Part 2 - Reimbursement for Digital Health: CPT Codes.
Cameron Jacox is the founder of Rocket Digital Health, the foremost digital health scale consultancy. Go-to-market is hard in healthcare, and we believe that you don’t need to reinvent the wheel to bring your brilliant invention to market. Having helped scale 13 digital health startups, including for 4 years as Chief Growth Officer at Lark Health from Series A to Unicorn status, Cameron & his team work with select startups to bring growth strategy to bear to beat their growth goals and catch their stride.
Reimbursement plays a pivotal role in the success of digital health startups. As digital health startups continue to revolutionize the healthcare landscape, one crucial aspect for us is securing reimbursement for our innovations. Reimbursement is a big pool of money, and most people don’t expect to pay for most healthcare services in full. Reimbursement not only validates the clinical efficacy and value but drives adoption. In this article, we explore the reimbursement landscape for digital health startups like you. We’re looking at a few specific solution areas here in part 2: insomnia, sleep apnea, DEXA scans, remote patient monitoring for cardiovascular disease, family caregiver supports, postpartum physical recovery, continuous glucose monitoring, personalized cancer care, functional genomic analysis, and prescription drug management.
We also provide relevant CPT codes associated for each category to help you navigate the complex reimbursement process and optimize your chances of success.
Solution Area: Insomnia
Digital health startups targeting insomnia should focus on providing innovative, evidence-based solutions to improve sleep quality, duration, and patient outcomes. Key considerations include:
Validating the product through clinical trials or real-world evidence
Demonstrating the product's ability to improve sleep quality, reduce sleep latency, or enhance patient engagement
Ensuring compatibility with existing sleep assessment tools and treatment strategies
Relevant CPT codes:
96150-96155: Health and behavior assessment and intervention services
95800-95811: Sleep study services
Solution Area: Sleep Apnea
Digital health startups targeting sleep apnea should aim to provide innovative, evidence-based solutions that improve patient outcomes, adherence to therapy, and quality of life. Key considerations include:
Validating the product through clinical trials or real-world evidence
Demonstrating the product's ability to improve diagnostic accuracy, treatment adherence, or patient engagement
Ensuring compatibility with existing sleep apnea assessment tools and treatment strategies
Relevant CPT codes:
95800-95811: Sleep study services
94660: Continuous positive airway pressure (CPAP) therapy management
Solution Area: Remote Cardiovascular Patient Monitoring
Digital health startups focusing on remote patient monitoring for cardiovascular health should aim to provide innovative, evidence-based solutions that improve patient outcomes and facilitate early intervention. Key considerations include:
Validating the product through clinical trials or real-world evidence
Demonstrating the product's ability to improve diagnostic accuracy, treatment efficacy, or patient engagement
Ensuring compatibility with existing cardiovascular assessment tools and management strategies
Relevant CPT codes:
93296, 93297: Remote monitoring of cardiovascular implantable electronic devices
99091: Collection and interpretation of physiologic data
99453, 99454, 99457, 99458: Remote physiologic monitoring services
Solution Area: Caregiver Support/Eldercare/Aging-at-Home
Digital health startups focusing on family caregiver support should aim to provide innovative, evidence-based solutions that improve caregiver well-being, reduce burnout, and enhance patient outcomes. Key considerations include:
Validating the product through clinical trials or real-world evidence
Demonstrating the product's ability to improve caregiver well-being, reduce burnout, or enhance patient engagement
Ensuring compatibility with existing caregiver support tools and resources
Relevant CPT codes:
99483: Cognitive assessment and care plan services
96161: Family caregiver health risk assessment
90846, 90847: Family psychotherapy services
Solution Area: Postpartum Recovery
Digital health startups focusing on postpartum physical recovery should aim to provide innovative, evidence-based solutions that improve the health and well-being of new mothers. Key considerations include:
Validating the product through clinical trials or real-world evidence
Demonstrating the product's ability to improve physical recovery, reduce complications, or enhance maternal engagement in self-care
Ensuring compatibility with existing postpartum care tools and resources
Relevant CPT codes:
97110-97116, 97124, 97140: Therapeutic procedure codes related to postpartum physical therapy and rehabilitation services, including therapeutic exercises, manual therapy, and other interventions to address postpartum physical recovery needs.
I hope this information is helpful. Let me know if you need any further clarification or information on other topics.
Solution Area: CGM
Digital health startups focusing on continuous glucose monitoring should aim to provide innovative, evidence-based solutions that improve diabetes management and patient outcomes. Key considerations include:
Validating the product through clinical trials or real-world evidence
Demonstrating the product's ability to improve glucose control, treatment adherence, or patient engagement
Ensuring compatibility with existing diabetes management tools and strategies
Relevant CPT codes:
95249, 95250, 95251: Continuous glucose monitoring services
Solution Area: Personalized Cancer Care (Genomics, Immunoresponse)
Digital health startups focusing on personalized cancer care should aim to provide innovative, evidence-based solutions that improve patient outcomes, facilitate precision medicine, and enhance patient engagement. Key considerations include:
Validating the product through clinical trials or real-world evidence
Demonstrating the product's ability to improve treatment efficacy, reduce adverse events, or streamline care coordination
Ensuring compatibility with existing oncology care tools and resources
Relevant CPT codes:
81539, 81545, 81595, 81599: Oncology genomic sequence analysis panels
88360, 88361: Tumor immunohistochemistry services
Solution Area: Functional Genomic Analysis
Digital health startups focusing on functional genomic analysis should aim to provide innovative, evidence-based solutions that improve patient outcomes, facilitate precision medicine, and enhance patient engagement. Key considerations include:
Validating the product through clinical trials or real-world evidence
Demonstrating the product's ability to improve diagnostic accuracy, treatment efficacy, or streamline care coordination
Ensuring compatibility with existing genomics tools and resources
Relevant CPT codes:
81415-81422: Exome sequence analysis services
81430-81471: Targeted genomic sequence analysis panels
Solution Area: Prescription Drug Management
Digital health startups focusing on prescription drug management should aim to provide innovative, evidence-based solutions that improve medication adherence, patient outcomes, and reduce medication-related problems. Key considerations include:
Validating the product through clinical trials or real-world evidence
Demonstrating the product's ability to improve medication adherence, reduce adverse events, or streamline care coordination
Ensuring compatibility with existing medication management tools and resources
Relevant CPT codes:
99605, 99606, 99607: Medication therapy management services
90863: Pharmacologic management, including prescription and review of medication
By understanding the relevant CPT codes for each health category, digital health startups can better navigate the reimbursement landscape and tailor their products to meet the requirements of insurers and healthcare providers.