Overview of Chronic Care Remote Physiologic Monitoring
In 2018, CMS began providing standalone reimbursement for Remote Patient Monitoring (“RPM”) services under CPT Code 99091. Then, the final 2019 Medicare Physician Fee Schedule (the “Rule”), released on November 1, 2018, created several additional RPM codes for 2019 in the category titled “Chronic Care Remote Physiologic Monitoring” (“CCRPM”) (CPT Codes 99453, 99545, and 99457). Finally, for in the 2020 MPFS CMS finalized the addition of CPT Code 99458, an add-on code that represents each additional 20 minutes of time spent providing RPM services beyond what is required for CPT Code 99457.
RPM uses digital technologies to gather physiologic data from patients in one location (e.g., their home) and transmit that information to healthcare providers in another location (e.g., their doctor’s office) for analysis. RPM devices can collect various forms of health data, including vital signs, blood pressure, heart rate, and electrocardiograms, among others. Providers can use this data to monitor patients’ health conditions, provide recommendations, and/or make changes to a patient’s care plan.
RPM services can be beneficial to patients, providers, and healthcare facilities. RPM helps patients by keeping them healthy and offering fast, easy access to their physicians without having to leave their home, increasing their quality of life and decreasing their healthcare costs. RPM can help physicians and health care facilities reduce the overall number of hospitalizations, readmission rates, and patients’ length of stay. All of these factors can help reduce the overall cost of care.
Physicians and other eligible practitioners that incorporate RPM services into their practice may also increase their performance scores under MACRA’s Quality Payment Program (“QPP”). Implementing RPM services can boost scores in both the Improvement Activities category and the Promoting Interoperability category (formerly Advancing Care Information category), contributing to a higher overall performance score.
Please note, as of the date of last update of this FAQ, CMS has not issued any formal Guidance with respect to implementation of RPM services or use of any of the RPM codes. CMS may or may not choose to do so, and CMS’ interpretation of various components of the codes may differ from that of any individual outside CMS.Nothing in this document should be construed as a guarantee that services will be reimbursed.
The descriptors and approximate reimbursement amounts for the RPM codes are as follows:
CPT Code 99453 ($19):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
CPT Code 99454 ($62): 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
CPT Code 99457 ($51): 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
CPT Code 99458 ($42): Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes
CPT Code 99091 ($59): Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days
NOTE: Reimbursement amounts may vary by geography. Providers should check with their local Medicare Administrative Contractor (MAC) for reimbursement rates in their region.
Frequently Asked Questions
Are the CCRPM Codes only available for patients with chronic conditions?
No. Despite their name, CMS clarified in its first 2020 Interim Final Rule that services provided under CPT Codes 99453, 99454, 99457, and 99458 are not limited to patients with chronic conditions, but that RPM can be provided to patients with acute conditions as well.
Are there patient co-pays for the CCRPM CPT Codes 99453, 99454, 99457, and 99458 (the “CCRPM Codes”)?
Yes. As with all Medicare services, patients are responsible for all applicable copayments and cost-sharing amounts. Medicare Part B beneficiaries are typically responsible for a 20% copay each time a code is billed.
*During the temporary COVID-19 Public Health Emergency (the “PHE”), providers may waive patient copays associated with RPM services.
Is there a recommended billing format for the CCRPM Codes?
As of the date of this posting, CMS has not issued any guidance with respect to billing CCRPM codes. Providers should follow current billing practices and ensure that all the requirements for each code are met, such as documenting patient consent in the medical record.
Can we use CPT Code 99091 in conjunction with CPT Code 99457 for the same patient?
No. The American Medical Association CPT Manual (the “CPT Manual”) states that CPT Codes 99457 and 99091 cannot be billed within 30 days of each other.
Can CPT Code 99091 be billed in conjunction with CPT Codes 99453 and 99454?
The CPT Manual indicates that CPT Codes 99453 and 99454 can be used for patient education, setup, and supply of monitoring devices that are used to provide RPM services billable under CPT Code 99091. However, time spent providing services billable under CPT Code 99453 and/or 99454 cannot also be counted as time spent providing services billable under CPT Code 99091.
Can CPT Code 99091 be billed in conjunction with CPT Code 99458?
Likely no. The 2020 Medicare Physician Fee Schedule Final Rule (the “2020 Rule”) does not explicitly state whether CPT code 99091 can be billed in conjunction with CPT code 99458 and as of the date of this response, CMS has not issued additional guidance with respect to this question. However, the CPT Manual states, “[u]se 99458 in conjunction with 99457” and 99458 carries different requirements for billing than 99091, so the two likely should not be billed in conjunction with one another.
Is CPT Code 99453 reimbursed per device or per patient? For example, if a patient has two devices that require two separate education and setup appointments, is reimbursement available for both sessions?
CPT Code 99453 can only be reported once per patient per episode of care, regardless of how many devices are used to monitor the patient for that episode of care. For purposes of RPM and CCRPM, an “episode of care” begins when the service is initiated and ends when targeted treatment goals are attained. If another device is used at some point for the same patient but relating to a different episode of care, setup and education for that device would be separately reimbursable.
