Telehealth and remote patient monitoring
The ability to monitor certain aspects of a patient’s health from their own home has become an increasingly popular telehealth option. Remote patient monitoring lets providers manage acute and chronic conditions. And it cuts down on patients’ travel costs and infection risk.
How to use remote patient monitoring with telehealth
Remote patient monitoring pairs well with telehealth when patients need to be monitored for certain health conditions. It can also prevent health complications in patients who aren’t able to easily travel.
There are many symptoms and conditions that can be tracked through remote patient monitoring, including:
- High blood pressure
- Diabetes
- Weight loss or gain
- Heart conditions
- Chronic obstructive pulmonary disease
- Sleep apnea
- Asthma
Many of the devices that patients will use may be familiar to them, including:
- Weight scales
- Pulse oximeters
- Blood glucose meters
- Blood pressure monitors
Other conditions require more complicated devices that will require patient training, including:
- Apnea monitors
- Heart monitors
- Specialized monitors for dementia and Parkinson’s disease
- Breathing apparatuses
- Fetal monitors
As the popularity and convenience of telehealth grows, so does remote patient monitoring. More providers are implementing remote patient monitoring for several reasons, including:
- Advanced medical technology
- A growing awareness of telehealth for providers and patients
- More insurance coverage during the
COVID-19
public health emergency
- The ability to monitor and prevent serious complications in remote locations
A practical guide to remote patient monitoring
Learn simple, essential tips for leveraging remote patient monitoring in your practice (PDF), including applications for care management, implementing best practices, and more.
How to help patients use at-home health monitors
Remote monitoring may be new for your patients, and for you also. The best way to help your patients is to be informed about the devices you will be using. This includes how they work and how you will receive the data from the device.
Make sure patient understands why you are prescribing at-home health monitors
There are a number of ways to share information with your patients:
- A telehealth appointment before they begin using the device
- A follow-up telehealth appointment after they’ve been using the device for several days
- An email or downloadable PDF explaining remote patient monitoring for their condition or symptoms
Help your patient understand how to use their device
Some products, such as a weight scale, may not need a lot of explanation. But other devices may be more high tech or confusing for patients. Here’s a few tips:
- Walk your patient through operating the device in a telehealth appointment
- Refer your patient to an at-home medical equipment provider in their area who can set them up with the device and provide support
- Tell your patient what types of readings you will get from their device and how you will receive that information
- Make sure your patient has written instructions they can refer to, including paper copies, email, or downloadable PDF
- Encourage your patient to write down their questions and either call your office, email you the questions through a patient portal, or request a follow-up telehealth appointment
- Have a member of your staff let your patient know when you are receiving their information correctly from the device
Talk to your patients about the benefits of remote patient monitoring
Some patients will need in-person testing, diagnostics, or monitoring. This depends on their condition, Internet capabilities, or personal preferences and abilities. But there are many ways that remote patient monitoring can help with chronic conditions, pregnancy complications, and short-term illness.
These benefits include:
- Reduced hospitalizations
- Shorter hospital stays if the patient can be discharged with a remote monitoring device to use at home
- Fewer visits to the emergency room
- Better health outcomes for patients in rural areas
- Better preventative management for chronic conditions
- Reduced risk of
COVID-19
exposure, along with other illnesses, for patients and health care workers
Tip: Medicare uses the term, “remote physiologic monitoring” in their coding and billing language. Remote physiologic monitoring (RPM) is a set of codes that describes non-face-to-face monitoring and analysis of physiologic factors used to understand a patient’s health status. For example, the RPM codes allow remote monitoring of oxygen saturation levels in patients with COVID-19. CPT codes 99453, 99454, 99457, and 99458
Billing and payment for remote physiologic monitoring
Billing for Medicare
While private insurance companies set their own terms, Medicare has its own payment policies.
They include:
- An established patient-physician relationship is required. But there does not have to be an established relationship between the patient and physician for the duration of the public health emergency
- Consent to receive remote physiologic monitoring services at the time services are furnished is allowed
- Physicians and non-physician practitioners who are eligible to furnish evaluation and management services (E/M) may bill for remote physiologic monitoring services
Update on the
COVID-19
Public Health Emergency
On Thursday, Oct. 13, 2022, the Department of Health and Human Services announced an extension (renewal) of the COVID-19 public health emergency (PHE) for an additional 90 days. The latest extension of the COVID-19 PHE will end on January 11, 2023.
