The Centers for Medicare & Medicaid Services (CMS) is the division in the U.S. Department of Health and Human Services (HHS) responsible for managing Medicaid, Medicare, the Health Insurance Marketplace, and the Children’s Health Insurance Program (CHIP).

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CMS leverages ‌Current Procedural Terminology (CPT) codes to ensure that healthcare providers capture patient data precisely and submit accurate claims for medical services rendered to Medicare and Medicaid beneficiaries.

What are CPT Codes?

CPT is a uniform coding system for reporting and describing medical services and procedures. The CPT coding system is created and managed by the American Medical Association (AMA). Depending on their category, CPT codes comprise five characters that are either numeric or alphanumeric:

  • Category I CPT Codes: 00100-99499
  • ‌Category II CPT Codes: 0001F-9007F 
  • ‌Category III CPT Codes: 0016T-0207T

How are CPT Codes Used?

Qualified healthcare professionals (QHPs) in all states use CPT codes to record and describe surgical, medical, evaluation and management, anesthesiology, laboratory, genomic sequencing, and radiology services offered to patients. Physicians send CPT codes to federal or private health insurance carriers for reimbursement. 

‌As a physician or QHP, you must have sufficient knowledge of the CPT coding system so you can bill CMS accurately and get paid correctly and on time. This is especially true if you’re offering RPM services in your practice or have an RPM system in the works.

Remote Patient Monitoring CPT Codes

‌In 2018, CMS introduced CPT codes to reimburse healthcare practitioners who are providing RPM services. You must be well-acquainted and updated with the billing requirements of each RPM CPT code to avoid compensation challenges with CMS. Here are some of the RPM CPT codes you need to know.

1. CPT Code 99453

Code 99453 covers the one-time cost of setting up RPM devices and onboarding a patient in your remote healthcare monitoring system. You should bill for CPT 99453 once per patient when starting services.

Billing requirements: 

  • You must collect a patient’s physiologic data for 16 days during the 30-day billing period. 
  • During the COVID-19 PHE period, you can bill for code 99453 with less than 16 days worth of data, for a COVID related RPM service.
  • ‌You must use an RPM device that meets the FDA’s description of a medical device. 
  • Must be ordered by a physician or QHP.
  • Auxiliary personnel (including those “not clinical staff” but employees or leased or contracted employees) are allowed to furnish services under the general supervision of the billing physician or QHP.

Reimbursement rate: $19.19 for both facility and non-facility.* 

 

2. CPT Code 99454

Code 99454 reimburses you for supplying patients with home health monitoring devices and programming the devices to record physiologic data. You should bill for 99454 once per patient in a 30-day billing period.

Billing requirements:

  • You must have  16 days of physiological data and/or alerts during a 30 day period.
  • During the COVID-19 PHE period, you can bill for code 99454 with less than 16 days worth of data, for a COVID related RPM service.
  • ‌You must dispense the RPM devices for your patients without additional cost to the patient. You cannot allow patients bring their own devices or allow leasing of the devices.
  • The supplied home monitoring devices must fit the FDA’s description of a medical device.  
  • ‌Even if you issue multiple RPM devices to one patient, you can only bill for code 99454 once in 30 days for all the services, and at least one device must have collected physiologic data and/or alerts for 16 days.
  • Must be ordered by a physician or QHP.
  • Auxiliary personnel (including those “not clinical staff” but employees or leased or contracted employees) are allowed to furnish services under the general supervision of the billing physician or QHP.

Reimbursement rate: $63.16 for both facility and non-facility.*‌

3. CPT Code 99457

Code 99457 reimburses you for the time you spend monitoring, interpreting, and reviewing a patient’s physiological data remotely. You should bill for 99457 once in each calendar month.

Billing requirements: 

  • ‌You must provide remote health monitoring services for at least 20 minutes per month.
  • One live interaction is required,  CMS calls it an interactive communication. It refers to real-time two-way remote communication via video, text, email, phone call, and other virtual interactions between you and your patients. 
  • You must be able to  furnish CMS with a patient’s treatment plan and recent data outlining beneficiary encounters, when requested. 
  • Performed by QHPs who are eligible to furnish evaluation and management, or auxiliary personnel/clinical staff under the general supervision of the billing provider.
  • A live interaction cannot be text or email. It must be a live video, phone call, or face to face conversation

Reimbursement rate: $50.94 for non-facility and $31.75 for facility.*

4. CPT Code 99458

Code 99458 is an add-on code to 99457 and covers each additional 20 minutes of monitoring. CMS allows up to 3 units in a calendar month, based on medical necessity.

Billing requirements:

  • ‌You can bill for 99458 only as an add-on to code 99457, not as an independent code.
  • Performed by QHPs who are eligible to furnish evaluation and management, or auxiliary personnel/clinical staff under the general supervision of the billing provider.

Reimbursement: $41.17 for non-facility and $31.75 for facility.*

The 20 minutes required to bill for 99457 and 99458 includes the time used to set up RPM devices and the time used for interactive communication.

5. CPT Code 99091 

Code 99091 compensates physicians for the time they spend analyzing, interpreting, and reviewing physiologic data. You can bill for 99091 once in a 30-day billing period.

Billing requirements:

  • ‌You must spend at least 30 minutes reviewing patient data during the 30-day billing period.
  • ‌You must obtain and record beneficiary consent in your patient records. 
  • Auxiliary staff cannot provide any part of this service, it must be delivered by QHP. 

Reimbursement rate: $56.87 for both facility and non-facility.* 

 * These are average Medicare rates. Actual reimbursement varies by MAC locality. Private payers set their own rates and are not required to reimburse at the rates set by Medicare. 

‌How RPM Reimbursements Work 

‌You must comply with CMS billing rules to receive compensation for the remote healthcare monitoring services you offer patients. RPM compensation rates may vary among private insurance companies. However, their figures are based on the prevailing rates set by CMS. When reimbursement figures change upon review, CMS publishes the new rates in their annual Physician Fee Schedule report.

Tips for Facilitating CMS Compliance in Your Practice

Outsource Tasks

Ensuring RPM compliance in your practice can tie up much of your productive time. A good rule of thumb is to outsource your RPM administrative tasks to your RPM platform provider.

These are duties such as documenting your patient’s data, obtaining patient consent, setting up and onboarding patients and staff on your remote health monitoring system and supplying RPM devices to your patients.

Choose the Right RPM Devices 

Partner one of the top remote patient monitoring companies to get the most appropriate health monitoring devices for your patients. You must ensure that your patients have a smooth user experience with their wearable health monitoring devices. This way, patients can easily transmit physiological data with minimum downtimes. As a result, you’ll have the required data to bill for codes 99453 and 99454.

Target the Right Patients 

‌Patients with acute conditions, as well as those with chronic conditions such as diabetes, heart disease, and hypertension, benefit most from remote patient monitoring services since they provide an opportunity to collect physiological data daily. You should train such patients to use their RPM devices to collect and transmit data effectively. This will allow you to monitor their health remotely and collect sufficient data to satisfy billing requirements.

Today’s Patients Prefer RPM 

‌Patients desire RPM because of the convenience it provides. They can access treatment from the comfort of their homes, which is a big plus in our post-pandemic world. RPM allows you to monitor and review a patient’s physiological data and health in real-time.

By understanding the five RPM CPT Codes in-depth and the ins and outs of RPM reimbursement, you can scale your remote patient monitoring telehealth services substantially.

To deliver the best in class RPM services to your patients and receive maximum reimbursements, you must offer cutting-edge remote patient monitoring solutions. You can count on CoachCare to supply you with advanced remote patient monitoring systems and FDA-compliant devices.