. (Accessed Dec. 2024).

Continuous Glucose Monitoring

Has an established diagnosis of type I or type II diabetes mellitus that is poorly controlled as defined below:
- Unexplained hypoglycemic episodes,
- Nocturnal hypoglycemic episode(s),
- Hypoglycemic unawareness and/or frequent hypoglycemic episodes leading to impairments in activities of daily living,
- Suspected postprandial hyperglycemia,
- Recurrent diabetic ketoacidosis, or
- Unable to achieve optimum glycemic control as defined by the most current version of the American Diabetes Association (ADA).
Be able, or have a caregiver who is able, to hear and view CGM alerts and respond appropriately.
Has documented self-monitoring of blood glucose at least four (4) times per day.
Requires insulin injections three (3) or more times per day or requires the use of an insulin pump for maintenance of blood glucose control.
Requires frequent adjustment to insulin treatment regimen based on blood glucose testing results,
Had an in-person visit with the ordering physician within six (6) months prior to ordering to evaluate their diabetes control and determined that criteria (1-4) above are met,
Has an in-person visit every six (6) months following the prescription of the CGM to assess adherence to the CGM regimen and diabetes treatment plan.

The CGM is a Food and Drug Administration (FDA) approved medical device and is capable of accurately measuring and transmitting beneficiary blood data.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 4.3. (Accessed Dec. 2024).

PROVIDER LIMITATIONS

Providers of remote patient monitoring services must have protocols in place to address all of the following:

A mechanism for monitoring, tracking and responding to changes in a beneficiary’s clinical condition, and
A process for notifying the prescribing physician of significant changes in the beneficiary’s clinical signs and symptoms.

Remote patient monitoring services must be delivered by an enrolled Medicaid provider acting within their scope-of-practice and license and in accordance with state and federal guidelines.

The Division of Medicaid covers remote patient monitoring of devices when medically necessary, ordered by a physician, physician assistant or nurse practitioner.

Continuous glucose monitoring services must be delivered by an enrolled Medicaid provider acting within their scope-of-practice and license and in accordance with state and federal guidelines.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 2.2 & 2.3. (Accessed Dec. 2024).

A health insurance or employee benefit plan can limit coverage to health care providers in a telemedicine network approved by the plan.

SOURCE: MS Code Sec. 83-9-353(18). (Accessed Dec. 2024).

Continuous Glucose Monitoring

Continuous glucose monitoring services must be delivered by an enrolled Medicaid provider acting within their scope-of-practice and license and in accordance with state and federal guidelines.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 4.2. (Accessed Dec. 2024).

Certified Community Behavioral Health Clinic

The CCBHC uses telehealth/telemedicine, video conferencing, remote patient monitoring, asynchronous interventions, and other technologies, to the extent possible, in alignment with the preferences of the person receiving services to support access to all required services.

For those presenting with emergency or urgent needs, the initial evaluation may be conducted by phone or through use of technologies for telehealth/telemedicine and video conferencing, but an in-person evaluation is preferred. If the initial evaluation is conducted telephonically, once the emergency is resolved, the person receiving services must be seen in person at the next subsequent encounter and the initial evaluation reviewed.

For individuals and families who live within the CCBHC’s service area but live a long distance from CCBHC clinic(s), the CCBHC should consider use of technologies for telehealth/telemedicine, video conferencing, remote patient monitoring, asynchronous interventions, and other technologies in alignment with the preferences of the person receiving services, and to the extent practical. These criteria do not require the CCBHC to provide continuous services including telehealth to individuals who live outside of the CCBHC service area. CCBHCS may consider developing protocols for populations that may transition frequently in and out of the services area such as children who experience out-of-home placements and adults who are displaced by incarceration or housing instability.

Telehealth/telemedicine may be used to connect individuals in crisis to qualified mental health providers during the interim travel time. Technologies also may be used to provide crisis care to individuals when remote travel distances make the 2-hour response time unachievable, but the ability to provide an in- person response must be available when it is necessary to assure safety. The CCBHC should consider aligning their programs with the CMS Medicaid Guidance on the Scope of and Payments for Qualifying Community-Based Mobile Crisis Intervention Services if they are in a state that includes this option in their Medicaid state plan.

The CCBHC directly, or through a DCO, provides screening, assessment, and diagnosis, including risk assessment for behavioral health conditions. In the event specialized services outside the expertise of the CCBHC are required for purposes of screening, assessment, or diagnosis (e.g., neuropsychological testing or developmental testing and assessment), the CCBHC refers the person to an appropriate provider. When necessary and appropriate screening, assessment and diagnosis can be provided through telehealth/telemedicine services. Note: See program requirement 3 regarding coordination of services and treatment planning.

The preferences of the person receiving services regarding the use technologies such as telehealth/telemedicine, video conferencing, remote patient monitoring, and asynchronous interventions.

In the event specialized or more intensive services outside the expertise of the CCBHC or DCO are required for purposes of outpatient mental and substance use disorder treatment the CCBHC makes them available through referral or other formal arrangement with other providers or, where necessary and appropriate, through use of telehealth/telemedicine, in alignment with state and federal laws and regulations.

SOURCE: MS Temporary Rule Title 24, (Accessed Dec. 2024).

OTHER RESTRICTIONS

A remote patient monitoring prior authorization request form may be required for approval of telemonitoring services. If prior authorization is required, the law lists certain requirements for the form.

The telemonitoring equipment must:

Be capable of monitoring any data parameters in the plan of care; and
Be a FDA Class II hospital-grade medical device.

The telemedicine equipment and network used for remote patient monitoring services should meet the following requirements:

Comply with applicable standards of the United States Food and Drug Administration;
Telehealth equipment be maintained in good repair and free from safety hazards;
Telehealth equipment be new or sanitized before installation in the patient’s home setting;
Accommodate non-English language options; and
Have 24/7 technical and clinical support services available for the patient user.

SOURCE: MS Code Sec. 83-9-353 (Accessed Dec. 2024).

Providers of remote patient monitoring services must have protocols in place to address all of the following:

A mechanism for monitoring, tracking and responding to changes in a beneficiary’s clinical condition, and
A process for notifying the prescribing physician of significant changes in the beneficiary’s clinical signs and symptoms.

See admin code for list of requirements for prior authorization form.

Remote patient monitoring services must be provided in the beneficiary’s private residence.

SOURCE: MS Admin. Code 23, Part 225, Rule. 2.2 & 2.3. (Accessed Dec. 2024).

CGM service only when the blood glucose data is obtained from a Federal Drug Administration (FDA) approved durable medical equipment (DME) medical device for home use.

The Division of Medicaid does not require the provider to have a face-to-face office visit with the beneficiary to download, review and interpret the blood glucose data.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 4.3. (Accessed Dec. 2024).

Continuous glucose monitoring (CGM) service documentation must include, but is not limited to:

The beneficiary and/or care giver is capable of operating the continuous glucose monitoring system,

The beneficiary:

Has an established diagnosis of type I or type II diabetes mellitus that is poorly controlled as defined in Miss. Admin. Code Part 225, Rule 4.3.A.1.a),
Requires three (3) insulin injections per day, or use of an insulin pump, for maintenance of blood glucose control,
Requires regular self-monitoring of at least four (4) times a day,
Requires frequent adjustment to insulin treatment regimen based on blood glucose testing results,
Had an in-person visit with the ordering physician within six (6) months prior to ordering to evaluate their diabetes control and determined that criteria (1-4) above are met,
Has an in-person visit every six (6) months following the prescription of the CGM to assess adherence to the CGM regimen and diabetes treatment plan.

The CGM is a Food and Drug Administration (FDA) approved medical device and is capable of accurately measuring and transmitting beneficiary blood data.

SOURCE: MS Admin. Code Title 23, Part 225, Rule. 4.6. (Accessed Dec. 2024).

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Missouri

Last updated 09/06/2024

POLICY

Subject to appropriations, the department shall establish a statewide …

POLICY

Subject to appropriations, the department shall establish a statewide program that permits reimbursement under the MO HealthNet program for home telemonitoring services.

“Home telemonitoring service” shall mean a health care service that requires scheduled remote monitoring of data related to a participant’s health and transmission of the data to a health call center accredited by the Utilization Review Accreditation Commission (URAC).

SOURCE: MO Revised Statute Sec. 208.686. (Accessed Sept. 2024).

CONDITIONS

The program shall: Provide that home telemonitoring services are available only to persons who: Are diagnosed with one or more of the following conditions:

Pregnancy
Diabetes
Heart disease
Cancer
Chronic obstructive pulmonary disease
Hypertension
Congestive heart failure
Mental illness or serious emotional disturbance
Asthma
Myocardial infarction; or
Stroke

The beneficiary must also exhibit two or more the following risk factors:

Two or more hospitalizations in the prior twelve-month period;
Frequent or recurrent emergency department admissions;
A documented history of poor adherence to ordered medication regimens;
A documented history of falls in the prior six-month period;
Limited or absent informal support systems;
Living alone or being home alone for extended periods of time;
A documented history of care access challenges; or
A documented history of consistently missed appointments with health care providers

SOURCE: MO Revised Statute Sec. 208.686. (Accessed Sept. 2024).

The Assistive Technology service is available in all four of the Developmental Disabilities Waiver.

Electronic support systems using on demand video and/or web-cameras, or other technology is only available on an individual, case-by-case basis when an individual requests the service and the planning team agrees it is appropriate and meets the health and safety needs of the individual. Video and/or web-cameras shall not record audio or video feed of an individual. When video equipment is utilized, the data system shall track all utilization of the equipment including who activated it, when it was activated, how long it was active, and why it was activated. When cameras are utilized, they may not be placed in or provide view of private spaces such as bedrooms and bathrooms. See manual for more details.

SOURCE: MO HealthNet, Provider Manual, Developmental Disabilities Waiver Manual, Section 6.2, p. 140 (5/6/24). (Accessed Sept. 2024).

Effective August 29, 2024, MO HealthNet will expand coverage of Continuous Glucose Monitors (CGMs) to participants currently diagnosed with Gestational Diabetes allowing this vulnerable population to obtain a CGM without a prior authorization. Claims for a CGM will auto-approve if the participant has had a gestational diabetes diagnosis billed to MO HealthNet recently OR if the pharmacy submits the appropriate gestational diabetes diagnosis code with the claim.

As a reminder, any MO HealthNet participant who currently utilizes insulin can also obtain a CGM without a prior authorization.

SOURCE: MO Department of Social Services. Updates to Coverage of Continuous Glucose Monitors (CGMs), 8/15/24, (Accessed Sept. 2024).

PROVIDER LIMITATIONS

Provider must ensure that clinical information gathered by a home health agency or hospital while providing home telemonitoring services is shared with the participant’s physician.

SOURCE: MO Revised Statute Sec. 208.686. (Accessed Sept. 2024)

OTHER RESTRICTIONS

Provider must ensure that the program does not duplicate any disease management program services provided by MO HealthNet.

If, after implementation, the department determines that the program established under this section is not cost effective, the department may discontinue the program and stop providing reimbursement under the MO HealthNet program for home telemonitoring services.

The department shall promulgate rules and regulations to implement the provisions of this section.

SOURCE: MO Revised Statute Sec. 208.686. (Accessed Sept. 2024).

No Reference Found

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Nebraska

Last updated 12/19/2024

POLICY

Telemonitoring: The remote monitoring of a client’s vital signs, …

POLICY

Telemonitoring: The remote monitoring of a client’s vital signs, biometric data, or subjective data by a monitoring device which transmits such data electronically to a health care practitioner for analysis and storage.

Medicaid will reimburse for telemonitoring when all of the following requirements are met:

Telemonitoring is covered only when the services are from the originating site;
The client is cognitively capable to operate the equipment or has a willing and able person to assist in the transmission of electronic data;
The originating site has space for all program equipment and full transmission capability; and
The provider must maintain a client’s record containing data supporting the medical necessity of the service, all transmissions and subsequent review received from the client, and how the data transmitted from the client is being utilized in the continuous development and implementation of the client’s plan of care.

Telemonitoring is paid at a daily per diem rate set by Medicaid and includes the following:

Health care practitioner review and interpretation of the client data;
Equipment and all supplies, accessories, and services necessary for proper functioning and effective use of the equipment;
Medically necessary visits to the home by a health care practitioner; and
Training on the use of equipment and completion of necessary records.

No additional or separate payment beyond the fixed payment is allowable.

SOURCE: NE Admin. Code Title 471 Sec. 1-004.01(F) & 1-004.07, Ch. 1, (Accessed Dec. 2024).

No later than January 1, 2023, the department shall provide coverage for continuous glucose monitors under the medical assistance program for all eligible recipients who have a prescription for such device.

SOURCE: NE Revised Statute Sec. 68-911, (Accessed Dec. 2024).

Nebraska Medicaid will provide coverage for Continuous Glucose Monitoring (CGM) devices for eligible beneficiaries with diabetes beginning January 1, 2023.

