The following are questions that frequently arise related to Medicare coverage and billing for remote patient monitoring (RPM).
What is Remote Patient Monitoring?
Remote patient monitoring services (RPM) are performed when physicians, qualified health care professionals (QHPs), and clinical staff monitor and collect patient physiological data, such as blood pressure readings, weight, blood glucose levels, and use such data to manage a patient under the patient’s treatment plan.
AMA RPM Code Descriptors
99091 RPM 2018
Collection and interpretation of physiological data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the end 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.
99457 RPM 2019
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.
99453 RPM 2019
Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment.
99454 RPM 2019
Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days.
99457 RPM 2020
This code revision is proposed for CY 2020 and covers the initial 20 minutes of RPM services, CMS will issue final determination in the fall of 2019. Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health are professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; initial 20 minutes.
994X0 RPM 2020
This code is proposed for CY 2020 and covers additional 20 minutes of RPM services, CMS will issue final determination in the fall of 2019. Remote physiologic monitoring treatment management services, clinical staff/physician/other qualified health are professional time in a calendar month requiring interactive communication with the patient/caregiver during the month; additional 20 minutes.
What codes can be used to bill RPM to Medicare?
Currently, codes 99453, 99454, 99457 and 99091. All of these codes are professional evaluation and management (E/M) service codes. Codes 99454 and 99453 are practice expense only codes, which account for costs of the service rendered, other than physician time or work.
Note: In the summer of 2019, CMS proposed a revision to code 99457 to apply to the initial 20 minutes of RPM services and a new code 994X0 which applies to the subsequent 20 minutes. If finalized, providers may receive additional reimbursement for RPM services that exceed 20 minutes, starting in January 2020.
What type of devices can be used to perform RPM?
The device must meet the FDA’s definition of a medical device. While Medicare does not require the device to be FDA “approved” or “cleared” by the FDA, your specific use of a device with patients may require such FDA approval. You should obtain legal counsel to determine your FDA compliance obligations and whether or not your device meets the FDA’s definition.
The device should automatically collect and transmit the monitored patient data. There should be no need for human intervention or patient “journal” data entry.
What practitioners can bill RPM codes?
Only physicians and other QHPs who are able to bill E/M services can bill for RPM.
Code 99091 does not allow for use of clinical staff; only physicians and QHPs may perform the service.
Code 99457 does allow for physicians and QHPs to utilize clinical staff and bill for the staff member(s)’ time “incident to” their own professional services. Currently, Medicare requires clinical staff to be under direct supervision, which requires the physician or QHP to be on the same premises as, and immediately available to, the clinical staff. However, in the summer of 2019, CMS has proposed to allow for general supervision which allows for remote supervision of clinical staff, provided the supervising provider is available by phone when needed. CMS will issue its final determination in the fall of 2019. You must meet all the requirements for incident to billing, not just the supervision requirement.
Who is a QHP? Who constitutes clinical staff?
QHPs are professionals qualified by education, training, licensure and facility privileging to perform a professional service within his/her scope of practice and independently bill for that service. Examples of QHPs who can bill for E/M are nurse practitioners, physician assistants and clinical nurse specialists. These QHPs can provide RPM services. But not all QHPs can bill for E/M services. For example, although a physical therapist meets the definition of a QHP, they cannot bill Medicare for E/M services and therefore cannot bill for RPM.
Clinical staff are individuals who work under the supervision of a physician or eligible QHP and who are allowed by law, regulation or facility policy to perform or assist in the performance of a specific professional service. Common examples are nurses and medical assistants. Clinical staff do not independently bill Medicare for the service, but physicians and QHPs can bill under their provider number for clinical staff services performed “incident to” the physician or QHP’s professional service. The required level and scope of supervision of clinical staff is governed by both Medicare policy and applicable state law.
Can two providers render RPM to the same patient during the same time period?
Medicare policy currently does not prohibit this, so long as the time counted is not duplicative between the providers and the time and services remain distinct. In addition, all services (RPM or otherwise) must be reasonable and medically necessary in order for Medicare to reimburse them.
Can a technology company bill Medicare for RPM?
No. Only group practices properly formed under state law may furnish professional services, such as RPM, through their practitioners (group practice members). These group practice members must retain all clinical decision making and patient care management. Only group practices enrolled in Medicare and to which a physician or QHP has properly reassigned billing rights may furnish bill Medicare for RPM. Pure technology companies do not meet these requirements.
When can the codes be billed? What is the frequency of billing?
Code 99091 may be billed once per 30 days.
Code 99457 may be billed once per calendar month.
Code 99454 may be billed once per 30 days. (Note: The use of both calendar month and 30-day time periods highlights a discrepancy CMS may clarify in future guidance).
Code 99453 may be billed once per episode of care. (Note: An episode of care begins when the monitoring initiates and ends with the attainment of targeted treatment goals.)
Can RPM be reported on the same day as other E/M services?
Medicare rules state RPM Codes 99091 and 99457 may not be reported in the same time period or on the same day as an E/M service. However, either code may be reported during the same service period as chronic care management (CCM)1 transitional care management (TCM)2, and behavioral health integration (BHI)3 – but the time spent on each of these services must be distinct and not overlap with the other services. You cannot double count minutes.
Does the data have to be collected and monitored in-person or face-to-face?
No. RPM is inherently remote and a non-face-to-face service. However, prior to billing Code 99091, the patient must have had an in-person exam with the billing practitioner within the prior 12 months. Note: a patient exam is not required to bill Code 99457.
Do patient co-payments apply?
Yes. A Medicare patient will be obligated to pay a co-pay for RPM. Accordingly, Medicare requires that a patient’s written or verbal consent be documented in advance. These co-pays cannot be routinely waived.
How much monitoring must be performed?
Code 99091 requires 30 minutes per month of professional monitoring which can done by a physician or QHP.
Code 99457 requires 20 minutes per month of professional monitoring which can be done by a physician, QHP, or with the use of supervised clinical staff.
The practice expense Codes of 99453 and 99454 require the RPM medical device to monitor at least 16 days per month, in total. The days need not be consecutive days.
Chronic Care Management Codes: CPT codes 99487, 99489, and 99490
Transitional Care Management Codes: CPT codes 99495 and 99496
Behavioral Health Integration Codes: CPT codes 99484, 99492, 99493, and 99494
Final 2019 Medicare Physician Fee Schedule, 83 Fed. Reg. 59452 (November 23, 2018)
Proposed 2020 Medicare Physician Fee Schedule, 84 Fed. Reg. 40482 (August 14, 2019)
American Medical Association (AMA) CPT Professional 2019
42 C.F.R. § 410.32(b)(3)
Medicare Benefit Policy Manual Ch. 15 Sections 60.1, 60.4 & 80