Sunday, December 13, 2020

CMS and Some Digital Health Codes, 2018, 2019

Entry points to the discussion on Medicare and digital health are too numerous to cite.   In this blog, I look at some actual digital-health-related codes in CY2019 and, for a few codes, 2018 data which is more granular.  Bottom line?  Some codes like remote physiological monitoring and a new type of e-consult based on electronic records, saw remarkably little use in CY2019.

In a December 1 blog on the final PFS rule, I discussed how Medicare bumps and collides against some payment concepts that will be needed in digital health (here).  In today's blog, I just lay out some plain-jane data and numbers from 2018 and 2019.

CMS Data Sources

CMS has released 2019 data as national Part B utilization and payment files at the level of CPT codes.  See my original blog here.   If you go back to 2018, CMS recently released cloud data file for CPT code utilization and payment level at the national, state, and even the provider level (e.g. Dr Jones used CPT 92011 30 times).   These latter cloud databases are easier to use than Excel files, for but 2019, Excel is all we have.  

I've cherry-picked a few groups of codes:

E-Consults between physicians - Codes

Historically,  physicians got "consult codes" for seeing a patient at the recommendation of another physician, primarily to report back their judgment rather than to take over a new patient.  New CPT codes allow non-face-to-face interprofessional communications.  These are codes 99446-99449, for up to 10, 20, 30, or >31 minutes of time.

Remote Physiological Monitoring - Codes

These were exciting new codes in 2019, and I got a lot of questions on them from d-health startups.  99453 provides the device, 99454 compensates for 30 days of use (e.g. as if rented from physician).  99091 is collection and interpretation of data (minimum 30 minutes of time).  (If I read correctly, 99091 will continue to exist in 2020, 2021, but largely replaced by 99457, 99458.  I'm not looking at 2020 data, so I haven't studied this).

iRhythm - Codes 

In 2021, iRhythm will graduate from its longstanding Category III codes to Category I codes, an issue that required extensive discussion by CMS regarding RVU valuations (CMS ended up declining to assign national RVUs for some of the codes for CY2021; see iRhythm transcript here).  But we do have access to CMS payment data for the Cat III codes in CY2018 (by provider) and CY2019 (at the national level).   Codes are 0296T for recording including connection, 0297T for analysis and report, and 0298T for final physician interpretation.  0295T also exists, a comprehensive code for each component together. So, 0295T-0297T.  I'll shorthand these as iRhythm codes, but they apply to any comparable technology coded the same way.

- - - - Data - - - - 

E-Consults 2019 - Data


Despite the excitement about physician-to-physician electronic consults (consults based on provided EHR records),  national use was very low, relative to the tens of millions of Medicare Part B patients.  The entire budget for this services in 2019 was less than $400K and only several thousand uses of this service were filed by clinicians.

Remote Monitoring 2019 - Data


This is pretty similar data.  Despite all the interest in remote physiological monitoring codes newly launched by CMS in 2019, the payments for these codes were only a couple million dollars.  The months of monitoring used were about 60,000, which is about one month of remote monitoring for every 800 Medicare patients (it's not terribly far from 1:1000).  


IRhythm (or similar technologies) - Data

2019 National Data


The comprehensive code was used in less than 10% of patients, and paid an average of $264.  The partial code 0297T, in contrast, was used 240,000 times, and paid an average of $311.  Physician interpretation paid an average of $27.  In 2021, the RVU prices for the successors to 0295T, 0298T, will not be priced by CMS, while the successors to 0296T, 0298T, will be priced by CMS in RVU values at about the same value as shown in the carrier pricing (local pricing) above.

2018 Line Item (Physician) Data

Note that you can get extremely granular summary data, such as the age distribution, race distribution, state distribution, of payments for 0295-0298T, in CY2018 here.  See aggregate cloud data links in the lower part of the webpage.  For example, at your fingertips you can get the number of 0298T patients that were African-American, or Medicare-Medical patients, or >age 85 patients.

  • I've put an excel spreadsheet of provider information (5000 lines of Excel) in the cloud here. 
  • It's sorted by CPT code then dollar volume per line. 

In 2018, 0295T, the comprehensive code, was billed by 150 doctors, the highest being a North Carolina physician with 299 services paid $67,806.   The payment level varied greatly, from $88 to $315. One doctor in California, Palm Springs, billed CMS for $4800 per use (he was paid $68).

In 2018, 0296T, the provision code, was billed by about 1850 doctors.  Payments ran from the single digits to the mid-$20's.  The highest volume was an Illinois doctor with 566 provisions of the device netting $18,061 or $24 per device (he billed $142).  

In 2018, 0297T, the analysis code, was billed 130,486 times by an IDTF in Illinois, charging $397, paid on average $238 (allowable $307) totaling $40M.  The next-highest IDTF was in Malvern PA, with 17,224 cases for $261 (charge $2784, allowed $335).  The two top IDTFs had 97% of the market for 0297T.  Several other IDTFs billed far smaller amounts in Texas and Maryland.  

But there's more for 0297T.  About 70 clinicians also billed for "analysis" 0297T.  Cases were typically 100 or less, and payments $300 or less, sometimes as little as $25.  3,116 cases of 0297T were paid to physicians, for about $1M.  One doc with a Cedars Sinai office building address in LA charged $500 per 0297T service (allowed by Noridian for 0297T, $43.)

In 2018, 0298T, the physician interpretation code, was billed by about clinicians.  The highest billed 783 services for $20 each.  Three other clinicians billed >500 cases each.  About 2800 clinicians billed for interpretations, whereas only 1850 billed for provision of the device.  

In the table below, I pull only the IDTF-based billings for 0297T in 2018.  Interestingly, PA TX MD are under one MAC Novitas, but appear to pay different rates, and IL, where iRhythm is shown as billing, pays the lowest average allowable rate ($307) of the 8 IDTFs listed.