SOURCE: NE Medicaid, Provider Bulletin 22-22, CGM Coverage by Medicaid, Dec. 29, 2022, (Accessed Dec. 2024).

The continued use of CGM may be considered medically necessary for someone who is being assessed every 6 months by the prescribing healthcare practitioner for adherence to the CGM regimen and diabetes treatment plan. The initial authorization period for therapeutic CGM is 6 months and is then renewed on a yearly basis. Supplies will be provided for 30 days or up to 90 days at a time.

SOURCE: NE Medicaid, Provider Bulletin 24-17, Update to Continuous Glucose Monitor Policy for Fee-for-Service Members, July 12, 2024, (Accessed Dec. 2024).

CONDITIONS

Outpatient cardiac rehabilitation programs consisting of individually prescribed physical exercise or conditioning and concurrent telemetric monitoring. When a program is provided by a hospital to its outpatients, the service is covered as an outpatient service.

SOURCE: NE Admin. Code Title 471 Ch. 10, Sec. 006.16(B), Hospital Services, (Accessed Dec. 2024).

Nebraska Medicaid will provide coverage for both long-term (therapeutic) and short-term (diagnostic) CGM for eligible beneficiaries who have diabetes mellitus when medically necessary. CGM devices measure interstitial glucose, which correlates well with plasma glucose.

The initial authorization period for therapeutic CGM is 6 months, while the renewal period is yearly. Supplies will be provided for 30 days or up to 90 days at a time. Beneficiaries must meet medical necessity criteria in order to be eligible for coverage. See bulletin for prior authorization requirements.

SOURCE: NE Medicaid, Provider Bulletin 22-22, CGM Coverage by Medicaid, Dec. 29, 2022, (Accessed Dec. 2024).

Medicaid fee-for-service members must meet eligibility criteria for the coverage of a long-term CGM for therapeutic purposes. The following criteria are used to determine medical necessity:

Is insulin-treated, or
Has a history of problematic hypoglycemia with documentation of at least one of the following:
- Recurrent (more than one) hypoglycemic events with blood glucose <54mg/dL (3.0mmol/L) that persist despite multiple (more than one) attempts to adjust medication(s) and/or modify the diabetes treatment plan, or
- A history of one hypoglycemic event with blood glucose <54mg/dL (3.0mmol/L) characterized by altered mental and/or physical state requiring third-party assistance for treatment of hypoglycemia.
And is being assessed every 6 months by the prescribing healthcare practitioner for adherence to a comprehensive diabetes treatment plan.

SOURCE: NE Medicaid, Provider Bulletin 24-17, Update to Continuous Glucose Monitor Policy for Fee-for-Service Members, July 12, 2024, (Accessed Dec. 2024).

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

Effective February 1, 2024, Nebraska Medicaid’s preferred Continuous Glucose Monitoring (CGM) devices are as follows:

Dexcom G6
Dexcom G7
Freestyle Libre 2
Freestyle Libre 3

Nebraska Medicaid covers CGM devices for Type 1, Type 2, and gestational diabetes mellitus as medically necessary.

SOURCE: NE Medicaid, Provider Bulletin 24-01, Update to Nebraska Medicaid’s Preferred CGM Devices (Jan. 8, 2024), (Accessed Dec. 2024).

The following devices are covered under Medicaid:

FreeStyle Libre 2
Dexcom G6

The Medtronic CGM may be covered for beneficiaries who meet the medical necessity criteria for long-term CGM and are on a Medtronic insulin pump.

CGM devices that use an implantable glucose sensor such as an Eversense CGM system (CPT codes 0046T, 00447T, and 0448T) or a noninvasive glucose sensor (e.g., optical and transdermal sensors) are considered investigational and not medically necessary due to insufficient evidence of clinical efficacy and long-term health outcomes. Any related HCPC codes for implantable or noninvasive glucose sensors are also considered investigational and not medically necessary.

SOURCE: NE Medicaid, Provider Bulletin 22-22, CGM Coverage by Medicaid, Dec. 29, 2022, (Accessed Dec. 2024).

No Reference Found

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New Hampshire

Last updated 12/16/2024

POLICY

“Remote patient monitoring (RPM)” means “remote patient monitoring” as …

POLICY

“Remote patient monitoring (RPM)” means “remote patient monitoring” as defined in RSA 167:4-d, II(e) namely “the use of electronic technology to remotely monitor a patient’s health status through the collection and interpretation of clinical data while the patient remains at an originating site. Remote patient monitoring may or may not take place in real time. Remote patient monitoring shall include assessment, observation, education and virtual visits provided by all covered providers including licensed home health care providers”.

Payment for store and forward and remote patient monitoring shall only be available as funding and resources within the current state fiscal year are available.

Source: NH Admin Rules, HE-C 5004.01, .13 (Accessed Dec. 2024).

“Remote patient monitoring” means the use of electronic technology to remotely monitor a patient’s health status through the collection and interpretation of clinical data while the patient remains at an originating site. Remote patient monitoring may or may not take place in real time. Remote patient monitoring shall include assessment, observation, education and virtual visits provided by all covered providers including licensed home health care providers.

Coverage under this section shall include the use of telehealth or telemedicine for Medicaid-covered services provided within the scope of practice of a physician or other health care provider as a method of delivery of medical care:

(1) Which is an appropriate application of telehealth services provided by physicians and other health care providers, as determined by the department based on the Centers for Medicare and Medicaid Services regulations, and also including persons providing psychotherapeutic services as provided in He-M 426.08 and 426.09;

(2) By which telemedicine services for primary care and remote patient monitoring shall only be covered in the event that the patient has already established care at an originating site via face-to-face in-person service. A provider shall not be required to establish care via face-to-face in-person service when:

The provider is a Department of Veteran Affairs (VA) practitioner or VA-contracted practitioner not required to obtain a special registration pursuant to 21 U.S.C. section 831(h);
The patient is being treated by, and is physically located in a correctional facility administered by the state of New Hampshire or a New Hampshire county;
The patient is being treated by, and is physically located in a doorway as defined in RSA 167:4-d, II(c);
The patient is being treated by and is physically located in a state designated community mental health center pursuant to RSA 135; or
The patient is being treated by, and physically located in, a hospital or clinic registered in a manner fully consistent with 21 U.S.C. section 823(f); and

(3) By which an individual shall receive medical services from a physician or other health care provider who is an enrolled Medicaid provider without in-person contact with that provider.

SOURCE: NH Revised Statutes 167:4-d (Accessed Dec. 2024).

Medicaid covers services delivered via telehealth, as well as remote patient monitoring and store and forward services.

SOURCE: NH Medicaid, General Billing Manual, Oct. 2023, (Accessed Dec. 2024).

New Hampshire Medicaid now covers remote patient monitoring and store & forward telehealth services as required with the passage of NH SB258 to amend RSA 167:4-d.

The following new procedure codes have been added to MMIS with an effective date of 10/1/2023:

CPT code 99453: “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.” This service may be billed once per year.
CPT code 99454: “Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.” This service may be billed once per month.
CPT code 99457: “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.” Max unit of one per month
CPT code 99458: CPT code 99458 (Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes) This service may be billed once per month.
CPT code 99091: Collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional. This service may be billed once per month.

These procedure codes do not require a service authorization.

SOURCE: NH Division of Medicaid Services. Provider Message. Oct. 2023. (Accessed Dec. 2024).

CONDITIONS

The following considerations shall apply to RPM, as defined in He-C 5004.01(i) above, medical conditions that may be treated or monitored by means of RPM include but are not limited to:

Congestive heart failure;
Diabetes;
Chronic obstructive pulmonary disease;
Wound care;
Polypharmacy, mental or behavioral conditions, and technology dependent care such as the use of continuous oxygen, ventilator care, total parenteral nutrition, or enteral feeding;
Hypertension;
Pneumonia; or
Patients at high risk of hospitalization.

Source: NH Admin Rules, HE-C 5004.05, (Accessed Dec. 2024).

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

Medical devices supplied to patients as part of RPM services shall comply with section 201 of the Federal Food, Drug and Cosmetic Act (FDA) which requires the wirelessly synced device to be reliable and to transmit data electronically for interpretation and recommendations automatically rather than the patient having to self-report to providers.

Telehealth for developmental disabilities and acquired brain disorder home and community based care waiver services shall be provided in accordance with the Centers for Medicare and Medicaid’s “Appendix K: Emergency Preparedness and Response for Home and Community Based (HCBS) 1915(c) Waivers” (effective March 2020 through 6 months after the end of the federal public health emergency), as available in Appendix A.

Telehealth for choices for independence home and community based waiver services shall be provided in accordance with the Centers for Medicare and Medicaid’s “Appendix K: Emergency Preparedness and Response for Home and Community Based (HCBS) 1915(c) Waivers” (effective March 2020 through 6 months after the end of the federal public health emergency), as available in Appendix A.

Telehealth for in home supports home and community based waiver services shall be provided in accordance with the Centers for Medicare and Medicaid’s “Appendix K: Emergency Preparedness and Response for Home and Community Based (HCBS) 1915(c) Waivers” (effective March 2020 through 6 months after the end of the federal public health emergency), as available in Appendix A.

Source: NH Admin Rules, HE-C 5004.05, (Accessed Dec. 2024).

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New Jersey

Last updated 08/20/2024

POLICY

The State Medicaid and NJ FamilyCare programs shall provide …

POLICY

The State Medicaid and NJ FamilyCare programs shall provide coverage and payment for health care services delivered to a benefits recipient through telemedicine or telehealth, on the same basis as, and at a provider reimbursement rate that does not exceed the provider reimbursement rate that is applicable, when the services are delivered through in-person contact and consultation in New Jersey, provided the services are otherwise covered when delivered through in-person contact and consultation in New Jersey. Reimbursement payments under this section may be provided either to the individual practitioner who delivered the reimbursable services, or to the agency, facility, or organization that employs the individual practitioner who delivered the reimbursable services, as appropriate.

[Remote patient monitoring is included in definition of telehealth.]

In no case shall the State Medicaid and NJ FamilyCare Programs:

Deny coverage for or refuse to provide reimbursement for routine patient monitoring performed using telemedicine and telehealth, including remote monitoring of a patient’s vital signs and routine check-ins with the patient to monitor the patient’s status and condition, if coverage and reimbursement would be provided if those services are provided in person, and the provider is able to meet the same standard of care as would be provided if the services were provided in person.

SOURCE: NJ Statute C.30:4D-6K – cites: NJ Statute C.45:1-61. (Accessed Aug. 2024).

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

No Reference Found

No Reference Found

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New York

Last updated 12/10/2024

POLICY

“Remote patient monitoring” means the use of synchronous or …

POLICY

“Remote patient monitoring” means the use of synchronous or asynchronous electronic information and communication technologies to collect personal health information and medical data from a patient at an originating site that is transmitted to a telehealth provider at a distant site for use in the treatment and management of medical conditions that require frequent monitoring. Such technologies may include additional interaction triggered by previous transmissions, such as interactive queries conducted through communication technologies or by telephone.

RPM included within definition of “telehealth” in statute requiring Medicaid Reimburse telehealth delivery of services.

Subject to the approval of the state director of the budget, the commissioner may authorize the payment of medical assistance funds for demonstration rates or fees established for home telehealth services provided pursuant to subdivision three-c of section thirty-six hundred fourteen of the public health law.

Subject to federal financial participation and the approval of the director of the budget, the commissioner shall not exclude from the payment of medical assistance funds the delivery of health care services through telehealth, as defined in subdivision four of section two thousand nine hundred ninety-nine-cc of the public health law.

SOURCE: Social Services Law Title 11, Article 367-u & NY Public Health Law Article 29 – G Section 2999-cc. (Accessed Dec. 2024).

Remote patient monitoring (RPM) uses digital technologies to collect medical data and other personal health information from members in one location and electronically transmit that information securely to health care providers in a different location for assessment and recommendations. Monitoring programs can collect a wide range of health data from the point of care, such as vital signs, blood pressure, heart rate, weight, blood sugar, blood oxygen levels and electrocardiogram readings. RPM may include follow-up on previously transmitted data conducted through communication technologies or by telephone.

Telehealth services provided by means of RPM should be billed using CPT code “99091” [collection and interpretation of physiologic data (e.g., Electrocardiography (ECG), blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training and licensure/regulation (when applicable) requiring a minimum of 30 minutes of time].

A fee of $48.84 per month will be paid for RPM.

Providers are not to bill “99091” more than one time per member per month.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 7, 19. (Accessed Dec. 2024).

CONDITIONS

Medical conditions that may be treated/monitored by means of RPM include, but are not limited to:

Congestive heart failure
Diabetes
Chronic obstructive pulmonary disease
Wound care
Polypharmacy
Mental or behavioral problems
Technology-dependent care, such as continuous oxygen, ventilator care, total parenteral nutrition, or enteral feeding.

