Provider Bulletins

Provider Bulletins

We would like to share and remind our providers about important information from the Centers for Medicare & Medicaid (CMS) regarding billing and coding guidelines. Below you will find important information and links to guide you through:

Remote Patient Monitoring of Health Data

Telehealth and Remote Patient Monitoring (RPM) are helpful tools that facilitate data sharing, patient engagement, and ongoing monitoring of patients' health. But did you know that three mandatory components must be present to ensure RPM is being used correctly and adheres to compliance requirements? Please review your current process to confirm that the following components are always part of your RPM implementation:

1. Education and Device Setup: As a provider, you must educate patients about how to use the device and transmit the health data. This is an important step to ensure that they use the device appropriately and that the data collected is accurate.
2. Device Supply: Providers must ensure that devices such as connected blood pressure cuffs, weight scales, and pulse oximeters are supplied to their patients and are working appropriately. These devices must be connected and in working order to be able to gather correct health information. 
3. Treatment Management: Providers must regularly review data collected through RPM and use it to manage patients' conditions. 

WHAT PATIENT MONITORING SERVICES ARE BILLABLE? 
RPM includes remote physiological monitoring and remote therapeutic monitoring (RTM), both of which are billable. The following Medicare requirements must be followed for RPM to be covered:   
- Patient consent is required at the time RPM is furnished.
- Monitoring must be medically reasonable and necessary.
- Remote physiologic monitoring:
- Requires an established patient relationship.
- Must monitor an acute or chronic condition.
- Must be collected for at least 16 days out of 30 days. 16-day data collection in a 30-day period does not apply to treatment management codes 99457, 99458, 98980, and 98981.
- Physiologic data must be electronically collected and automatically uploaded to a secure location where the data can be available for analysis and interpretation by the billing practitioner.
- The device used to collect and transmit the data must meet the definition of a medical device as defined by the FDA.
- Only one practitioner can bill for RPM per patient in a 30-day period.
- Remote physiologic monitoring and RTM cannot be billed together.
- Remote physiologic monitoring and RTM, but not both, may be billed concurrently with the following care management services for the same patient as long as time and effort are not counted twice: chronic care management (CCM), transitional care management (TCM), behavioral health integration (BHI), principal care management (PCM), chronic pain management (CPM).
- For global periods of surgery, remote physiologic monitoring and RTM may be billed by practitioners that are not receiving the global service payment.

To view the Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes frequently used to bill for RPM services, click here

CenterLight Healthcare PACE is here to support you. Please stay up-to-date on Centers for Medicare and Medicaid Services (CMS) notices via www.cms.gov and the Medicare Learning Network (MLN). You may also visit our Provider Bulletins web page to access information about other topics relevant to you.

Medicaid Recertification — What You Need to Know

To remain enrolled in CenterLight Healthcare’s PACE program, participants must maintain active Medicaid coverage. CenterLight is partnering with SPS Community Solutions (SPSCS) to assist participants throughout their recertification process. It is for the benefit of CenterLight’s participants to allow SPSCS to help with this important task.

The Medicaid recertification application requires that participants enrolled in a managed long- term care plan provide relevant information on the application and include a copy of their membership card. Failure to complete this process may result in the participant being transferred to the Health Benefits Exchange (H78), leading to loss of services through CenterLight.

What if a participant refuses to cooperate or cannot be reached to complete the required assessment?

CenterLight is required to initiate the involuntary disenrollment with New York Medicaid Choice (NYMC), also known as Maximus, within five business days of exhausting all efforts to gain participant cooperation to complete the required assessment (the mandatory annual assessment or significant change in condition assessment, if needed).
CenterLight must submit a statement detailing at least 10 outreach attempts over 30 calendar days to schedule and complete the required assessment. The outreach attempts must be conducted on different days of the week and different times of day, including at least two visits to the enrollee’s home. Documentation should also include details about engagement with the participant’s care providers, including their personal care agency, the Fiscal Intermediary (FI), primary care physician and other providers that render services to the enrollee in the community.
For more information, visit MLTC Policy 24.02 xi. (NYS.gov).


