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CPT Codes 99453 and 99454: What Healthcare Providers Should Know

Feb 23, 2021 7:45:00 AM

This is the first part of our series on the remote patient monitoring (RPM) CPT codes. Check out Part 2, which covers CPT Codes 99457, 99458, and 99091, and Part 3, which addresses some of the most frequently asked questions regarding the RPM CPT codes.

Remote patient monitoring (RPM) programs have grown in recent years. The COVID-19 pandemic, coupled with advances in technology, and increasing adoption among doctors and patients, have increased demand even further. In response, the Centers for Medicare and Medicaid Services (CMS) have expanded reimbursement codes available for RPM.

There are five Current Procedural Terminology (CPT) codes most relevant to providers looking to develop their own RPM programs:

  • 99453
  • 99454
  • 99457
  • 99458
  • 99091

In this post, we’ll break down everything you need to know about the first two CPT codes on that list, 99453 and 99454.

What Do CPT Codes 99453 and 99454 Entail?

CPT codes 99453 and 99454 codes reimburse for expenses associated with providing RPM services for chronic conditions, such as obesity, hypertension, and heart failure. This includes the cost associated with the monitoring device, distribution of the device to the patient, and the transmission of data.

99453 is a one-time reimbursement code related to setup. It's meant to take into account the time and effort spent educating a patient about the device they’re going to be using for monitoring their particular condition.

Note that it can only be used one single time. Regardless of the number of RPM devices a patient uses, or the number of discrete providers caring for the patient, CPT code 99453 can be billed only once per episode of care per patient.

99454 is related to the supply of the device (or devices) to be used for monitoring. The device must be ordered by the patient’s physician or other qualified healthcare provider. Additionally, the device must be approved by the FDA.

Unlike 99453, 99454 can be used more than once. In fact, 99454 can be reported every 30 days. However, 99454 can be used only once per month, regardless of the number of devices used. In other words, even if a patient uses a weight scale, a blood pressure monitor, and a pulse oximeter, CPT code 99454 can only be used once per month.

What to Consider When Billing for 99453 and 99454

Average Medicare Reimbursement Rate for 99453 and 99454

According to the 2021 Medicare Physician Fee Schedule, the general national Medicare average reimbursement amount is:

  • $19 for 99453; and
  • $62 for 99454

However, commercial reimbursement amounts vary—some are higher, some are lower than others. It’s a good idea to consult with local payer representatives or a local Medicare Administrative Contractor (MAC) to get a more accurate sense of exact reimbursement rates for any given geographic region.

Minimum 16-Day Requirement for Billing

In order to bill for CPT code 99453 and 99454, data from an RPM device must be transmitted for a minimum of 16 days in a 30-day period. Even if a healthcare provider spends time to educate and distribute an RPM device to a patient, guidelines state that CPT code 99453 “should not be reported if monitoring is less than 16 days.” Thus, it’s imperative that patients are actively engaged in taking their measurements, so the data can be transmitted at least 16 days.

COVID-19 Exception to 16-Day Rule

For patients with suspected or confirmed cases of COVID-19, an exception to the 16-day rule has been put in effect. For the duration of the COVID-19 public health emergency (PHE), a minimum of only 2 days of monitoring is required for patients with suspected or confirmed cases of COVID-19 to bill CPT 99453 or 99454. Again, this only applies to patients with suspected or confirmed cases of COVID-19.

Best Practices for Utilizing 99453 and 99454

Meet in Person for Initial Setup

The pandemic has changed the way many businesses operate. Healthcare providers are now conducting many appointments through remote sessions. It can be an adequate option for some situations, but certainly not for all.

For the initial setup, it’s ideal to meet with patients face-to-face. By doing so, you can demonstrate the device, and then observe the patient set up and use it. This hands-on coaching can be especially beneficial for patients who may be less experienced with technological devices. In the long-term, this actually saves time. Trying to get a patient setup remotely will likely take longer. Also, getting off on a solid start will positively impact sustained patient engagement and retention

Note, that this in-person setup is generally going to be required by CMS, but has been temporarily waived for the duration of the PHE. When the PHE ends, in-person setup must resume.

Have Devices on Hand for Impromptu Demonstrations

During the course of the day, your office will see any number of patients with various conditions. Say a patient comes in for a sprained ankle, but also presents with an elevated blood pressure. If the physician suspects the patient might be hypertensive, they can demonstrate how easy it can be to use an RPM blood pressure cuff. Having just enough extra inventory on hand can facilitate easy device demonstration and potential adoption.

Employ Easy-to-Use Technology

No matter how impressive your patient education materials may be, having equipment that is simple for patients to use is essential. Devices that employ cellular communications technology, versus bluetooth, can ensure more reliable data collection and transmission. If patients find the equipment cumbersome, there’s going to be a higher risk of non-compliance.

Train the Trainer

There are a number of devices on the market that can serve the needs of various RPM programs. For the purposes of 99453, they all serve the same purpose – generating and wirelessly transmitting patient physiological data. However, each of these devices may have different functionality.

When choosing an RPM solution, it’s important to find technology vendors that provide support and training. A dedicated support manager can demonstrate and teach the intricacies and nuances of the device to the dedicated clinical staff at your office who will ultimately distribute them to patients.

Engage with Patients to Ensure Compliance

RPM systems with automated behavior based reminders can help ensure compliance. A smart reminder enables providers to set up a schedule for patients. If the patient misses the recording, the patient will get an automated text or phone call. The result will be more readings with less effort. With the right equipment, training, and systems in place, healthcare providers can handily take advantage of CPT codes 99453 and 99454.

Quality Matters

Choosing the right RPM program might seem like a daunting task. It can be tempting to simply choose the least expensive option. However, it’s wise to take time to research which ones will work best for you and your patients. The level and quality of customer service, and seamless technology can have a big impact on your RPM experience. If you’d like to learn more, you can request a demo to see how Optimize Health can work for you.

The Optimize Health 3-Part Remote Patient Monitoring CPT Code Series

Part 1 (current): CPT Codes 99453 and 99454: What Healthcare Providers Should Know
Part 2: CPT Codes 99457, 99458, and 99091: What Healthcare Providers Should Know
Part 3: Remote Patient Monitoring (RPM) CPT Codes Frequently Asked Questions

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