SOURCE: NY Public Health Law Article 29 – G Section 2999-cc. (Accessed Dec. 2024).

RPM may be used during pregnancy and postpartum, as outlined in the September 2022 issue of the Medicaid Update.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 7. (Accessed Dec. 2024).

Maternal Care RPM Coverage

Effective October 1, 2022, for fee-for-service (FFS), and December 1, 2022, for Medicaid Managed Care (MMC) Plans, New York State (NYS) Medicaid is expanding coverage for remote patient monitoring (RPM) during pregnancy and up to 84 days postpartum to further improve and expand access to prenatal and postpartum care. This expansion of coverage includes an additional monthly fee to cover the cost of RPM devices/equipment. See Medicaid Update for additional billing guidance.

SOURCE: NY Dept. of Health, Medicaid Update, Vol. 38, Number 10, September 2022 (Accessed Dec. 2024)

The additional allowance that may be reimbursable for maternity RPM equipment provided by enrolled providers to pregnant and postpartum NYS Medicaid members calls for using CPT codes “99453” and “99454” with HD modifier. Please note: “99091” and “99454” are both intended to be billed once monthly but cannot be billed on the same day. This replaces the guidance for billing these codes that was included in the September 2022 issue of the Medicaid Update that stated, “CPT Code “99454” is billed along with CPT Code “99091”.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 19. (Accessed Dec. 2024).

Continuous Glucose Monitoring (CGM)

NYS Medicaid covers continous glucose monitoring for:

Members with a diagnosis of gestational diabetes; or
Members with a diagnosis of type 1 or type 2 diabetes, who meet all the following criteria:
- Are under the care of an endocrinologist, or an enrolled Medicaid provider with experience in diabetes treatment, who orders the device.
- Are compliant with regular visits to review CGM data with their provider.
- Are on an insulin treatment plan or an insulin pump.
- Are able, or have a caregiver who is able, to hear and view CGM alerts and respond appropriately

SOURCE: NY Dept. of Health, Provider Communication, Updated Continuous Glucose Monitoring Criteria, Oct. 2023. (Accessed Dec. 2024).

PROVIDER LIMITATIONS

Remote patient monitoring shall be ordered by a physician licensed pursuant to article one hundred thirty-one of the education law, a nurse practitioner licensed pursuant to article one hundred thirty-nine of the education law, or a midwife licensed pursuant to article one hundred forty of the education law, with which the patient has a substantial and ongoing relationship.

SOURCE: NY Public Health Law Article 29 – G Section 2999-cc. (Accessed Dec. 2024)

FQHCs that have opted out of Ambulatory Patient Groups (APGs) are unable to bill for RPM services at this time.

Coverage is not available for services provided solely by a technician or for technical support of device interrogation at this time.

SOURCE: NY Dept. of Health Medicaid Telehealth Policy Manual (May 2024), p. 7, 19. (Accessed Dec. 2024).

Expansion of Remote Patient Monitoring Coverage to Clinical Staff

Remote patient monitoring (RPM) uses digital technologies to collect medical data and other personal health information from the New York State (NYS) Medicaid member in one location and electronically transmit that information to health care providers in a different location for assessment and recommendations.

Effective January 1, 2025, NYS Medicaid will reimburse RPM Current Procedural Terminology (CPT) code “99457“. Medicaid Managed Care (MMC) Plans must comply with this coverage, by March 1, 2025. This service may be delivered by clinical staff; however, the service must be ordered by a physician or other qualified health care professional. Clinical staff includes individuals under the direction of a physician or qualified health care professional who do not independently bill professional services, such as pharmacists and some registered dieticians. Providers delivering RPM must confirm that they operate within their scope of practice. Clinical staff may not order nor modify prescriptions. This service is not intended for retail pharmacists.

Providers should refer to the Telehealth Policy Manual – New York State Medicaid Fee-for-Service Provider Policy Manual, for additional details on RPM CPT codes and billing guidance.

SOURCE: New York State Medicaid Update – October Volume 40 – Number 11. (Accessed Dec. 2024).

OTHER RESTRICTIONS

No Reference Found

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North Carolina

Last updated 12/09/2024

POLICY

Remote Patient Monitoring is the use of digital devices …

POLICY

Remote Patient Monitoring is the use of digital devices to measure and transmit personal health information from a beneficiary in one location to a provider in a different location. Remote patient monitoring enables providers to collect and analyze information such as vital signs (blood pressure, heart rate, weight, blood oxygen levels) in order to make treatment recommendations. There are two types of remote patient monitoring addressed within this policy:

Self-Measured and Reported Monitoring: When a beneficiary uses a digital device to measure and record their own vital signs, then transmits the data to a provider for evaluation.
Remote Physiologic Monitoring: When a beneficiary’s physiologic data is wirelessly synced from a beneficiary’s digital device where it can be evaluated immediately or at a later time by a provider.

Remote patient monitoring, including:

self-measured blood pressure monitoring; and
remote physiologic monitoring.

List of eligible Remote Patient Monitoring Services provided on page 14 of Attachment A of the Telehealth, Virtual Communications and Remote Patient Monitoring manual. FQHCs, FQHC Lookalikes and RHCs are allowed to bill for RPM codes.

Guidance: Self-Measured Blood Pressure Monitoring (SMBPM)

SMBPM is a beneficiary’s regular use of a personal blood pressure monitoring device to assess and record blood pressure across different points in time outside of a clinical setting, typically at home. This service is available for new or established patients. SMBPM require a device that is wirelessly synced where the provider can evaluate the data in real or near-real time. All remote patient monitoring must be conducted in a HIPAA compliant manner, particularly with respect to protecting transmission of patient health data.

Guidance: Remote Physiologic Monitoring (RPM)

RPM is the collection and interpretation of an established beneficiary’s physiologic data digitally transmitted to the eligible provider. Codes 99453 and 99454 are used for device set-up, training and supply – the following guidance applies to both of these codes:

99453 and 99454 can be used for blood pressure RPM if the device used to measure blood pressure meets RPM requirements. If the beneficiary self-reports blood pressure readings, the provider should instead bill SMBPM codes 99473/99474.
99453 and 99454 cannot be reported if monitoring is less than 16 days in duration.
Providers should not report codes 99453 or 99454 if the services are included in any other codes covered by NC Medicaid for the duration of time of the RPM (for example, continuous glucose monitoring that is covered under code 95250).

RPM treatment management services are the use of the RPM results by the eligible provider to manage an established patient’s treatment plan. Codes 99457 and 99458 are used to report RPM treatment management services – the following guidance applies to both of these codes.

Codes 99457 and 99458 require a live, interactive communication between the beneficiary or caregiver.
Providers may not bill code 99457 or 99458 for interactions of less than 20 minutes.

For all RPM and RPM treatment management service codes in table C.3: If the services described by codes 99453, 99454, 99457 or 99458 are provided on the same day a beneficiary presents for an evaluation and management service to the same provider (whether by telehealth or in-person), these services should be considered part of the E/M service and not billed under the RPM code.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1H, Telehealth, Virtual Communications and Remote Patient Monitoring, June 1, 2023. (Accessed Dec. 2024).

North Carolina Innovations – Supported Living

The Supported Living provider shall be responsible for providing an individualized level of supports determined during the assessment process, including risk assessment, and identified and approved in the Individual Support Plan (ISP) and have 24 hour per day availability, including back-up and relief staff and in the case of emergency or crisis. Some beneficiaries receiving Supported Living services may be able to have unsupervised periods of time based on the assessment process. In these situations, a specific plan for addressing health and safety needs must be included in the ISP and the Supported Living provider shall have staffing available in the case of emergency or crisis. Requirements for the beneficiary’s safety in the absence of a staff person must be addressed and may include use of tele care options. When assessed to be appropriate Assistive Technology elements may be utilized in lieu of direct care staff.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy 8-P, North Carolina Innovations Amended Apr. 1, 2023, (Accessed Dec. 2024).

CONDITIONS

Phase II Outpatient Cardiac Rehabilitation Programs

Telemetry monitoring is available for at risk patients. See manual for details.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1R-1, Phase II Outpatient Cardiac Rehabilitation Programs, June 1, 2023. (Accessed Dec. 2024).

PROVIDER LIMITATIONS

Providers that may bill NC Medicaid for remote patient monitoring include physicians, nurse practitioners; psychiatric nurse practitioner; certified nurse midwives; and physician’s assistants.

FQHCs, FQHC Lookalikes and RHCs are allowed to bill for RPM codes.

Electrocardiography, Echocardiography, and Intravascular Ultrasound

Holter monitoring is not covered for less than a 24-hour monitored period.

Home-based telemetry systems are not covered by N.C. Medicaid.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual, Clinical Coverage Policy No: 1R-4, Electrocardiography, Echocardiography, and Intravascular Ultrasound, November 1, 2023. (Accessed Dec. 2024).

Federally Qualified Health Centers & Rural Health Clinics

FQHCs and RHCs would be reimbursed on a fee-for-service basis for delivering non-core visit services via telehealth, virtual patient communications, or remote patient monitoring.

SOURCE: NC Div. of Medical Assistance, Medicaid and Health Choice Manual: Core Services Provided in Federally Qualified Health Centers and Rural Health Clinics ID-4 Aug. 15, 2023. (Accessed Dec. 2024).

OTHER RESTRICTIONS

Remote patient monitoring requires use of a device that is defined by the FDA as a medical device and is in real-time and transmittable. Some forms of remote patient monitoring, such as remote physiologic monitoring (detailed below), require a device that is wirelessly synced where the provider can evaluate the data in real or near-real time. All remote patient monitoring must be conducted in a HIPAA compliant manner, particularly with respect to protecting transmission of patient health data.

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North Dakota

Last updated 11/11/2024

POLICY

Home Health Services

Home Health Telemonitoring will be covered …

POLICY

Home Health Services

Home Health Telemonitoring will be covered within the same limits noted above. Home Telemonitoring is not allowed for the initial home Health evaluation visit or for the discharge visit. In addition, Home Health Telemonitoring is limited to no more than forty percent (40%) of the total visits during each certification period.

SOURCE: ND Div. of Medical Services, Home Health and Private Duty Nursing, (Oct. 2024), (Accessed Nov. 2024).

Preventative Services and Chronic Disease Management

At-home self-monitored blood pressure monitoring may be medically necessary to:

Differentiate between hypertension occurring due to being in the doctor’s office for the measurement (i.e. “white coat hypertension”) and
to help monitor variation in blood pressure measurements and appropriately adjust treatment protocols to avoid “overtreatment”. The second reason also can result in more adherence to treatment.

Members must use a validated blood pressure device (CPT® A4670) from the Validated Device List – Blood Pressure Devices for blood pressure self-monitoring.

Patient Education and Training – Members may receive a one-time per monitor education and training on the set-up (CPT® code 99473) and use of a self-monitoring blood pressure (SMBP) measurement device, which includes device calibration.

SOURCE: ND Div. of Medical Services, Preventative Services and Chronic Disease Management Manual, (Oct. 2024), (Accessed Nov. 2024).

CONDITIONS

Preventative Services and Chronic Disease Management

SMBP Data Collection and Interpretation – CPT® code 99474 is used for members who self-measure their blood pressure twice daily for a one-month period.

SOURCE: ND Div. of Medical Services, Preventative Services and Chronic Disease Management Manual, (Oct. 2024), (Accessed Nov. 2024).

PROVIDER LIMITATIONS

Preventative Services and Chronic Disease Management

Blood pressure self-monitoring may be ordered by a member’s physician, pharmacist or Other Licensed Practitioner.

SOURCE: ND Div. of Medical Services, Preventative Services and Chronic Disease Management Manual, (Oct. 2024), (Accessed Nov. 2024).

OTHER RESTRICTIONS

Preventative Services and Chronic Disease Management

Members are to take their blood pressure four times daily. Twice in the morning and twice in the evening, with a minute between each blood pressure reading.

Measurements must be communicated from the member to their treating provider’s practice and can be recorded and transmitted manually or electronically. Treating providers must then create or modify the member’s hypertension treatment plan based on the documented average of the submitted readings. The new or modified treatment plan must be in the member’s medical record and communicated back to the member. If this communication takes place during an E/M visit, this service is not separately billable.

99473 – billed once per blood pressure measurement device. Cannot be billed separately if there is an E/M service billed by the same rendering provider on the same date of service.
99474 – may not be separately reimbursed when billed with an E/M service when performed on the same date of service by the same rendering provider. Member must have a minimum of twelve (12) readings in a calendar month to bill for this CPT code. Code may only be used once per calendar month per member.

SOURCE: ND Div. of Medical Services, Preventative Services and Chronic Disease Management Manual, (Oct. 2024), (Accessed Nov. 2024).