Is CPT Code 99454 reimbursed per device or per patient? For example, if a patient has a condition or conditions that require two separate monitoring devices for the same episode of care, is separate reimbursement available for the supply of each device?
CPT Code 99454 can only be billed once per patient each 30 days, regardless of whether the patient is using one device or multiple devices.
If a patient has multiple conditions, can we provide separate devices for each condition and receive reimbursement for the monitoring of each?
No. Billing practitioners can only report CPT Codes 99091, 99454, 99457, and 99458 once per billing period regardless of the number of parameters monitored or devices used.
If a billing practitioner clocks 30 minutes providing RPM services in a calendar month, can that time be recorded for both CPT Code 99457 and 99091?
No. Time spent providing services billable under either code can only be counted once. Counting the same time twice would constitute duplicative billing, which is not allowed.
Do the CCRPM codes require an initiating face-to-face visit?
Yes. For new patients or patients not seen by the billing practitioner within 1 year prior to billing CPT code 99457, CMS requires initiation of the service during a face-to-face visit with the billing practitioner. This face-to-face visit should be billed separately and may be an Annual Wellness Visit, an Initial Preventive Physical Exam, Levels 2-5 E/M visit, or the face-to-face visit included in Transitional Care Management services (CPT Codes 99495 and 99496).
*During the PHE, providers may order and bill for RPM services provided to new patients.
For purposes of billing CPT Code 99457, can the billing practitioner use time spent by clinical staff that are outsourced and located overseas?
Likely yes, so long as the clinical staff meet all licensing requirements for the states in which the patients they are working with are located.
CPT Code 99457 allows for clinical staff members to provide RPM services under the billing practitioner’s supervision. When a billing practitioner reports clinical staff time, the billing practitioner bills contributing clinical staff members’ time on an “incident-to” basis. For CPT Codes 99457 and 99458, CMS allows for the clinical staff member(s) to be supervised under general supervision, meaning the billing practitioner has to be available to the clinical staff if they have a question or need assistance, but does not necessarily have to be located within the same office building. This allows for a fully outsourced model in which one company provides RPM services for a particular patient population via clinical staff (similar to the model commonly used for Chronic Care Management services).
If a billing practitioner and/or care team bills CPT Code 99453 and 99454 for a device or devices, should the billing practitioner report CPT Code 99457 or 99091?
It depends on the services provided. CPT Codes 99457 and 99091 are similar, but they differ in some important ways. For example, clinical staff cannot provide services billable under CPT Code 99091, and CPT Code 99457 requires live, interactive communication between the individual performing the services and the patient. CPT Code 99091 requires an aggregate of 30 minutes of time by a physician or QHCP during a 30-day time period, while CPT Code 99457 requires an aggregate of 20 minutes of time by clinical staff, physician, or QHCP during the calendar month. The billing practitioner should carefully review the requirements for each and use his/her professional judgment to determine which code the provided services fall under.
The CPT Manual states that CPT Codes 99453 and 99454 require at least 16 days of monitoring before they can be billed. Does this mean that patients must transmit data every day for 16 days in order for the billing practitioner to bill these codes?
The CPT Manual states: “Do not report 99453 for monitoring of less than 16 days” and “Do not report 99454 for monitoring of less than 16 days.” However, neither the 2019 nor the 2020 Medicare Physician Fee Schedule reference a similar requirement, nor do they indicate that data must be transmitted every day for 16 days. It is quite possible that the “16 days” referenced in the CPT Manual is meant to distinguish short-term diagnostic monitoring that is generally separately billable under another CPT code from the longer-term monitoring contemplated by these RPM codes. Providers should use their professional judgement when deciding whether to bill CPT codes 99453 and 99454.
*CMS has proposed that data transmission must occur at least 16 days out of every 30 days to report 99453 and 99454 per the 2021 MPFS Proposed Rule; the industry is awaiting CMS’s final decision on this proposed change.
What does “physiologic” mean for purposes of billing the RPM codes?
The term “physiologic” was first introduced with respect to RPM in the 2018 Medicare Physician Fee Schedule. There, CMS provided some examples of physiologic data in the descriptor for CPT code 99091, including “ECG, blood pressure, [and] glucose monitoring.” Commenters to the 2019 and 2020 Final Rules urged CMS to provide further clarification as to the definition of “physiologic” for purposes of RPM, but CMS has yet to do so as of the date of this document. Stakeholders have interpreted “physiologic” to include an array of data collected via RPM services, including patient-reported pain and care plan adherence data. For now, providers should use their professional judgment in determining what constitutes “physiologic” for purposes of RPM and check with their local MAC for any specifics unless and until CMS issues further guidance.
What types of devices can be used for providing RPM services?
The CPT Manual states that devices used for RPM services must be “medical devices” as that term is defined by the U.S. Food and Drug Administration (FDA) in the Food, Drug & Cosmetics Act (FD&C Act). This does NOT mean the devices used must be FDA-approved or FDA-cleared, and the definition includes some mobile medical applications that meet the applicable FD&C Act definition. More information regarding medical devices under the FD&C Act can be found on the FDA website.
Please note: The information in this document does not constitute legal advice to the reader, nor is it a guarantee of reimbursement for any claims.