Remote Patient Monitoring Texas

Texas Medicaid will reimburse for home telemonitoring in the same manner as their other professional services provided by a home health agency.

Source: TX Admin Code, Title 1, Sec. 355.7001(e). (Accessed Sept. 2019). 

Online evaluation and management for home telemonitoring services is a benefit in the office or outpatient hospital setting when services are provided by a nurse practitioner, clinical nurse specialist, physician assistant or physician provider. Data must be reviewed by a registered nurse, nurse practitioner, clinical nurse specialist, or physician assistant who is responsible for reporting data to the prescribing physician even when there have been no readings outside the parameters established in the physician’s orders. The procedure code is limited to once per seven days. Scheduled periodic reporting of client data to the physician is required. Setup and daily monitoring are reimbursed when provided by a home health agency or out-patient hospital. Home telemonitoring services must be authorized by TX Medicaid. Clients must be diagnosed with diabetes or hypertension and exhibit two or more risk factors (see regulations).

Source: TX Medicaid Telecommunication Services Handbook, pg. 12-14 (Sept. 2019). (Accessed Sept. 2019). 

Home telemonitoring services may be approved for up to 60 days per prior authorization request. If additional home telemonitoring services are needed, the home health agency or hospital must request prior authorization before the current prior authorization period
ends.

Source: TX Medicaid Telecommunication Services Handbook, pg. 14 (Sept. 2019). (Accessed Sept. 2019). 

The hospital or home health agency is responsible for the provision and maintenance of home telemonitoring equipment, including the setup and installation of equipment in the client’s home. Reimbursement is limited to once per episode of care even if monitoring parameters are added after initial setup and installation. A claim for a subsequent setup and installation is not reimbursed unless there is a documented new episode of care or unless the provider submits documentation of extenuating circumstances that require another installation of telemonitoring equipment.
Home monitoring is a benefit when services are provided by a home health agency or an outpatient hospital. Providers must submit the revenue and modifier codes as specified in the Telecommunication Services Handbook.

Source: TX Medicaid Telecommunication Services Handbook, pg. 13 (Sept. 2019). (Accessed Sept. 2019). 

Conditions

Home Telemonitoring is available only to patients who:

• Are diagnosed with diabetes, hypertension; or
• When it is determined by Texas Health and Human Services Commission to be cost-effective and feasible the following conditions are also included: pregnancy, heart disease, cancer, chronic obstructive pulmonary disease, congestive heart failure, mental illness, asthma, myocardial infarction or stroke.

Source: TX Admin Code. Title 1, Sec. 354.1434 & TX Medicaid Telecommunication Services Handbook, p. 14 (Sept. 2019). & TX 
Government Code Sec. 531.02164. (Accessed Sept. 2019). 

Home telemonitoring services are also available to pediatric persons who:

• Are diagnosed with end-stage solid organ disease;
• Have received an organ transplant; or
• Require mechanical ventilation.

Source: TX Government Code Sec. 531.02164. (HB – 1063.) (Accessed Sept. 2019).

Provider Limitations

Providers must:

• Be enrolled and approved as home telemonitoring services providers
• Share clinical information gathered while providing home telemonitoring services with the patient’s physician; and
• Not duplicate disease management program services

Source: TX Admin Code. Title 1, Sec. 354.1434(c) & TX Medicaid Telecommunication Services Handbook, p. 3 & 12, (Accessed
Sept. 2019). 

Requests for additional home telemonitoring services that are received after the current prior authorization expires will be denied for dates of service that occurred before the date the submitted request was received.

To be eligible for home telemonitoring services, clients who are diagnosed with diabetes or hypertension must exhibit two or more of the following risk factors:

• Two or more hospitalizations in the prior 12-month period;
• Frequent or recurrent emergency room admissions;
• A documented history of poor adherence to ordered medication regimens;
• A documented history of falls in the prior six-month period;
• Limited or absent informal support system;
• Living alone or being home alone for extended periods of time; and
• A documented history of care access challenges.

Source: TX Admin Code. Title 1, Sec. 354.1434(d) & TX Medicaid Telecommunication Services Handbook, pg. 14 (Sept. 2019).
(Accessed Sept. 2019).