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Ohio

Last updated 11/04/2024

POLICY

Telehealth is the interaction with a patient via synchronous, …

POLICY

Telehealth is the interaction with a patient via synchronous, interactive, real-time electronic communication that includes both audio and video elements; OR

The following activities that are asynchronous or do not have both audio and video elements:

Telephone calls
Remote patient monitoring
Communication with a patient through secure electronic mail or a secure patient portal

For services rendered by behavioral health providers as defined in rule 5160-27-01 of the Administrative Code, telehealth is further defined in rule 5122-29-31 of the Administrative Code.

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide. Revised 7/15/2022, p. 4 & OAC 5160-1-18. (Accessed Nov. 2024).

Remote physiologic monitoring codes 99453, 99454, 99457, and 99458 are listed as a covered telehealth service.

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide. Revised 7/15/2022, p. 20-21. (Accessed Nov. 2024).

Federally Qualified Health Center and Rural Health Clinics

Remote patient monitoring will be paid through FFS as a covered non-FQHC/RHC service under the clinic provider type 50 (using ODM’s payment schedules).

SOURCE: The Ohio Department of Medicaid. Telehealth Billing Guide. Revised 7/15/2022, p. 9. (Accessed Nov. 2024).

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

No Reference Found

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Oklahoma

Last updated 11/26/2024

POLICY

“Remote patient monitoring” means the use of digital technologies …

POLICY

“Remote patient monitoring” means the use of digital technologies to collect medical and other forms of health data (e.g., vital signs, weight, blood pressure, blood sugar) from individuals in one (1) location and electronically transmit that information securely to health care providers in a different location for assessment and recommendations.

Health care services delivered by telehealth such as Remote Patient Monitoring, Store and Forward, or any other telehealth technology, must be compensable by OHCA in order to be reimbursed.

Services provided by telehealth must be billed with the appropriate modifier.

If the technical component of an X-ray, ultrasound or electrocardiogram is performed during a telehealth transmission, the technical component can be billed by the provider that provided that service. The professional component of the procedure and the appropriate visit code should be billed by the provider that rendered that service.

The cost of telehealth equipment and transmission is not reimbursable by SoonerCare.

SOURCE: OK Admin. Code Sec. 317:30-3-27(a) & (e). (Accessed Nov. 2024).

Continuous glucose monitoring (CGM)

CGM means a minimally invasive system that measures glucose levels in subcutaneous or interstitial fluid. CGM provides blood glucose levels and can help members make more informed management decisions throughout the day.

CGM must be determined by a provider to be medically necessary and documented in the member’s plan of care as medically necessary and used for medical purposes. A request by a qualified provider for CGM in and of itself shall not constitute medical necessity. The Oklahoma Health Care Authority (OHCA) shall serve as the final authority pertaining to all determinations of medical necessity. Refer to Oklahoma Administrative Code (OAC) 317:30-5-211.2 and 317:30-3-1(f) for policy on medical necessity. CGM devices must be approved by the U.S. Food and Drug Administration (FDA) as non-adjunctive and must be used for therapeutic purposes. Devices may only be used for members within the age range for which the devices have been FDA approved.

In-person or telehealth visit [within the last six (6) months] between the treating provider, member and/or family to evaluate their diabetes control.

SOURCE: OK Admin. Code Sec. 317:30-5-211.25. (Accessed Nov. 2024).

CONDITIONS

Continuous glucose monitoring (CGM)

Member must have a diagnosis that correlates to the use of CGM.

SOURCE: OK Admin. Code Sec. 317:30-5-211.25. (Accessed Nov. 2024).

Extended Ambulatory Cardiac Monitoring

Effective Nov. 1, 2023, OHCA has added coverage for extended ambulatory cardiac monitoring codes 93241-93244 and 93245-93248. Coverage is intended to evaluate syncope and lightheadedness, to document arrhythmia in members with a non-diagnostic Holter monitor or 48-hour telemetry, or in persons whose symptoms occur infrequently such that the arrhythmia is unlikely to be diagnosed by Holter monitoring.

SOURCE: OK Health Care Authority, 2023 Global Messages, Extended Ambulatory Cardiac Monitoring, 11/9/23, (Accessed Nov. 2024).

PROVIDER LIMITATIONS

Continuous glucose monitoring (CGM)

Prescription must be made by a qualified provider.

SOURCE: OK Admin. Code Sec. 317:30-5-211.25. (Accessed Nov. 2024).

Extended Ambulatory Cardiac Monitoring

Providers: 08, 09, 10, 31, and 52

SOURCE: OK Health Care Authority, 2023 Global Messages, Extended Ambulatory Cardiac Monitoring, 11/9/23, (Accessed Nov. 2024).

OTHER RESTRICTIONS

No Reference Found

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Oregon

Last updated 12/12/2024

POLICY

To encourage the efficient use of resources and to …

POLICY

To encourage the efficient use of resources and to promote cost-effective procedures in accordance with ORS 413.011 (1)(L), the Oregon Health Authority shall reimburse the cost of health services delivered using telemedicine, including but not limited to:

Health services transmitted via landlines, wireless communications, the Internet and telephone networks;
Synchronous or asynchronous transmissions using audio only, video only, audio and video and transmission of data from remote monitoring devices; and
Communications between providers or between one or more providers and one or more patients, family members, caregivers or guardians.

The authority shall pay the same reimbursement for a health service regardless of whether the service is provided in person or using any permissible telemedicine application or technology.

SOURCE: OR Statute 414.723. (Accessed Dec. 2024).

Teledentistry can take multiple forms, both synchronous and asynchronous, including but not limited to: …

Remote member monitoring, where personal health and dental information is collected by dental care providers in one location then transmitted electronically to a dentist in a distant site location for use in care

SOURCE: OR OAR 410-123-1265, Health Systems Division: Medical Assistance Programs, Oregon Health Plan, Teledentistry. (Accessed Dec. 2024).

“Asynchronous” means not simultaneous or concurrent in time. For the purpose of this general rule, asynchronous telecommunication technologies for telemedicine or telehealth services may include audio and video, audio without video, client or member portal and may include remote monitoring. “Asynchronous” does not include voice messages, facsimile, electronic mail or text messages.

SOURCE: OR OAR 140-120-0000, Medical Assistance Program: Acronyms and Definitions; OAR 410-141-3566. Health Systems Division: Medical Assistance Programs. Oregon Health Plan and 410-120-1990 [slight variations exist], (Accessed Dec. 2024).

CONDITIONS

No Reference Found

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

No Reference Found

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Pennsylvania

Last updated 09/10/2024

POLICY

Telehealth, for purposes of MA Program payment, does not …

POLICY

Telehealth, for purposes of MA Program payment, does not include asynchronous or store and forward technology or facsimile machines, electronic mail systems or remote patient monitoring devices. However, these technologies may be utilized as a part of the provision of a MA covered service.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin 99-23-08, p. 2-3, Aug. 2, 2023 (Accessed Sept. 2024).

CONDITIONS

PA Medicaid pays for some continuous glucose monitoring products with prior authorization.

SOURCE: PA Department of Human Services, Medical Assistance Bulletin Prior Authorization of Continuous Glucose Monitoring Products – Pharmacy Services, Jan. 8, 2024, (Accessed Sept. 2024).

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

No Reference Found

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Puerto Rico

Last updated 09/04/2024

Remote monitoring: Facilitates remote self-care through the use of electronic …

Remote monitoring: Facilitates remote self-care through the use of electronic equipment and systems (e.g. vital signs monitoring platforms).

Source: Telemedicina Y Telesalud. Departamento de Salud (Accessed Sept. 2024).

Tele-monitoring – Facilitates self-care with electronic equipment. The data is stored in a repository. It consists of measuring, observing and even modifying the course of one or more vital parameters of a patient through electronic means and remote communication. These parameters include, for example, pulse, respiration, blood pressure, blood glucose and oxygen, and many others.

Tele-Monitoring service utilizing technologies which measure and report the health status of at-risk waiver participants. This is done remotely by utilizing either existing telephone infrastructure or wireless communication technology in collecting and transmitting physiological data between the provider and participant. Monitoring is the primary purpose of this service. Remote monitoring will assist the individual to fully integrate into the community, participate in community activities, and avoid isolation.

SOURCE: SC Health and Human Svcs. Dept. HCBS Provider Manual, p. 32-33 (Jul. 2024). (Accessed Aug. 2024).

Continuous Glucose Monitoring

Effective for dates of service on or after July 1, 2024, the South Carolina Department of Health and Human Services (SCDHHS) is expanding its existing coverage of continuous glucose monitoring (CGM) for full-benefit Healthy Connections Medicaid members. CGM will be covered under either the pharmacy or durable medical equipment (DME) State Plan benefit.

SOURCE: SC Health and Human Svcs. Dept. Provider Bulletin 24-036. (Jun. 2024); SC Health and Human Svcs. Dept. Physicians Provider Manual, p. 55 (Aug. 2024); SC Health and Human Svcs. Dept. Durable Medical Equipment Services Provider Manual, p. 7 (Jul. 2024). (Accessed Aug. 2024).

CGM measures glucose levels in real-time. An electrode called a sensor is inserted under the skin to measure glucose levels in interstitial fluid. The sensor is connected to a transmitter which sends the information wirelessly to a monitoring and display device. The monitoring system may be either a stand-alone system or it may be integrated into an external insulin pump.

SOURCE: SC Health and Human Svcs. Dept. Durable Medical Equipment Services Provider Manual, p. 7 (Jul. 2024). (Accessed Aug. 2024).

Acute Hospital Care at Home

“Acute hospital care at home” means acute-level hospital care to treat a subset of diagnoses that respond safely and effectively to home-based acute care, utilizing technology to provide continuous remote patient monitoring and connectivity to the patient and developing in-home services to ensure the same level of care in the home as in a traditional hospital stay as well as patient safety. Acute hospital care at home must be provided by a hospital licensed in this State pursuant to this article to eligible patients who have provided consent to such care, utilizing a multidisciplinary team to deliver the care.

Acute hospital care at-home programs and services delivered by a licensed acute care hospital are exempted from Certificate of Need review. The delivery of acute hospital care at-home programs and services by a licensed acute care hospital does not require a written exemption from the department. Additionally, patients enrolled in the hospital care at-home program shall not be considered within the licensed bed capacity of the hospital participating in the program.

The department shall promulgate regulations for licensing an acute care hospital’s acute hospital care at home programs and services. At a minimum, the regulations must address:

diagnoses that respond safely and effectively to home-based acute care;
patient eligibility criteria and screening requirements, including patient consent;
multidisciplinary team requirements, including roles and responsibilities of team members;
standards for continuous remote patient monitoring and connectivity with the patient;
standards for the development of in-home services to ensure same level of care in the home as in a traditional hospital stay; and
standards for patient safety.

SOURCE: SC Code Sec. 44-7-130(25), SC Code Sec. 44-7-170(A)(4), SC Code Sec. 44-7-267 as proposed to be added and amended by S 858 (2024 Session). (Accessed Aug. 2024).

CONDITIONS

Continuous Glucose Monitoring

CGM will be covered with prior authorization (PA) that includes the following criteria.

Eligible Medicaid members must have one of the following clinical criteria:
1. Type 1 diabetes mellitus;
2. Gestational diabetes; or
3. Type 2 diabetes with one of the following:
  1. Any type of insulin dependency or
  2. Non-insulin treated diabetes who have recurrent moderate (level 2) or have had at least one severe (level 3) hypoglycemic event

PROVIDER LIMITATIONS

Home and Community Based Services

Participants receiving the telemonitoring service must have a primary care physician that approves the use of the telemonitoring service and is solely responsible for receiving and acting upon the information received via the telemonitoring service.

SOURCE: SC Health and Human Svcs. Dept. HCBS Provider Manual, p. 32-33 (Jul. 2024). (Accessed Aug. 2024).

Continuous Glucose Monitoring

CGM will be covered with prior authorization (PA) that includes the following criteria.

CGM must be prescribed by one of the following qualified healthcare providers:
1. primary care provider (a physician, physician assistant or advanced practice registered nurse);
2. obstetrician; or
3. endocrinologist

OTHER RESTRICTIONS

Home and Community Based Services

Telemonitoring equipment located in the participant’s home must, at a minimum, be an FDA Class II Hospital grade medical device that includes a computer/monitor that is programmable for a variety of disease states and for rate and frequency. The equipment must have a digital scale that measures accurately to at least 400 lbs. that is adaptable to fit a glucometer and a blood pressure cuff. All installed equipment must be able to measure, at a minimum, blood pressure, heart rate, oxygen saturation, blood glucose, and body weight.

Telephones, facsimile machines, and electronic mail systems do not meet the requirements of the definition of telemonitoring but may be utilized as a component of the telemonitoring system.

As communication of data occurs at scheduled daily “appointment times” and the information collected/sent is neither visible to others or remains stored on the device, the participant maintains constant control of their personal information within the residential environment.

