FAQ

While industry advocates generally applauded CMS for activating CPT 99091, they recognized how that code fails to optimally describe how RPM services are furnished using current technology and staffing models. This failure may be due to the fact that CPT 99091 is 16 years old and had never before been a separately payable service. (It is an older code CMS "unbundled" and designated as a separately-payable service.) Indeed, the AMA's CPT Editorial Panel developed and finalized the three new RPM codes in late 2017. These are the codes CMS finalized effective in 2019, which do a far better job in accurately reflecting contemporary RPM services.

The new Chronic Care Remote Physiologic Monitoring codes are:

CPT code 99453:

"Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment."

Reimbursement Rate: Approximately $19.19 (one-time)

CPT code 99454:

"76 days of Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.”

Reimbursement Rate: $63.16 (every 30 days per patient)

CPT code 99457:

"Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month."

Reimbursement Rate: $50.94 (each calendar month per patient)

CPT code 99458:

"Add-on code for patients who receive an additional 20 minutes of RPM services in a given month (i.e. 40 minutes of RPM services)

Reimbursement Rate: $41.17 (each calendar month per patient)

At least 20 minutes per calendar month. This differs from CPT 99091, which requires at least 30 minutes per 30-day period. CPT 99457 is much easier to track because it is based on a calendar month, not 30-day periods. This will more easily align with record keeping and claims submission, as CPT 99457 is reimbursed on a monthly basis.

Many advocates asked CMS to clarify the kinds of technology are covered under CPT codes 99453, 99454, and 99457. Some groups gave examples of the kinds of technology they believe these codes should cover, such as software applications that could be integrated into a beneficiary's smartphone, Holter-Monitors, Fitbits, or artificial intelligence messaging. Other examples included behavioral health data and data from wellness applications, or results of patients' self-care tasks. Unfortunately, CMS did not offer any specifics in the final rule on what technology qualifies, but CMS does plan to issue forthcoming guidance to help inform practitioners and stakeholders on these issues. This may likely be in the form of a CMS MLN article or Q&A.

Yes. CPT code 99457 may be furnished by auxiliary personnel, "incident to" the billing practitioner's professional services. An "incident to" service is one that is performed under the supervision of a physician (broadly defined), and billed to Medicare in the name of the physician, subject to certain requirements. As of January 1, 2020 Medicare has shifted from direct supervision to general supervision. Therefore, CPT codes 99457 and 99458 falls under general supervision - ie. the physician and auxiliary personnel are NOT required to be in the same building at the same time.

Yes. CPT 99453 offers separate reimbursement for the initial work associated with on-boarding a new patient, setting up the equipment, and patient education on use of the equipment.

Yes, patients can receive RPM services in their homes.

RPM services do not require the use of interactive audio-video, as these codes are inherently non face-to-face. A face to face visit is not required. A few groups urged CMS not to be prescriptive regarding the technology that could be used to perform consultations, including real-time video, a store-and-forward visit, or simply a patient-provider message via a patient portal. CMS expressed sympathy with the desire not to be overly prescriptive about the technology used to furnish RPM services, and stated CMS defers to the CPT code descriptors and guidance to ascertain the technological modalities used to furnish RPM services.

Yes, the practitioner must get the patient's consent for RPM services and document it in the patient's medical record. Although CMS did not directly address this in the final rule for the new codes, it is a requirement for CPT 99091 and can likely be expected as a requirement for CPT codes 99453, 99454, and 99457.

Yes, as a Medicare Part B service, the patient is responsible for a 20% co-payment for RPM services. While several groups asked CMS to eliminate any beneficiary co-payment for RPM services, CMS explained that it does not have the authority to change the applicable beneficiary cost sharing for most physician services, including RPM. Providers are cautioned to bill the patient (or the patient's secondary insurer) for the co-payment, as routine waivers of patient copayments can present a fraud & abuse risk under the federal Civil Monetary Penalties Law and the Anti-Kickback Statute.

The 2019 CPT Professional code book guidelines state that the reporting of CPT 99453, 99454 and 99457 requires that the device used be "a medical device as defined by the FDA." Whether a device meets the FDA's definition of a "medical device" is a different question than whether the device is "cleared" or "approved" by the FDA. Because the guidelines only require that a device is a FDA "medical device," at this time we interpret this to mean the device must only meet the definition of a "medical device."

Code 99457 requires a live interactive communication with the patient/caregiver and 20 minutes or more of clinical staff/physician or other qualified health care professional time per month. There is no guidance (or prohibition) as to whether the 20 minutes needs to address data collected in the same or prior month. What is clear is that time spent in a prior month cannot be counted toward the requisite 20 minutes in a subsequent month for purposes of billing the 99457 code.

One patient could be enrolled in two different providers RPM programs, however, the same time and activities could not be double counted by both providers for purposes of billing any of the four codes.

It is important to note that neither RPM nor CCM are Telehealth services as defined by Medicare and therefore not subiect to the restrictive requirements applicable to the location of the patient, type of provider, and type of technology. RPM 99457 may be reported during the same service period as CM services, TC services and BHI services. However, time spent providing any of these services should remain separate and no time should be counted toward the required time for more than one type of service.

No, the patient does not need to be located in a rural area or any specific originating site. Providers frustrated with the narrow Medicare coverage of telehealth services can take comfort in the fact that RPM is not considered a Medicare telehealth service. Instead, like a physician interpretation of an electrocardiogram or radiological image that has been transmitted electronically, RPM services involve the interpretation of medical information without a direct interaction between the practitioner and beneficiary. Medicare pays for RPM services under the same conditions as in-person physicians' services with no additional requirements regarding permissible originating sites or rural geographies.

Yes, a provider can bill both CPT 99457 and CPT 99490 in the same month. This is allowed because CMS recognizes the kind of analysis involved in furnishing RPM services is complementary to CCM and other care management services. However, time spent furnishing these services cannot be counted towards the required time for both RPM and CC codes for a single month (i.e., no double counting). Accordingly, billing both requires at least 40 minutes total (20 minutes of CCM and 20 minutes of RPM).

CPT code 99454 covers the provision and monitoring during at least 16 days of 30 days. In other words, the device must transmit data for a minimum of 16 days within a 30-day period.