Guidelines for remote physiologic monitoring services billed to CPT codes 99453 and 99454
- Physiologic data must be electronically collected and automatically uploaded to the secure location where the data can 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
- Remote physiologic monitoring data must be collected for at least 16 days out of 30 days. During the public health emergency for
COVID-19
, if a patient is suspected or diagnosed with
COVID-19
, data can be collected over as few as two days
- Remote physiologic monitoring services must monitor an acute care or chronic condition
- The services may be provided by auxiliary personnel under the general supervision of the billing practitioner
- The Centers for Medicare & Medicaid Services (CMS) recently published policy updates for Medicare telehealth services in the 2023 Physician Fee Schedule. Under Medicare Clinician Services, CMS will not implement new codes for remote therapeutic monitoring (RTM) as initially proposed.
For specific codes and requirements for Medicare’s remote physiologic monitoring coverage, visit the 2023 Medicare Physician Fee Schedule page from the Centers for Medicare & Medicaid Services.
Billing for private insurance
Check with the patient’s insurance company for information on their billing and reimbursement policies.
Billing for Medicaid
Each state has its own remote patient monitoring billing and reimbursement policies. Providers can check their state’s policies at the National Policy Center – Center for Connected Health Policy 
.
Featured Expert:
A spinal cord stimulator is an implanted device that sends low levels of electricity directly into the spinal cord to relieve pain.
Many of the latest devices are placed by physicians with highly specialized training in interventional pain management under X-ray and/or ultrasound guidance.
Traditional spinal cord stimulators replace the sensation of pain with light tingling, called paresthesia. For patients who find these paresthesiae uncomfortable, newer devices offer “sub-perception” stimulation that cannot be felt.
Experts still don’t fully understand the mechanisms behind spinal cord stimulation, but they now know that it may target multiple muscle groups directly from the spine and even alter how the brain senses pain.
Spinal cord stimulators consist of thin wires ( the electrodes ) and a small, pacemaker-like battery pack ( the generator ). The electrodes are placed between the spinal cord and the vertebrae ( the epidural space ), and the generator is placed under the skin, usually near the buttocks or abdomen. Spinal cord stimulators allow patients to send the electrical impulses using a remote control when they feel pain. Both the remote control and its antenna are outside the body.
What is spinal cord stimulation used for?
Spinal cord stimulation is used most often after nonsurgical pain treatment options have failed to provide sufficient relief. Spinal cord stimulators may be used to treat or manage different types of chronic pain, including:
- Back pain, especially back pain that continues even after surgery (failed back surgery syndrome)
- Post-surgical pain
- Arachnoiditis (painful inflammation of the arachnoid, a thin membrane that covers the brain and spinal cord)
- Heart pain (angina) untreatable by other means
- Injuries to the spinal cord
- Nerve-related pain (such as severe diabetic neuropathy and cancer-related neuropathy from radiation, surgery or chemotherapy)
- Peripheral vascular disease
- Complex regional pain syndrome
- Pain after an amputation
- Visceral abdominal pain and perineal pain
Spinal cord stimulation can improve overall quality of life and sleep, and reduce the need for pain medicines. It is typically used along with other pain management treatments, including medications, exercise, physical therapy and relaxation methods.
Who should get a spinal cord stimulator?
As with all treatments, your doctor will want to make sure spinal cord stimulation is right for you — and that it is likely to provide significant relief from your chronic pain. To make this recommendation, your pain specialist will likely order imaging tests and psychological screening. Some insurance companies require psychological screening to ensure disorders like depression or anxiety aren’t worsening your pain.
Each patient is different, but generally, people who benefit the most from spinal cord stimulation are those who:
- Have not experienced sufficient pain relief with medications, less-invasive therapies or prior surgeries
- Do not have psychiatric disorders that would decrease the effectiveness of the procedure
Spinal Cord Stimulator Types
Spinal cord stimulators come in three main types:
- Conventional implantable pulse generator (IPG) is a battery-operated spinal code stimulator. A battery is placed in the spine during an operation. When it runs out, the battery must be replaced with another surgery. This device can be a good choice for people with pain in just one body part because it has a lower electrical output.
- Rechargeable IPG works similarly to the conventional device, with the difference that the battery can be recharged without another surgery. Because the energy source is rechargeable, these stimulators can put out more electricity. This may be a better choice for people with pain in the lower back or in one or both legs, as the electrical signal can reach further.
- Radiofrequency stimulator uses a battery that’s outside the body. This stimulator is rarely used today because of newer designs and better technology. It has rechargeable batteries, and like the rechargeable IPGs, it may be better for people with pain in the lower back and legs because of the device’s power.
Your surgeon will explain how to operate the device and adjust the intensity of the electrical signal, which all three types of stimulators support. Different body positions may require different stimulator settings, such as one setting that works better for sitting and another for walking). To help you easily access the most used settings, most devices allow doctors to save two or three preset programs. Some newer devices feature several waveforms for electricity delivery, including high frequency, burst and high-density stimulation.
Spinal Cord Stimulator Surgery
Spinal cord stimulators require two procedures to test and implant the device: the trial and the implantation.