What if the participant is not enrolled in the aligned PACE Medicare Health Plan?


CenterLight is required to make three reasonable attempts over five business days to inform the participant that they are no longer enrolled in a CenterLight aligned Medicare Health Plan.
Should the participant wish to remain enrolled, CenterLight will assist with reinstating their enrollment. If they choose to disenroll, CenterLight is required to submit a voluntary disenrollment request to NYMC for processing.
We hope you find this information useful. Please visit our website at centerlighthealthcare.org where you can also access the CenterLight Provider Portal. Contact us at 1-833-252-2737 if you have any questions.

Complying with Medical Record Documentation Requirements

Patient medical records must show medical necessity. This may include records for services before the date of services listed on the medical record request. Examples include:

  • A signed office note from a previous visit where the provider ordered a diagnostic or other service
  • The care plan written by the supervising physician who bills for an “incident to” service
  • For incident to services, the care plan written by the supervising physician or non-physician practitioner (NPP)
  • Lab orders for recurring tests to meet the specific needs of an individual patient
  • Documentation may be insufficient if, for example, progress notes are unsigned, undated or lack detail; if records are unauthenticated, are missing signatures or applicable attestation; or lack of documentation of intent for services.

Sources:

Complying with Medical Record Documentation Requirements
Complying with Medicare Signature Requirements

Telehealth after the Public Health Emergency

The COVID-19 Public Health Emergency (PHE) formally ended May 11, 2023. Many exceptions allowed during the PHE, including some telehealth services, ended. One of the major changes includes the telephonic evaluation and management services reported with CPT 99441-99443. Telephone only telehealth services (99441-99443) must meet the minimum requirements noted below:

  • As of 05/12/2023 the patient must be established (at least one in-person encounter in the last 3 years)
  • Call must be personally performed and documented in the medical record by the provider
  • Encounter must be patient-initiated via phone call or by general consent
  • Information discussed cannot be directly related to a prior visit (within the last seven days)
  • Patient was not scheduled to be seen in-person during the next 24 hours or next business day
  • Total time spent on the call must be documented

Sources: 

Billing and coding Medicare Fee-for-Service Claims
Telehealth Services

Chronic Care Management

Chronic Care Management (CCM) services are extensive and include comprehensive Care
Management of two or more chronic conditions on a monthly basis. CCM is a service provided by CenterLight PACE in cooperation with Community-based PCPs and the IDT. CCM services
typically focus on advanced primary care characteristics like:

  • Structured recording of patient health information
  • Keeping comprehensive electronic care plans
  • Managing care transitions and other care management services
  • Continuous patient relationship with chosen care team member
  • Supporting patients with chronic diseases in achieving health goals
  • Patient receiving preventive care
  • Patient and caregiver engagement

Documentation must support the active involvement and management of the patient’s chronic
conditions. 
Source:

Chronic Care Management

Transitional Care Management

Transitional Care Management has very specific requirements that include communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge and high level of medical decision making during the service period face-to-face visit, within 7 calendar days of discharge). All documentation must support a corresponding admission and discharge, the specified timeframes, the telephone contact or attempted contact with the patient within 2 days of discharge, and appropriate medical decision making. These services are not to be reported when a patient has an emergency room encounter without admission.
Source: 

Transitional Care Management Services

CenterLight Healthcare has an approved PACE contract with the Centers for Medicare and Medicaid Services (CMS) and NY State Department of Health (NYSDOH). Enrollment in CenterLight Healthcare PACE depends on renewal of its contract with CMS and NYSDOH. Participants may be fully and personally liable for the cost of unauthorized or out-of-PACE program agreement services. Upon enrollment, the PACE program will be the participant’s sole service provider. Participants will have access to all services needed as identified by the Interdisciplinary Team, but not to a specific provider of these services. Please contact us for more information.

H3329 CLPACEWebsite Approved 10222024

Last Updated on November 22, 2024