SOURCE: SC Health and Human Svcs. Dept. HCBS Provider Manual, p. 32-33 (Jul. 2024). (Accessed Aug. 2024).

Continuous Glucose Monitoring

The treating provider must evaluate the patient on an annual basis to consider patient’s compliance and determine the necessity of continuation of CGM.

SOURCE: SC Health and Human Svcs. Dept. Durable Medical Equipment Services Provider Manual, p. 7 (Jul. 2024).(Accessed Aug. 2024).

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South Dakota

Last updated 12/11/2024

POLICY

Effective October 1, 2023, South Dakota Medicaid added permanent …

POLICY

Effective October 1, 2023, South Dakota Medicaid added permanent coverage of remote patient monitoring of physiologic functions when medically necessary for recipients with acute or chronic conditions when ordered and billed by providers who are eligible to bill Medicaid for E/M services. Certain criteria must be met (see below).

See table on page 7-8 for eligible codes.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Nov. 2024) (Accessed Dec. 2024).

The Office of Adult Services and Aging

“Telehealth services,” a home based health monitoring system used to collect and transmit an individual’s clinical data for monitoring and interpretation.

SOURCE: SD Regulation 67:40:19:01(21) (Accessed Dec. 2024).

Home Health

For the initial order for home health services, a physician or other licensed practitioner must document a face-to-face encounter related to the primary reason the beneficiary requires the services. The encounter may occur through telemedicine. The encounter must occur within the 90 days before or 30 days after the start of the services

SOURCE: SD Medicaid Billing and Policy Manual: Home Health Services, p. 2 (Feb. 2024). (Accessed Dec. 2024).

Continuous Glucose Monitoring

South Dakota Medicaid covers continuous 72-hour glucose monitoring provided by an endocrinologist or an advanced practice provider working with an endocrinologist through the endocrinologist’s office no more than twice annually with a prior authorization.

SOURCE: SD Medicaid Billing and Policy Manual: Physician Services, p. 9 (Aug. 2024), (Accessed Dec. 2024).

CONDITIONS

The recipient must be diagnosed with at least one of the following conditions:

Asthma
Congestive Heart Failure
Cardiac monitoring
Hypertension or Hypotension
Chronic Obstructive Pulmonary Disease
Diabetes
Gestational Diabetes
COVID-19 post infection monitoring

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, pg. 6 (Nov. 2024) (Accessed Dec. 2024).

PROVIDER LIMITATIONS

Only a physician, physician assistant, nurse practitioner, or certified nurse midwife are allowed to order RPM and bill for the services.

FQHC/RHC

FQHC/RHC providers may bill for these services on a fee for service basis using their non-Prospective Payment System (PPS) NPI if the service is ordered by one of the allowable practitioner types.

IHS and Tribal 638

IHS and Tribal 638 facilities can bill the encounter rate for remote patient monitoring CPT codes 99091, 99457, and 99458 as long as these services meet the definition of an encounter and are in accordance with the “Four Walls” requirement under 42 CFR 440.90 as provided in the IHS and Tribal 638 Facilities manual.

School District Services

School district providers may provide physical and occupational therapy via telemedicine using CPT code 97799 for physical therapy and CPT code 97139 for occupational therapy. Speech-language pathology services continue to be allowed when provided via telemedicine and should be billed using CPT code 92507. The service must be provided by means of “real-time” interactive telecommunications system and the provider must have a face-to-face visit within the first 30 days and every 90 days thereafter.

Psychology services may also be provided via telemedicine or real time, two-way audio-only using CPT code 90899. Audio-only services must be provided in accordance with the independent mental health practitioner coverage criteria stated in this manual.

Please refer to the School District Services manual for additional coverage information.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Nov. 2024) (Accessed Dec. 2024).

OTHER RESTRICTIONS

The recipient must be cognitively capable of operating the remote monitoring equipment or must be assisted by a caregiver capable of operating the equipment.

The recipient’s condition must be unmanaged or require frequent and on-going monitoring during a period where:

The recipient is newly diagnosed with the condition in the last 6 months and is learning to manage the condition;
The recipient has a chronic condition that has become difficult to manage in the last 6 months; or
The recipient has had 2 or more episodes that required either emergency department care, hospitalization, or emergency intervention in the last 6 months.

The medical device supplied to a recipient as part of RPM services must be a medical device as defined by Section 201(h) of the Federal Food, Drug, and Cosmetic Act, that the device must be reliable and valid, and that the data must be electronically (i.e., automatically) collected and transmitted rather than self-reported.

RPM is only allowed for established patients who are under the active care of a provider.

The provider must document the medical necessity of the service.

The provider must obtain consent from the recipient to furnish RPM services.

The provider must prescribe a care plan that denotes the need for remote monitoring and the impact on treatment and management of the recipient . The care plan must also address actions taken by the provider and/or care team to improve or address the recipient’s ability to self manage the condition including patient education.

Prior Authorization

The out-of-state prior authorization requirement does not apply if the recipient is located in South Dakota at the time of the service and the provider is located outside of the State. If the service otherwise requires a prior authorization, the provider is still required to obtain prior authorization prior to providing the service.

SOURCE: SD Medicaid Billing and Policy Manual: Telemedicine, (Nov. 2024), (Accessed Dec. 2024).

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Tennessee

Last updated 08/26/2024

POLICY

“Remote patient monitoring services” means using digital technologies to …

POLICY

“Remote patient monitoring services” means using digital technologies to collect medical and other forms of health data from a patient and then electronically transmitting that information securely to healthcare providers in a different location for interpretation and recommendation.

A health insurance entity may consider any remote patient monitoring service a covered medical service if the same service is covered by Medicare. The appropriate parties may negotiate the rate for these services in the manner in which is deemed appropriate by the parties.

SOURCE: TN Code Annotated, Sec. 56-7-1011 , (Accessed Aug. 2024).

CONDITIONS

No later than December 31, 2024, the bureau of TennCare shall amend existing rules, or promulgate new rules, on fee-for-service and medicaid managed care plans regarding reimbursement to allow for the reimbursement of remote ultrasound procedures and remote fetal nonstress tests utilizing established CPT codes for such procedures when the patient is in a residence or other off-site location that is separate from the patient’s provider and the same standard of care is met.

SOURCE: TN Code Annotated, Sec. 71-5-168, (Accessed Aug. 2024).

PROVIDER LIMITATIONS

No Reference Found

OTHER RESTRICTIONS

Reimbursement of expenses for covered remote patient monitoring services must be established through negotiations conducted by the health insurance entity with the healthcare services provider, healthcare system, or practice group in the same manner as the health insurance entity establishes reimbursement of expenses for covered healthcare services that are delivered by in-person means.

Remote patient monitoring services are subject to utilization review under the Health Care Service Utilization Review Act, compiled in chapter 6, part 7 of this title.

This section does not apply to a health incentive program operated by a health insurance entity that utilized an electronic device for physiological monitoring.

SOURCE: TN Code Annotated, Sec. 56-7-1011 , (Accessed Aug. 2024).

When amending or promulgating rules pursuant to subsection (b), the bureau shall ensure that:

A remote ultrasound procedure or remote fetal nonstress test is only reimbursable when the provider uses digital technology:
- To collect medical and other forms of health data from a patient and electronically transmit that information securely to a healthcare provider who is in a separate location for the purpose of interpretation and making recommendations;
- That is compliant with the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) (42 U.S.C. § 1320d et seq.); and
- That is approved by the federal food and drug administration; and

A fetal nonstress test is only reimbursable with a place of service modifier for at-home monitoring with remote monitoring solutions that are cleared by the federal food and drug administration for on-label use for monitoring fetal heart rate, maternal heart rate, and uterine activity.

SOURCE: TN Code Annotated, Sec. 71-5-168, (Accessed Aug. 2024).

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Texas

Last updated 12/17/2024

POLICY

“Home telemonitoring service” means a health service that requires …

POLICY

“Home telemonitoring service” means a health service that requires scheduled remote monitoring of data related to a patient’s health and transmission of the data to a licensed home and community support services agency, a federally qualified health center, a rural health clinic, or a hospital, as those terms are defined by Section 531.02164(a). The term is synonymous with “remote patient monitoring.”

SOURCE: TX Government Code, Sec. 531.001(4-a) (Accessed Dec. 2024).

HHSC reimburses eligible providers performing home telemonitoring services in the same manner as their other professional services described in §355.8021 of this title (relating to Reimbursement Methodology for Home Health Services).

SOURCE: TX Admin Code, Title 1, Sec. 355.7001(e). (Accessed Dec. 2024).

Home telemonitoring services, also known as remote patient monitoring, is a benefit of Texas Medicaid. Home telemonitoring is a health service that requires scheduled remote monitoring of data related to a client’s health, and transmission of the data from the client’s home to a licensed home health agency, hospital, FQHC, or RHC. Data and information collected remotely will be transmitted from the client’s home to the home health agency, hospital, FQHC, or RHC. The data transmission must comply with standards set by HIPAA.

Home telemonitoring providers must establish a plan of care (POC) with outcome measures based on the physician or requesting provider’s order for each client, and the POC and outcome measures must be reviewed by the client’s physician.

SOURCE: TX Medicaid Telecommunication Services Handbook, pg. 14-16 (Dec. 2024), (Accessed Dec. 2024).

CSHCN Program

Home telemonitoring services are a benefit of the CSHCN Services Program.

Home telemonitoring is a health service that requires scheduled remote monitoring of data related to a client’s health, and transmission of the data from the client’s home to a licensed home health agency or a hospital. The data transmission must comply with standards set by the Health Insurance Portability and Accountability Act (HIPAA).

Data parameters are established as ordered by a physician’s plan of care. Data must be reviewed by a registered nurse (RN), APRN, or PA, who is responsible for reporting data to the prescribing physician in the event of a measurement outside the established parameters.

Procedure code S9110 (with modifier U1) is limited to once per episode of care even if monitoring parameters are added after initial setup and installation. A claim for a subsequent set up and installation will not be reimbursed unless there is a documented new episode of care or documentation of the occurrence of extenuating circumstances.

Home monitoring (procedure code S9110 with the appropriate modifier) is a benefit when services are provided by a home health agency or an outpatient hospital. Hospital providers must submit revenue code 780 with procedure code S9110 and the appropriate modifier for monthly home monitoring. Refer to table below for the appropriate modifier.

Providers must bill the appropriate modifier to indicate the number of days that transmissions of data were received and reviewed for the client within a rolling month.

Providers are not required to submit modifiers U2, U3, U4, U7, U8, or U9 for telemonitoring on the prior authorization request, but are required to submit the appropriate modifier on the claim for reimbursement based on the number of days as outlined in the table.

Procedure code S9110 with or without modifier U1 requires prior authorization. Telemonitoring services may be requested and approved for up to 90 days per prior authorization request. The initial setup and installation (procedure code S9110 with modifier U1) may be prior authorized once per episode of care, unless the provider submits documentation of extenuating circumstances that require another installation of telemonitoring equipment. If additional home telemonitoring services are needed, the home health agency or hospital must request prior authorization before the current prior authorization period ends.

Telecommunication services may be reimbursed the lower of the billed amount or the amount allowed by Texas Medicaid.

See manual for prior authorization requirements.

SOURCE: TX Medicaid, CSHCN Program Services Provider Manual Telecommunication Services (Nov. 2024), p. 9-13. (Accessed Dec. 2024).

Concurrent services for telemonitoring are allowed for distinctly different medical reasons. Duplication of services by any provider will not be prior authorized.

SOURCE: TX Medicaid CSHCN Services Program Manual – Home Health Services, (Nov. 2024), pg. 7 (Accessed Dec. 2024).

CONDITIONS

Home telemonitoring is a benefit for clients who have been diagnosed with either diabetes or hypertension or both.

Home telemonitoring services are also a benefit for clients who are 20 years of age and younger, with one or more of the following conditions:

End-stage solid organ disease
Organ transplant recipient
Requiring mechanical ventilation

The physician or requesting provider who orders home telemonitoring services has a responsibility to ensure the following:

The client has a choice of home telemonitoring providers.
The client has the right to discontinue home telemonitoring services at any time.

Note: A nurse practitioner (NP), clinical nurse specialist (CNS) or physician assistant (PA) are considered requesting providers and may request home telemonitoring and sign prior authorization forms.
Although Texas Medicaid supports the use of home telemonitoring, clients are not required to use this service.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 14-15 (Dec. 2024). (Accessed Dec. 2024).

Home telemonitoring services are available only to Texas Medicaid clients who:

are diagnosed with diabetes, hypertension, or any other conditions allowed by Texas Government Code §531.02164 and determined by HHSC to be cost effective and feasible; and
exhibit two or more of the following risk factors:
- Two or more hospitalizations in the previous 12-month period
- Frequent or recurrent emergency department visits
- A documented history of poor adherence to ordered medication regime
- A documented history of falls in the previous 6-month period
- Limited or absent informal support systems
- Living alone or being home alone for extended periods of time
- A documented history of care access challenges

Home telemonitoring services are reimbursed in accordance with Chapter 355 of this title (relating to Reimbursement Rates).