Spinal Cord Stimulator Trial
The first step is a trial period. Your surgeon will implant a temporary device for you to test out. Guided by a specific type of X-ray called fluoroscopy, your surgeon will carefully insert the electrodes in the epidural space of the spine. The location of your pain affects where these electrodes will be placed along the spine. Your surgeon may ask for your feedback during the procedure to best position the electrodes.
This trial procedure typically requires only one incision in your lower back to place the electrodes. The generator/battery will be outside the body, typically on a belt, you’ll wear around your waist.
For about a week, you will evaluate how well the device reduces your pain. The trial is considered a success if you experience a 50% or greater reduction in pain level.
If unsuccessful, the wires can easily be removed in the clinic without damage to the spinal cord or nerves. If successful, surgery is scheduled to permanently implant the device.
Spinal Cord Stimulator Implantation
During the permanent implantation procedure, the generator is placed underneath the skin and the trial electrodes are replaced with sterile electrodes. Unlike the trial electrodes, these will be anchored by sutures to minimize movement.
The implantation can take about 1-2 hours and is typically performed as an outpatient procedure.
After the local anesthesia has been administered, your surgeon will make one incision (typically along your lower abdomen or buttocks) to hold the generator and another incision (along your spine) to insert the permanent electrodes. The incisions are about the length of a driver’s license. As in the trial procedure, fluoroscopy is used to determine where the electrodes are placed.
Once the electrodes and generator are connected and running, your surgeon will close the incisions.
Your surgeon may provide sedation to keep you comfortable and ask for your feedback during placement of the electrodes.
Spinal Cord Stimulator Recovery
Most patients leave the same day as their procedure — once the anesthesia has worn off. For several days after surgery, your incisions may be painful. Try not to stretch, twist or reach, which could pull at the incisions. Dressings will be placed over the incision sites, which can be removed after about 3 days. In most cases, incisions heal within about 2-4 weeks after surgery.
Your doctor will discuss your recovery plan, but generally lighter activity is recommended for about 2 weeks after surgery.
Once your surgeon approves you for regular activity, you can return to work and drive again (with the stimulator turned off). This is typically 1-2 weeks after surgery.
Spinal Cord Stimulator Complications
Complications of spinal cord stimulator surgery are rare, but no procedure is without risk. A small percentage of patients may experience:
- Infection, which may occur in the first 2-8 weeks.
- Bleeding.
- Device migration (i.e., the electrodes move from their original location and the stimulator doesn’t block pain as effectively). This often requires a follow-up surgery to put the electrodes back in the proper spot.
- Device damage (e.g., a fall or intense physical activity breaks the stimulator).
- Dural puncture. The dura mater surrounds the spinal cord. Spinal cord stimulators are inserted in the epidural space, the area just outside the dura mater. If a needle or electrode goes too deep and pierces it, cerebrospinal fluid may leak out. These punctures can cause severe headaches.
- Spinal cord trauma. Although extremely rare, spinal cord stimulator insertion can cause nerve injury and paralysis.
Living with a Spinal Cord Stimulator
Generally, the pain relief provided by spinal cord stimulators allows patients to do much more than they could before surgery, but there are certain restrictions to be mindful of.
Can I have X-rays and CT scans with a spinal cord stimulator?
So long as your spinal cord stimulator is powered off, X-rays and CT scans are generally safe. Before undergoing any scan, always let your doctor, nurse or technician know you have a spinal cord stimulator.
Are spinal cord stimulators MRI compatible?
No, MRIs are not always safe for those with spinal cord stimulation devices. Some newer devices are compatible with certain MRI machine models and scan locations, but your doctor will need to evaluate the specifics of your stimulator first. If your device is not MRI compatible, MRIs can cause serious injury.
Communicate with your pain specialist beforehand so that he or she can weigh in on whether a procedure will interfere with or harm your stimulator model.
Will my spinal cord stimulator set off airport security?
Yes, airport security gates will detect your stimulator, but your physician will give you an identification card that may allow you to bypass the machine.
Some people find that airport security gates cause uncomfortable (but harmless) interference with their stimulators. If you cannot avoid passing through the security screener, turn off your device before stepping through.
Can I drive with a spinal cord stimulator?
No, you should power off your stimulator when you’re driving or operating heavy machinery, as sudden changes in stimulation levels could cause distraction.
Can I swim with a spinal cord stimulator?
Swimming is fine with a permanent, implanted generator, but you cannot get your temporary stimulator wet. You will need to avoid baths and showers during that short trial period.
Can a spinal cord stimulator be removed?
Yes, a spinal cord stimulator can be removed safely if you are unsatisfied with the level of pain relief it provides or if there is an infection or mechanical problem with your system. Learn more about spinal cord stimulator removal.
