Telemonitoring for heart failure patients

Billing home health care telemonitoring services for heart failure patients

Approved telemonitoring providers

Only certain home health care providers are approved to be reimbursed for providing in-home telemonitoring services to heart failure patients.
Go to the page listing telemonitoring providers.

Covered telemonitoring services

Go to the page listing covered telemonitoring services.

Reporting and documentation

Go to the page listing monthly reporting requirements and discharge documentation criteria.

Jump down this page to:

• Guidelines for billing
• When services are not reimbursed
• Patient eligibility guidelines
  

Guidelines for billing

Use these guidelines to bill for the remote clinical monitoring, triage and support of Priority Health heart failure patients at high risk for admission.

• Your patient must meet the eligibility guidelines (below).
• You must have a prior authorization approved and on file. Use the Home Health Care prior authorization form (415KB PDF) to request authorization.
• Bill home health care visits using standard billing guidelines for UB04 Billing.
  
• Bill each telemonitoring service separately each month using roster billing: installation, deinstallation (no procedure codes), and procedure code S9109 for monthly service, monitoring, and telephone calls
• Monthly service & monitoring charge will be calculated in 15 day (half month) increments.
  Example: 1 – 15 days = Half month (see IIIC).  16 to 30 days = 1 month, etc.
• For more information, go to Covered services page, which includes reporting requirements.
  
• Billing must include:
  
• Agency name, address & tax identification number
  
• Member identification number, member name, and authorization number for each member
• Name of the service(s)
• Associated date(s) of service
• Type of service: installation, monthly service & monitoring (use S9109 procedure code), de-installation
• Fax billing to the Outpatient Care Manager.

When services are not reimbursed

• Home Health Care agencies must be specifically contracted by Priority Health as providers of telemonitoring services for heart failure patients to request reimbursement.
  View the list of contracted telemonitoring providers.
• When patients do not engage in the monitoring process within the first 5 calendar days of engagement, Priority Health will not reimburse for the monthly service & monitoring charge. We will still reimburse for the installation and de-installation of the monitor.
• For the duration of any hospital admissions, Priority Health will exclude payment for home telemonitoring and update the authorization to this effect.
  

Patient eligibility guidelines

Patients who are eligible for telemonitoring in the home include those who have a history of heart failure (HF) and:

• Recent hospitalization(s) with a primary diagnosis of heart failure
  
• A history of failing to adhere to their HF treatment plan and are at risk for an acute episode
• Emergency Department visits in the recent past for treatment of HF
• Renal failure as defined as GFR<30, hepatic failure or coronary disease that puts the patient at risk for myocardial function compromise

Patients excluded from telemonitoring include members who:

• Refuse telemonitoring services
• Are unwilling or unable to participate AND who have no caregiver able to prompt daily use
  
• Are enrolled in hospice services
• Receive high frequency (greater than 3 times per week) clinical interventions