Home telemonitoring services are available to Texas Medicaid clients who are 20 years of age and younger, with one or more of the following conditions [prior authorization applies according to telecommunications manual]:

end-stage solid organ disease;
organ transplant recipient; or
requiring mechanical ventilation.

SOURCE: TX Admin Code. Title 1, Sec. 354.1434, (Accessed Dec. 2024).

The executive commissioner shall adopt rules for the provision and reimbursement of home telemonitoring services under Medicaid as provided under this section. See sections below for additional details.

For purposes of adopting rules under this section, the commissioner shall:

Identify and provide home telemonitoring services to persons diagnosed with conditions for which the commission determines the provision of home telemonitoring services would be cost-effective and clinically effective;
consider providing home telemonitoring services under Subdivision (1) to Medicaid recipients who:
- Are diagnosed with one or more of the following conditions:
  - pregnancy;
  - diabetes;
  - heart disease;
  - cancer;
  - chronic obstructive pulmonary disease;
  - hypertension;
  - congestive heart failure;
  - mental illness or serious emotional disturbance;
  - asthma;
  - myocardial infarction;
  - stroke;
  - end stage renal disease; or
  - a condition that requires renal dialysis treatment; and
- Exhibit at least one of the following risk factors
  - two or more hospitalizations in the prior 12-month period;
  - frequent or recurrent emergency room admissions;
  - a documented history of poor adherence to ordered medication regimens;
  - a documented risk of falls; and
  - a documented history of care access challenges
Ensure that clinical information gathered by the following providers while providing home telemonitoring services is shared with the recipient ’s physician:
- a home and community support services agency;
- a federally qualified health center;
- a rural health clinic; or
- a hospital
Ensure that the home telemonitoring provided under this section do not duplicate disease management program services provided under 32.057, Human Resources Code; and require providers to:
- establish a plan of care that includes outcome measures for each recipient who receives home telemonitoring services under this section; and
- share the plan and outcome measures with the recipient ’s physician.

Not withstanding any other provision of this section, the commission shall ensure that home telemonitoring services are available to pediatric persons who:

are diagnosed with end-stage solid organ disease;
have received an organ transplant; or
require mechanical ventilation.

In addition to determining whether to provide home telemonitoring services to Medicaid recipients with the conditions described under Subsection (c)(2), the commission shall determine whether high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective. If the commission determines that high-risk pregnancy is a condition for which the provision of home telemonitoring services is cost-effective and clinically effective:

the commission shall, to the extent permitted by state and federal law, provide recipients experiencing a high-risk pregnancy with clinically appropriate home telemonitoring services equipment for temporary use in the recipient ’s home; and
the executive commissioner by rule shall:
- establish criteria to identify recipients experiencing a high-risk pregnancy who would benefit from access to home telemonitoring services equipment;
- ensure that, if cost-effective, feasible, and clinically appropriate, the home telemonitoring services equipment provided includes uterine remote monitoring services equipment and pregnancy-induced hypertension remote monitoring services equipment;
- subject to Subsection (c-3), require that a provider obtain:
  - prior authorization from the commission before providing home telemonitoring services equipment to a recipient during the first month the equipment is provided to the recipient; and
  - an extension of the authorization under Subparagraph (i) from the commission before providing the equipment in a subsequent month based on the ongoing medical need of the recipient; and
- prohibit payment or reimbursement for home telemonitoring services equipment during any period that the equipment was not in use because the recipient was hospitalized or away from the recipient ’s home regardless of whether the equipment remained in the recipient ’s home while the recipient was hospitalized or away.

For purposes of Subsection (c-2), the commission shall require that:

a request for prior authorization under Subsection (c-2)(2)(C)(i) be based on an in-person assessment of the recipient; and
documentation of the recipient ’s ongoing medical need for the equipment is provided to the commission before the commission grants an extension under Subsection (c-2)(2)(C)(ii).

If, after implementation, the commission determines that a condition for which the commission has authorized the provision and reimbursement of home telemonitoring services under Medicaid under this section is not cost-effective and clinically effective, the commission may discontinue the availability of home telemonitoring services for that condition and stop providing reimbursement under Medicaid for home telemonitoring services for that condition, notwithstanding Section 531.0216 or any other law.

The commission shall determine whether the provision of home telemonitoring services to persons who are eligible to receive benefits under both Medicaid and the Medicare program achieves cost savings for the Medicare program.

To comply with state and federal requirements to provide access to medically necessary services under Medicaid, including the Medicaid managed care program, and if the commission determines it is cost-effective and clinically effective, the commission or a Medicaid managed care organization, as applicable, may reimburse providers for home telemonitoring services provided to persons who have conditions and exhibit risk factors other than those expressly authorized by this section.

SOURCE: TX Government Code Sec. 531.02164 (Accessed Dec. 2024).

CSHCN Program

Home telemonitoring services are a benefit only for clients who are diagnosed with one or more of the following conditions:

Diabetes
Hypertension
Congestive heart failure
End-stage solid organ disease
Organ transplant recipient
Requiring mechanical ventilation

Clients with diabetes or hypertension must exhibit two or more of the following risk factors for approval of telemonitoring services:

Two or more hospitalizations in the previous 12-month period
Frequent or recurrent emergency department visits
A documented history of poor adherence to ordered medication regimens
Documented history of falls in the previous six-month period
Limited or absent informal support systems
Living alone or being home alone for extended periods of time
A documented history of care access challenges

SOURCE: TX Medicaid CSHCN Services Program Provider Manual Telecommunications Services (Nov. 2024), p. 11. (Accessed Dec. 2024).

PROVIDER LIMITATIONS

The RN, NP, CNS, or PA in a licensed home health agency, hospital, FQHC, or RHC is responsible for reporting data to the physician or requesting provider. Telemonitoring providers must be available 24 hours a day, 7 days a week. Although transmissions are generally at scheduled times, they can occur any time of the day or any day of the week, according to the client’s plan of care.

Scheduled periodic reporting of the client data to the physician or requesting provider is required in the event of a measurement outside the parameters established in the physician’s orders, or at least once per month when there have been no readings outside the established parameters.

Collection and interpretation of a client’s data for home telemonitoring services (procedure code 99091) is a benefit in the office or hospital setting when services are provided by a physician or other qualified health care professional. Procedure code 99091 is limited to once in a 30-day period to the physician or provider ordering the services.

SOURCE: TX Medicaid Telecommunication Services Handbook, p. 14-15 (Dec. 2024). (Accessed Dec. 2024).

Home telemonitoring service providers must:

Comply with all applicable federal, state and local laws and regulations;
Be enrolled and approved as home telemonitoring services providers;
Bill for the services covered under the Texas Medicaid Program in the manner and format prescribed by HHSC;
Share clinical information gathered while providing home telemonitoring services with the patient’s physician; and
not duplicate disease management program services provided under Human Resources Code §32.057 and further described in Division 32 of this subchapter (relating to Texas Medicaid Wellness Program).

See specific documentation requirements for telemonitoring providers in manual.

SOURCE: TX Admin Code. Title 1, Sec. 354.1434(c). (Accessed Dec. 2024).

OTHER RESTRICTIONS

Facility Services: The provision and maintenance of home telemonitoring equipment is the responsibility of the home health agency, hospital, FQHC, or RHC. Procedure code S9110 with modifier U1 is reimbursed one time to a home health agency or hospital for the initial setup and installation in the client’s home. A claim for a subsequent set up and installation will not be reimbursed unless there is a documented new episode of care. There will not be reimbursement for the addition of monitoring parameters during the current episode of care. Monthly home telemonitoring services (procedure code S9110 with the appropriate modifier) are a benefit when services are provided by a home health agency or hospital. Home health agency and hospital providers must submit revenue code 780 with procedure code S9110 and one of the appropriate modifiers listed in the table within this section.

Use one of the modifiers [listed in the manual] with monthly home telemonitoring services procedure code S9110 to indicate the number of days per month data is transmitted from the client’s home to the home telemonitoring provider.

Documentation supporting medical necessity for home telemonitoring services must be maintained in the client’s medical record by the entity providing the service (home health agency, hospital, FQHC, or RHC) and is subject to retrospective review. All paid home telemonitoring services not supported by documentation of medical necessity are subject to recoupment.

FQHCs/RHCs: FQHC and RHC providers may be reimbursed outside the encounter rate for the provision of home telemonitoring services if the services follow all requirements as outlined in this section and in the following subsections 3.7.1, “Prior Authorization of Telemonitoring Services,” and 3.8.1, “Documentation Requirements.”

Procedure code G0511 may be reimbursed to an FQHC or RHC for the provision of home telemonitoring services.

Initial equipment set up, patient education on use of equipment, monthly collection and transmission of physiologic data, and physician or requesting provider services must be billed by one provider
under procedure code G0511.

Procedure code G0511 is reimbursed once per month, per client. The place of service code reported on the claim must reflect the physical location of the client. At least 16 days of data collection per month are required for reimbursement.

See manual for more on prior authorization requirements.

Home telemonitoring providers, the home health agency, hospital, FQHC, or RHC must maintain all documentation in the client’s medical record (see manual for more details).

SOURCE: TX Medicaid Telecommunication Services Handbook, (Dec. 2024). (Accessed Dec. 2024).

CSHCN Program

The CSHCN Program has certain requirements around equipment, prior authorization, and billing instructions similar to the main Telecommunication Services manual above. Please refer to manual for specifics.

SOURCE: TX Medicaid, CSHCN Program Services Provider Manual Telecommunication Services (Nov. 2024), p. 9-13 (Accessed Dec. 2024).

A cardiac rehabilitation program in which the cardiac monitoring is done using telephonically transmitted electrocardiograms to a remote site is not covered by Texas Medicaid.

Cardiac rehabilitation must be provided in a facility that has the necessary cardiopulmonary, emergency, diagnostic, and therapeutic life-saving equipment (i.e. oxygen, cardiopulmonary resuscitation equipment, or defibrillator) available for immediate use. If no clinically significant arrhythmia is documented during the first three weeks of the program, the provider may have the client complete the remaining portion without telemetry monitoring by the physician’s order.

SOURCE: TX Medicaid Inpatient and Outpatient Hospital Services Handbook, p. 54 (Dec. 2024). (Accessed Dec. 2024).

DME and Supplies

CGMs are devices that measure glucose levels taken from interstitial fluid continuously throughout the day and night, providing real-time data to the client or physician. See manual for complete description.

There are no devices on the United States market that function as stand-alone adjunctive CGM devices. Current technology for adjunctive CGM devices operates in conjunction with an insulin pump.

See manual for non-adjunctive CGM device procedure codes and related supplies that are a benefit when provided by medical supplier durable medical equipment (DME) providers in the home setting.

Prior authorization requirements apply. See manual.

Non-Covered Services (CGM)

CGM devices (procedure code A9278) and supplies (procedure codes A9276 and A9277) for use with non-durable medical equipment are informational only. DME is defined as:

Medical equipment or appliances that are manufactured to withstand repeated use, ordered by a physician or allowed practitioner for use in the home, and required to correct or ameliorate a client’s disability, condition, or illness.

The following services are not benefits of Texas Medicaid:

Rental of adjunct CGM devices
Smart devices (smart phones, tablets, personal computers, etc.) used as GCM monitors
Medical supplies used with non-covered equipment

SOURCE: TX Medicaid DME and Supplies Handbook, p. 52-53 (Dec. 2024). (Accessed Dec. 2024).

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Utah

Last updated 11/25/2024

POLICY

“Telemedicine services” means telehealth services including:

clinical care;
health

…

POLICY

“Telemedicine services” means telehealth services including:

clinical care;
health education;
health administration;
home health;
facilitation of self-managed care and caregiver support; or
remote patient monitoring occurring incidentally to general supervision; and

provided by a provider to a patient through a method of communication that:

uses asynchronous store and forward transfer or synchronous interaction; and
meets industry security and privacy standards, including compliance with the federal Health Insurance Portability and Accountability Act of 1996, Pub. L. No. 104-191, 110 Stat. 1936, as amended, and the federal Health Information Technology for Economic and Clinical Health Act, Pub. L. No. 111-5, 123 Stat. 226, 467, as amended.

SOURCE: UT Code Sec. 26B-4-704, (Accessed Nov. 2024).

