Note: For the purposes of this article, “advanced practice registered nurse (APRN)” includes nurse practitioner (NP) clinical nurse specialist (CNS) providers only.
Effective for dates of service on or after September 1, 2021, telemonitoring benefits will change for the Children with Special Health Care Needs (CSHCN) Services Program.
Overview of Benefit Changes
Major changes to this medical benefit include the following:
- Additional medical conditions covered for home telemonitoring services
- Updated documentation requirements
- A new procedure code for the collection and interpretation of client data (procedure code 99091)
- Changes to prior authorization guidelines
- Revised prior authorization form
Additional Medical Conditions
In addition to the current conditions of diabetes and hypertension, home telemonitoring services will also be a benefit for clients with one or more of the following conditions:
- Congestive heart failure
- End-stage solid organ disease
- Organ transplant recipient
- Requiring mechanical ventilation
Documentation Requirement Updates
The home health agency or hospital must maintain documentation of all the following information:
- The telemonitoring equipment meets all the following requirements:
- The equipment is capable of monitoring any data parameters included in the plan of care
- The equipment is classified as a Food and Drug Administration Class II hospital-grade medical device
- The equipment is capable of measuring and transmitting client weight, oxygen levels in blood, glucose levels in blood, or blood pressure data
- The client’s medical record, which must include data transmission information that demonstrates the use of monitoring equipment, such as the following:
- Date of transmission
- Frequency of transmission
- Clinical data provided to the client’s primary care physician, or his or her designee
- The provider’s staff is qualified to install the telemonitoring equipment and to monitor the client data transmitted according to the client’s care plan.
- Monitoring of the client’s clinical data is not duplicated by any other provider.
- The client’s ability to operate the equipment or has a willing and able person to assist in completing electronic transmission of data, unless the equipment does not require active participation from the recipient.
- Written protocols, policies, and procedures on the provision of home telemonitoring services are available to the Health and Human Services Commission (HHSC) or its designee upon request. Written protocols must include all of the following:
- Authentication and authorization of users
- Authentication of the origin of client data transmitted
- Prevention of unauthorized access to the system or information
- System security, including the integrity of information that is collected, program integrity, and system integrity
- Maintenance of documentation about system and information usage
- Information storage, maintenance, and transmission
- Synchronization and verification of patient profile data
- Ability to operate the equipment – The client is able to operate the equipment or the client has a willing and able person to assist in completing electronic transmission of data. (Not required if the equipment does not require active participation from the client.)
The registered nurse (RN), APRN, or physician assistant (PA) in a licensed home health agency or a hospital is responsible for reporting data to the prescribing physician. Scheduled periodic reporting of the client data to the physician is required at least once every 30 days, even when there have been no readings outside the parameters established in the physician’s orders.
The physician who orders home telemonitoring services has a responsibility to ensure that the client has a choice of home telemonitoring providers.
The physician must maintain documentation of medical necessity in the client’s medical record.
Collection and Interpretation of Client Data
The collection and interpretation of a client’s data (procedure code 99091) for home telemonitoring services will be a benefit when services are provided by a physician, PA, or APRN in the office and outpatient hospital settings.
Procedure code 99091 will be limited to once per 30 days.
Effective September 1, 2021, online evaluation and management for home telemonitoring services (procedure codes 99421, 99422, and 99423) will no longer be a benefit.
Prior Authorization Updates
Home telemonitoring services are available to clients only after the home health agency or hospital has received prior authorization. Dates of service requested before the prior authorization request is received will be denied.
Telemonitoring services may be requested and approved for up to 90 days per prior authorization request. The initial setup and installation (procedure code S9110 with modifier U1) may be prior authorized once per episode of care, unless the provider submits documentation of extenuating circumstances that require another installation of telemonitoring equipment.
The Home Telemonitoring Services Prior Authorization Request form must be signed and dated by the prescribing provider within 30 days before the start of care. If the form is signed after the start of care, all dates of services before the prescribing provider’s signature date will be denied.
An RN, APRN, or PA may sign the prior authorization request form on behalf of the client's physician when the physician delegates this authority to the RN, APRN, or PA. The RN, APRN, or PA must complete Section D, then sign and date the form.
To avoid unnecessary denials, the prescribing physician must provide correct and complete information, including documentation of medical necessity for the equipment and supplies requested.
Revised Prior Authorization Form
Effective September 1, 2021, the Home Telemonitoring Services Prior Authorization Request form will be updated with the following additions:
- New qualifying conditions
- A new section for specific details about the requested authorization period
Providers may submit prior authorization requests for home telemonitoring services through the electronic prior authorization portal, fax, or mail. The revised form will be available on the electronic prior authorization portal, and as a fillable PDF on the TMHP website beginning September 1, 2021.
The Home Telemonitoring Services Prior Authorization Request form (Revised: 02/01/2016 version) will no longer be accepted after September 30, 2021. If the discontinued form is submitted on or after October 1, 2021, TMHP will return the form to the provider with a request that the revised form be submitted.
For more information, call the TMHP-CSHCN Services Program Contact Center at 800-568-2413.