Healthcare services and providers offering Remote Patient Monitoring (RPM) need to maintain accurate documentation and records for various reasons. They must evidence care services to claim reimbursements, log patient consent for care, and track medications prescribed and interactions with each patient.
Vague or incomplete documentation is a serious issue in the medical sector. It often means a service cannot claim reimbursements without the appropriate audit trails to show that time-tracked services have been delivered.
In this article, the Wanda Health team reviews some of the most important documentation used throughout the field of RPM to ensure you create appropriate internal controls and have all the records necessary to comply with regulatory, patient safety, and reimbursement requirements.
Related reading - what is remote patient monitoring?
Recording Patient Consent for RPM Service Enrolment
The first piece of documentation is consent from a patient, normally stored within a patient’s medical records, either as a record of verbal consent given within a discussion or as a signed form.
Patients are often keen to participate in RPM programs since they offer convenience, accessibility, and personalized care. Still, a practitioner must ensure they have logged this consent at some point before beginning RPM care delivery.
Although the rules were modified during the COVID-19 pandemic, permitting physicians to record consent simultaneously as beginning RPM care delivery, this was a temporary change. Otherwise, permission must be documented before dispatching an RPM device or beginning virtual consultations.
Note that Medicare usually accepts confirmation that a patient has given verbal consent. However, other payers may have different criteria and require written evidence.
Basic Record-Keeping Requirements for RPM Service Providers
Following patient consent, clinicians and practitioners must document the initial process of enrolling a patient onto their RPM program and dispatching an RPM device – or multiple devices, depending on the patient's condition and health.
Healthcare professionals should keep a log of:
Diagnoses, screening, testing, or lifestyle indicators that make a patient a candidate for RPM, outlining the conditions, symptoms, or other factors being monitored.
The devices deployed to the patient, alongside the identification codes for each device and details about when the device(s) are delivered to the patient.
Training delivered, showing the patient how to use their device(s), when to take readings, and how to ensure measurements are accurate – such as tracking symptoms before or after food, at a certain time of the day, and before or after medication.
Payers, whether Medicare or a private insurer, will normally need to see the initial documentation before they are prepared to accept reimbursement claims, including details of clinical diagnoses and the services recommended by an appropriately accredited medical professional.
Reimbursements vary depending on the services delivered, in what volume, and the area – but precise coding is imperative since incorrect claim codes or those that do not correspond to the patient's RPM file may be rejected.
RPM Patient Selection and Onboarding Workflows
One of the best practice solutions, particularly when introducing RPM as a new service, is to work through a predefined process that sets out how patients are selected and assessed.
This system will necessarily vary depending on the type of healthcare provider and the patient demographics or conditions treated but could include:
Determining which patient groups and demographics are best suited to RPM – whether the service will deliver broad-scope RPM, invite patients with specific barriers to care, or those with certain conditions. The criteria should be recorded so all patients are assessed on an equal basis.
Inviting identified patients to discuss RPM, offering information about the service, how it works, the commitment required from the patient, and how it may change their current pattern of appointments or interactions.
If the patient consents, the practitioner should record the consent alongside details of the condition, symptoms, or vital signs being measured, how these relate to ongoing treatment plans, and any targets such as improving baseline metrics or maintaining good control of chronic conditions like diabetes.
Dispatching the RPM devices identified as most appropriate and scheduling a session to educate the patient about how to take measurements and transmit these to their care team, walking through the first reading with the patient to verify their understanding.
Beginning tracking and recording data, reviewing the measurements, and defining which readings will indicate a need for emergency intervention, further patient consultations, or a medication change.
Working through this process ensures any medical provider introducing RPM has a clear, transparent, and recorded system for patient selection, enrolment, and onboarding. When submitting reimbursement claims, these records will prove useful as a point of reference and to substantiate or offer further evidence of claim values requested by the relevant payer.
Other RPM documentation Requirements - a 14 point summary
Here's a summary of 14 key documentation requirements for RPM:
1. Informed Consent:
Obtain patient consent to participate in remote monitoring.
Clearly explain the purpose, data collection methods, and privacy considerations.
2. Patient Identification:
Maintain accurate patient records, including demographics and contact information.
3. Monitoring Plan:
Develop an individualized monitoring plan for each patient.
Specify the monitored parameters (e.g., vital signs, symptoms, medications).
4. Data Collection:
Regularly collect and record patient data, which may include vital signs, symptoms, medication adherence, and other relevant information.
Document the date and time of data collection.
5. Data Transmission:
Document the method used for transmitting data from patients to healthcare providers.
Ensure data security and encryption.
6. Alerts and Alarms:
Define criteria for alerts and alarms.
Document the response protocol for healthcare providers when alerts are triggered.
Document any interventions, such as medication adjustments or counseling, based on the monitored data.
Maintain records of all patient-provider communications related to RPM.
Ensure that communication is secure and complies with privacy regulations.
9. Data Storage and Security:
Safeguard patient data with secure storage and access controls.
Comply with Health Insurance Portability and Accountability Act (HIPAA) regulations in the United States or equivalent data protection laws in other countries.
10. Reimbursement and Billing:
Document all relevant information for billing and reimbursement purposes, including the use of specific RPM codes and CPT (Current Procedural Terminology) codes.
11. Regulatory Compliance:
Adhere to any local, national, or international regulations governing RPM and telehealth services.
Document compliance with applicable laws and guidelines.
12. Patient Education:
Document patient education efforts, including the provision of instructions on using monitoring devices and understanding data.
Generate reports summarizing patient progress and outcomes from RPM.
Maintain a record of these reports for reference.
14. Periodic Reviews:
Schedule regular reviews of the monitoring plan and make necessary updates.
Document any changes to the monitoring plan and reasons for modifications.
These documentation requirements for remote patient monitoring play a crucial role in providing high-quality care, complying with regulations, and safeguarding patient privacy and data security. Healthcare providers should establish clear protocols and maintain organized records to facilitate effective remote monitoring services.
Recording RPM Care Delivery for Reimbursement
Some CPT codes specific to RPM are used as a one-off, such as providing training for new RPM patients to ensure they are comfortable using their assigned devices. Further CPT codes, including CPT 99457 and 99458, are claimed on a rolling basis, normally once per 30-day billing cycle.
Codes payable against time-based care delivery mean that providers need to have a method to record the time spent interacting with a patient, reviewing their RPM readings, and consulting with other professionals. A detailed log of work may be essential to claiming full reimbursements.
Most providers use a ‘stop/start’ basis to track the time allocated to the care and supervision of each patient enrolled in RPM. That may include logging virtual calls, data reviews, and interventions through the patient's EMR or another time-tracking software used by the practice or healthcare service.
CPT 99454 should be claimed when a new RPM patient is provided with an FDA-approved device and once per month thereafter to cover the reimbursements for the transmission service.
CPT 99453 is claimable when the patient is onboarded and receives device training.
CPT 99457 reimburses the first 20 minutes of care, including one instance of live communication.
CPT 99458 is billable for each subsequent 20 minutes of care, monitoring, or interaction provided.
In-house staff training and published policies setting out how providers identify billable CPT codes, submit precise claims, and ensure they do not miss a claimable reimbursement can reinforce good practice, using checklists so that all the relevant details are documented from initial onboarding to patient discharge.
Are you a healthcare provider looking to enhance the care you offer your patients as well as tap into new revenue streams? Get in touch with Wanda Health today and speak to us about our innovative remote patient monitoring solutions.