Home Telemetry

Outpatient, long-term cardiac (Holter) monitoring codes 93224, 93225, 93226, and 93227 will require prior authorization if more than 3 units of any code are reported in one year. Prior authorization will use the following criteria:

A cardiologist must order outpatient, long-term cardiac (Holter) monitoring
Member must have had a stroke or TIA with no identifiable cause
Member should have already had 24-hour monitoring done previously (either with outpatient, long-term cardiac monitoring, or as inpatient with telemetry)
Member should not be currently taking anti-coagulated or Warfarin for any other reason
Member should not have a known contraindication for Warfarin
Outpatient long-term cardiac monitoring may only be authorized for the 30-day test
Data from the test must be reviewed and interpreted by a cardiologist

SOURCE: Utah Medicaid Provider Manual: Physician Manual, (July 2024). (Accessed Nov. 2024).

Medicaid does not cover telehealth services when performed by means of asynchronous communication. Examples of asynchronous communication include: …

Remote patient monitoring (RPM)
- - Blood pressure monitors
  - Pacemakers
  - Glucose meters
  - Oximeters
  - Wireless scales
  - Heart rate monitors

SOURCE: Utah Medicaid Provider Manual: Section I: General Information (July 2024). (Accessed Nov. 2024).

CONDITIONS

Only for patients with a long-term cardiac monitoring.

SOURCE: Utah Medicaid Provider Manual: Physician Manual, (July 2024). (Accessed Nov. 2024).

PROVIDER LIMITATIONS

Test must be ordered by a cardiologist and reviewed and interpreted and interpreted by a cardiologist.

SOURCE: Utah Medicaid Provider Manual: Physician Manual, (July 2024). (Accessed Nov. 2024).

OTHER RESTRICTIONS

No Reference Found

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Vermont

Last updated 11/27/2024

POLICY

See Health Care Administrative Rule 3.101 on Telehealth for …

POLICY

See Health Care Administrative Rule 3.101 on Telehealth for requirements of telemonitoring.

Home Telemonitoring is a health service that allows and requires scheduled remote monitoring of data related to an individual’s health, and transmission of the data from the individual’s home to a licensed home health agency. Scheduled periodic reporting of the individual’s data to a licensed physician is required, even when there have been no readings outside the parameters established in the physician’s orders. In the event of a measurement outside of the established individual’s parameters, the provider shall use the health care professionals noted above to be responsible for reporting the data to a physician.

SOURCE: VT Agency of Human Services. Home Health Agency, Assistive Community Care and Enhanced Residential Care Supplement. Sec. 1.3.11 Telemonitoring, p. 7 (May 30, 2024), (Accessed Nov. 2024).

“Remote Patient Monitoring” means a health service that enables remote monitoring of a beneficiary’s physiological health-related data by a home health agency done outside of a conventional clinical setting and in conjunction with a plan of care ordered by a physician, nurse practitioner, clinical nurse specialist, or physician assistant.

To be covered, services shall be:

Clinically appropriate for delivery through telemonitoring, and
Medically necessary, and
Limited to a Congestive Heart Failure, Hypertension, or Diabetes diagnosis.

SOURCE: VT Health Care Administrative Rule 3.101 (Accessed Nov. 2024).

VT Medicaid is required to cover home telemonitoring services performed by home health agencies or other qualified providers for beneficiaries who have serious or chronic medical conditions that can result in frequent or recurrent hospitalizations and emergency room admissions.

“Home telemonitoring service” means a health service that requires scheduled remote monitoring of data related to a patient’s health, in conjunction with a home health plan of care, and access to the data by a home health agency or other qualified provider as defined by the Agency of Human Services.

SOURCE: VT Statutes Annotated Title 33 Sec. 1901g. (Accessed Nov. 2024).

CONDITIONS

The Agency shall provide coverage for home telemonitoring for one or more conditions or risk factors for which it determines, using reliable data, that home telemonitoring services are appropriate and that coverage will be budget-neutral. The Agency may expand coverage to include additional conditions or risk factors identified using evidence-based best practices if the expanded coverage will remain budget-neutral or as funds become available.

SOURCE: VT Statutes Annotated Title 33 Sec. 1901g(a). (Accessed Nov. 2024).

To be covered, services shall be:

Clinically appropriate for delivery through telemonitoring,
Medically necessary, and
Be limited to a Congestive Heart Failure, hypertension or diabetes diagnosis.

For telemonitoring services, beneficiaries shall:

Have Medicaid as their primary insurance or Medicaid and dually enrolled in Medicare with a non-homebound status,
Have a Congestive Heart Failure diagnosis,
Be clinically eligible for home health services, and
Have a physician’s plan of care with an order for home telemonitoring services.

SOURCE: VT Health Care Administrative Rules 13.174.003 (3.101.2) & (3.101.4), Telehealth, (Accessed Nov. 2024).

PROVIDER LIMITATIONS

The Agency of Human Services shall provide Medicaid coverage for home telemonitoring services performed by home health agencies or other qualified providers as defined by the Agency of Human Services for Medicaid beneficiaries who have serious or chronic medical conditions that can result in frequent or recurrent hospitalizations and emergency room admissions.

A home health agency or other qualified provider shall ensure that clinical information gathered by the home health agency or other qualified provider while providing home telemonitoring services is shared with the patient’s treating health care professionals. The Agency of Human Services may impose other reasonable requirements on the use of home telemonitoring services.

SOURCE: VT Statutes Annotated Title 33 Sec. 1901g. (Accessed Nov. 2024).

Telehealth services must be provided by a provider who is working within the scope of his or her practice and enrolled in Vermont Medicaid.

Qualified telemonitoring providers shall:

Use the following licensed health care professionals to review data:
- Registered nurse (RN)
- Nurse Practitioner (NP)
- Clinical nurse specialist (CNS)
- Licensed practical nurse (LPN) under the supervision of a RN or physician assistant (PA), and
Follow data parameters established by a plan of care, and
Meet or exceed applicable federal and state legal requirements of medical and health information privacy, including compliance with HIPAA.

SOURCE: VT Health Care Administrative Rules 13.174.003 (3.101.5), Telehealth, (Accessed Nov. 2024).

When Telemonitoring services are provided to clinically eligible Vermont Medicaid patients, qualified providers may bill CPT code 99091 for the collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days. Additionally, providers should use 99453: 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 and 99454: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days, with revenue code 0780.

SOURCE: VT Agency of Human Services. Home Health Agency, Assistive Community Care and Enhanced Residential Care Supplement. Sec. 1.3.11 Telemonitoring, p. 7 (May 30, 2024). (Accessed Nov. 2024).

OTHER RESTRICTIONS

No Reference Found

No reference found.

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Virginia

Last updated 12/18/2024

POLICY

The Board, subject to the approval of the Governor,

…

POLICY

The Board, subject to the approval of the Governor, is authorized to prepare, amend from time to time, and submit to the U.S. Secretary of Health and Human Services a state plan for medical assistance services pursuant to Title XIX of the United States Social Security Act and any amendments thereto. Such plan shall include a provision for payment of medical assistance for remote patient monitoring services provided via telemedicine for specific conditions (see section below).

For the purposes of this subdivision, “remote patient monitoring services” means the use of digital technologies to collect medical and other forms of health data from patients in one location and electronically transmit that information securely to health care providers in a different location for analysis, interpretation, and recommendations, and management of the patient. “Remote patient monitoring services” includes monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, blood glucose, and other patient physiological data, treatment adherence monitoring, and interactive videoconferencing with or without digital image upload.

SOURCE: VA Code Annotated Sec. 32.1-325 (Accessed Dec. 2024).

Remote Patient Monitoring (RPM) involves the collection and transmission of personal health information from a beneficiary in one location to a provider in a different location for the purposes of monitoring and management. This includes monitoring of both patient physiologic and therapeutic data.

SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual Supplement-Telehealth Services, (5/13/24) (Accessed Dec. 2024).

VA Medicaid reimburses for Continuous Glucose Monitoring.

SOURCE: VA Department of Medical Assistance Services. Medicaid Memo. Clarification of Existing Medicaid Coverage of Continuous Glucose Monitoring for Members in Medicaid/FAMIS/FAMIS MOMS Fee-for-Service Programs. (Nov. 2016) (Accessed Aug. 2024).

The purpose of this bulletin is to inform the provider community that DMAS will cover CGM for Fee-for-Service programs using InterQual criteria effective immediately.

DMAS has updated its CGM coverage policy due to an evolving evidence base supporting increased access to CGM to improve glycemic control. We have made this decision to align with InterQual CGM criteria which are derived from a systematic, continuous review and critical appraisal of the most current evidence-based literature from various sources, including American Diabetes Association (ADA), Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and the National Institute for Health and Clinical Excellence (NICE).

SOURCE: VA Department of Medical Assistance Services. Medicaid Memo. Continuous Glucose Monitoring (CGM) Criteria Update – Effective July 1, 2024 (Oct. 16, 2-24) (Accessed Dec. 2024).

Home Health

Face-to-face encounters may occur through telemedicine, which is defined as the two-way, real time interactive electronic communication between the member and the Provider located at a site distant from the member. This electronic communication must include, at a minimum, the use of audio and video equipment. Telemedicine shall not include encounters by telephone or email.

SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual, Home Health Manual, Covered Services and Limitations. (8/28/24). (Accessed Dec. 2024).

Personal Emergency Response System (PERS)

Personal emergency response system (PERS) service is an electronic device and monitoring service that enables certain individuals to secure help in an emergency. PERS service is limited to those individuals who live alone or are alone for significant parts of the day and who have no regular caregiver for extended periods of time and who would otherwise require supervision.

SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual Developmental Disabilities Waiver (BI, FIS, CL), (10/10/24) (Accessed Dec. 2024).

CONDITIONS

The member receiving the RPM service must fall into one of the following five populations, with duration of initial service authorization in parentheses as per below:

High-risk pregnant persons (6 months);
Medically complex infants and children under 21 years of age (6 months);
Transplant patients (6 months);
Patients who have undergone surgery (up to 3 months following the date of surgery);
Patients with a chronic or acute health condition who have had two or more hospitalizations or emergency department visits related to such health condition in the previous 12 months when there is evidence that the use of remote patient monitoring is likely to prevent readmission to a hospital or emergency department (6 months)

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services, (5/13/24) & Updates to Telehealth Services Supplement Memo, May 13, 2024, (Accessed Dec. 2024).

A provision for payment of medical assistance for remote patient monitoring services provided via telemedicine, as defined in § 38.2-3418.16, for (i) high-risk pregnant persons; (ii) medically complex infants and children; (iii) transplant patients; (iv) patients who have undergone surgery, for up to three months following the date of such surgery; and (v) patients with a chronic or acute health condition who have had two or more hospitalizations or emergency department visits related to such health condition in the previous 12 months when there is evidence that the use of remote patient monitoring is likely to prevent readmission of such patient to a hospital or emergency department. For the purposes of this subdivision, “remote patient monitoring services” means the use of digital technologies to collect medical and other forms of health data from patients in one location and electronically transmit that information securely to health care providers in a different location for analysis, interpretation, and recommendations, and management of the patient. “Remote patient monitoring services” includes monitoring of clinical patient data such as weight, blood pressure, pulse, pulse oximetry, blood glucose, and other patient physiological data, treatment adherence monitoring, and interactive videoconferencing with or without digital image upload …
A provision for payment of medical assistance for remote ultrasound procedures and remote fetal non-stress tests. Such provision shall utilize established CPT codes for these procedures and shall apply when the patient is in a residence or other off-site location from the patient’s provider that provides the same standard of care. The provision shall provide for reimbursement only when a provider uses digital technology (i) to collect medical and other forms of health data from a patient and electronically transmit that information securely to a health care provider in a different location for interpretation and recommendation; (ii) that is compliant with the federal Health Insurance Portability and Accountability Act of 1996 (42 U.S.C. § 1320d et seq.); and (iii) that is approved by the U.S. Food and Drug Administration. For fetal non-stress tests under CPT Code 59025, the provision shall provide for reimbursement only if such test (a) is conducted with a place of service modifier for at-home monitoring and (b) uses remote monitoring solutions that are approved by the U.S. Food and Drug Administration for on-label use to monitor fetal heart rate, maternal heart rate, and uterine activity.

SOURCE: VA Code Annotated Sec. 32.1-325 as amended by SB 250 (2024 Session), (Accessed Dec. 2024).

SOURCE: VA Department of Medical Assistance Services. Medicaid Memo. Continuous Glucose Monitoring (CGM) Criteria Update – Effective July 1, 2024 (Oct. 16, 2-24) (Accessed Dec. 2024).

Personal Emergency Response System (PERS)

PERS service is available to individuals enrolled in the FIS, CL, and BI waivers. PERS service may be authorized when there is no one else in the home with the individual enrolled in the waiver who is competent or continuously available to call for help in an emergency. Physician-ordered medication monitoring units may be provided simultaneously with PERS service.

SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual Developmental Disabilities Waiver (BI, FIS, CL), (10/10/24) (Accessed Dec. 2024).

PROVIDER LIMITATIONS

Remote Patient Monitoring

The Provider must have an established relationship with the member receiving the RPM service, including at least one visit in the last 12 months (which can include the date RPM services are initiated).
All service authorization criteria outlined in the DMAS Form “DMAS-P268” are met prior to billing the following CPT/HCPCS codes:
- Physiologic Monitoring: 99453, 99454, 99457, 99458, and 99091
- Therapeutic Monitoring: 98975, 98976, 98977, 98980, and 98981
- Self-Measured Blood Pressure: 99473, 99474
Providers must meet the criteria outlined in the DMAS Form “DMAS-P268” and submit their requests to the DMAS service authorization contractor by direct data entry (DDE) via their provider portal. See Appendix D of the Physician/Practitioner manual for details on the current service authorization contractor and accessing the provider portal.
Service authorization requests must be submitted at least 30 days prior to the scheduled date of initiation of services.
Reauthorizations will be permitted for select services, as appropriate and as per criteria in the DMAS Form “DMAS-P268”.

No billing modifier is required on claims for services delivered via RPM.

Services billed for using CPT 99457, 99458 and 99091 may involve review of data collected in conjunction with codes CPT 99453, 99454, or physiologic data manually captured and submitted by the patient/caregiver for billing providers to review. Services billed for using CPT 98980 and 98981 may involve review of data collected in conjunction with codes 98975, 98976, 98977, or therapeutic data (including self-reported data) manually captured and submitted by the patient/caregiver for billing providers to review.

Time requirements associated with CPT 99457, 99458, 98980, 98981, and 99091 can include time spent furnishing care management services, if not billed for under other reported services, as well as time spent on required direct interactive communication. Interactive communication is defined as real-time synchronous, two-way audio interaction. Time spent on a day when the billing provider reports an E/M service (office or other outpatient services) shall not be included. Time counted toward time requirements of other reported services must also not be counted toward the time requirements of the aforementioned codes.

Only providers eligible to bill CMS Evaluation & Management (E&M) services are eligible to bill for RPM services. Clinical staff members—who work under the supervision of the eligible billing provider and are allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who do not individually report that professional service—are allowed to assist in delivery and satisfaction of appropriate RPM service requirements for 99453, 98975, 99457, 99458, 98980, and 98981, but not 99091.

Codes including the provision of RPM devices (99454, 98976, 98977) shall not be billed if patients supply their own device, or have been separately provided relevant durable medical equipment by DMAS.

SOURCE: VA Dept. of Medical Assistant Svcs., Medicaid Provider Manual Supplement-Telehealth Services, (5/13/24) & Updates to Telehealth Services Supplement Memo, May 13, 2024, (Accessed Dec. 2024).

Personal Emergency Response System (PERS)

The agency providing monitoring services must be capable of continuously monitoring and responding to emergencies under all conditions, including power failures and mechanical malfunctions. The provider is responsible for ensuring that the monitoring agency and the agency’s equipment meet the requirements of this section. The monitoring agency must be capable of simultaneously responding to multiple signals for help from multiple individuals’ PERS equipment.

These units must be refilled as needed by either a LPN or RN.

SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual Developmental Disabilities Waiver (BI, FIS, CL), (10/10/24) (Accessed Dec. 2024).

OTHER RESTRICTIONS

Devices used to satisfy conditions for CPT 99453 and 99454 must automatically digitally upload patient data (i.e., not self-recorded or reported by patients) and automatically transmit either daily recordings of the beneficiary’s physiologic data OR the device must record daily values and transmit an alert if the beneficiary’s values fall outside predetermined parameters for 16 days in a 30-day period. Devices used to satisfy conditions for CPT 98975, 98976 and 98977 must be used to monitor data for 16 days in a 30-day period. These codes cannot be used for monitoring of parameters for which more specific codes are available (i.e., CPT 93296, 93264, 94760).

An individual provider must not bill for more than one set of RPM services per patient at any given time.

Equipment utilized for Remote Patient Monitoring must meet 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.

SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual Supplement-Telehealth Services (Physician/Practitioner), (5/13/24) (Accessed Dec. 2024).

Personal Emergency Response System (PERS)

The monitoring agency’s equipment must include the following:

A primary receiver and a back-up receiver, which must be independent and interchangeable;
Back-up information retrieval system;
A clock printer, which must print out the time and date of the emergency signal, the PERS individual’s identification code, and the emergency code that indicates whether the signal is active, passive, or a responder test;
Back-up power supply;
A separate telephone service;
A toll-free number to be used by the PERS equipment in order to contact the primary or back-up response center; and
A telephone line monitor, which must give visual and audible signals when the incoming telephone line is disconnected for more than 10 seconds.

See manual for additional requirements.

SOURCE: VA Dept. of Medical Assistance Svcs., Medicaid Provider Manual Developmental Disabilities Waiver (BI, FIS, CL), (10/10/24) (Accessed Dec. 2024).

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Washington

Last updated 06/19/2024

POLICY

Certain service procedure codes are covered for remote patient …

POLICY

Certain service procedure codes are covered for remote patient monitoring (RPM) when specific medical necessity criteria are met.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 102-103 (Apr. 2024), WAC 182-551-2125(1). (Accessed Jun. 2024).

Home Health Services

The medicaid agency pays for one telemedicine interaction, per eligible client, per day, based on the ordering physician’s home health plan of care. To receive payment for the delivery of home health services through telemedicine, the services must involve:

(a) An assessment, problem identification, and evaluation which includes:

Assessment and monitoring of clinical data including, but not limited to, vital signs, pain levels and other biometric measures specified in the plan of care. Also includes assessment of response to previous changes in the plan of care; and
Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care; and

(b) Implementation of a management plan through one or more of the following:

Teaching regarding medication management, as appropriate;
Teaching regarding other interventions as appropriate to both the patient and the caregiver;
Management and evaluation of the plan of care including changes in visit frequency or addition of other skilled services;
Coordination of care with the ordering physician regarding findings;
Coordination and referral to other medical providers as needed; and
Referral to the emergency room as needed.

The medicaid agency does not require prior authorization for the delivery of home health services through telemedicine. The medicaid agency does not pay for the purchase, rental, or repair of telemedicine equipment. Electronic visit verification requirements are not applicable to home health services delivered through telemedicine. Other program rules may apply similar or the same record requirements to providers of home health services.

SOURCE: WAC 182-551-2125. (Accessed Jun. 2024).

HCA covers the delivery of home health services through telemedicine for clients who have been diagnosed with an unstable condition who may be at risk for hospitalization or a more costly level of care. See manual for codes.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 28-30. (Jul. 2024). (Accessed Jun. 2024).

CONDITIONS

Specific medical necessity criteria must be met for RPM coverage, including disease-specific criteria. In addition to meeting other defined general criteria, the client must have a qualifying diagnosis of congestive heart failure, chronic obstructive pulmonary disease, or hypertension.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 102-103. (Apr. 2024). (Accessed Jun. 2024).

Home Health Services

The client must have a diagnosis or diagnoses where there is a high risk of sudden change in medical condition which could compromise health outcomes. See manual for specific codes to bill.

SOURCE: Washington Apply Health Medicaid Home Health Billing Guide, pg. 28. (Jul. 2024). (Accessed Jun. 2024).

PROVIDER LIMITATIONS

FQHCs/RHCs

CPT® code 99453 is encounter-eligible when performed by a Rural Health Clinic (RHC) or Federally Qualified Health Center (FQHC) encounter-qualified provider. Other RPM procedure codes are not RHC- or FQHC-encounter eligible.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 103 (Apr. 2024). (Accessed Jun. 2024).

OTHER RESTRICTIONS

Specific medical necessity criteria must be met for RPM coverage, including the following:

Client-specific criteria. The client must exhibit at least one of the following risk factors in each category:
- Health care utilization:
  - Two or more hospitalizations in the prior 12-month period
  - Four or more emergency department admissions in the prior 12-month period
- Other risk factors that present challenges to optimal care:
  - Limited or absent informal support systems
  - Living alone or being home alone for extended periods of time
  - A history of care access challenges
  - A history of consistently missed appointments with health care providers
Device-specific criteria. The device must have both of the following:
- Capability to directly transmit patient data to provider
- An internet connection and capability to use monitoring tools

Informed consent documentation requirements and quantitative limits also apply to RPM services.

SOURCE: WA State Health Care Authority, Medicaid Provider Guide, Physician-Related Svcs./Health Care Professional Svcs., p. 102 (Apr. 2024). (Accessed Jun. 2024).

Home Health Services

HCA pays for one telemedicine interaction, per eligible client, per day, based on the ordering licensed practitioner’s home health plan of care.

To receive payment for the delivery of home health services through telemedicine, the services must involve:

A documented assessment, identified problem, and evaluation, which includes:
- Assessment and monitoring of clinical data including, but not limited to, vital signs, pain levels and other biometric measures specified in the plan of care. Also included is an assessment of response to previous changes in the plan of care.
- Detection of condition changes based on the telemedicine encounter that may indicate the need for a change in the plan of care

Implementation of a documented management plan through one or
more of the following:
- Education regarding medication management as appropriate, based on the findings from the telemedicine encounter
- Education regarding other interventions as appropriate to both the patient and the caregiver
- Management and evaluation of the plan of care, including changes in visit frequency or the addition of other skilled services
- Coordination of care with the ordering licensed provider regarding findings from the telemedicine encounter
- Coordination and referral to other medical providers as needed
- Referral to the emergency room as needed

Except as provided by the department by rule, remote …

POLICY

Except as provided by the department by rule, remote patient monitoring of a Medical Assistance recipient in which the medical data pertains to a Medical Assistance recipient must be reimbursed.

Except as provided by the department by rule, services that are covered under Medicare for which the federal department of health and human services provides Medical Assistance federal financial participation and that are … remote physiologic monitoring shall be reimbursed.

SOURCE: WI Statute Sec. 49.45 (61). (Accessed Dec. 2024).

Remote physiologic monitoring is the collection and interpretation of a member’s physiologic data, such as blood pressure or weight checks, that are digitally transmitted to a physician, nurse practitioner, or physician assistant for use in the treatment and management of medical conditions that require frequent monitoring. Such conditions include congestive heart failure, diabetes, chronic obstructive pulmonary disease, wound care, polypharmacy, and mental or behavioral problems. It is also used for members receiving technology-dependent care, such as continuous oxygen, ventilator care, total parenteral nutrition, or enteral feeding.

The following policy requirements apply for remote physiologic monitoring services:

Only physicians, nurse practitioners, and physician assistants enrolled in ForwardHealth are eligible to render and submit claims for remote physiologic services.
The member’s consent for remote physiologic monitoring services must be documented in the member’s medical record.
The provider must document how remote physiologic monitoring is tied to the member-specific needs and will assist the member to achieve the goals of treatment.
Services are not separately reimbursable if the services are bundled or covered by other procedure codes (for example, continuous glucose monitoring is covered under CPT procedure code 95250 and should not be submitted under CPT procedure codes 99453–99454).
CPT procedure codes 99453 and 99454 can be used for blood pressure remote physiologic monitoring if the device used to measure blood pressure meets remote physiologic monitoring requirements. If the member self-reports blood pressure readings, the provider must instead submit self-measured blood pressure monitoring CPT procedure codes 99473–99474.
CPT procedure code 99457 should be used when the physician, nurse practitioner, or physician assistant uses medical decision making based on interpreted data received from a remote physiologic monitoring device to assess the member’s clinical stability, communicate the results to the member, and oversee the management and/or coordination of services as needed.

Providers are expected to follow CPT guidelines.

SOURCE: WI ForwardHealth Online Handbook. Topic #22740 Remote Patient Monitoring. (Accessed Dec. 2024).

CONDITIONS

Such conditions include congestive heart failure, diabetes, chronic obstructive pulmonary disease, wound care, polypharmacy, and mental or behavioral problems. It is also used for members receiving technology-dependent care, such as continuous oxygen, ventilator care, total parenteral nutrition, or enteral feeding.

SOURCE: WI ForwardHealth Online Handbook. Topic #22740 Remote Patient Monitoring. (Accessed Dec. 2024).

PROVIDER LIMITATIONS

Only physicians, nurse practitioners, and physician assistants enrolled in ForwardHealth are eligible to render and submit claims for remote physiologic services.

SOURCE: WI ForwardHealth Online Handbook. Topic #22740 Remote Patient Monitoring. (Accessed Dec. 2024).

OTHER RESTRICTIONS

The device used to capture a member’s physiologic data must meet the Food and Drug Administration definition of a medical device. To submit claims for CPT procedure codes 99453–99458, the members’ physiologic data must be wirelessly synced so it can be evaluated by the physician, nurse practitioner, or physician assistant. Transmission can be synchronous or asynchronous (data does not have to be transmitted in real time as long as it is automatically updated on an ongoing basis for the provider to review).

SOURCE: WI ForwardHealth Online Handbook. Topic #22740 Remote Patient Monitoring. (Accessed Dec. 2024).

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