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CPT Codes 99457, 99458, and 99091: What Healthcare Providers Should Know

Mar 9, 2021 7:00:00 AM

This is the second in our series on the remote patient monitoring (RPM) CPT codes. Check out Part 1, which covers CPT Codes 99453 and 99454, and Part 3, which addresses some of the most frequently asked questions regarding the RPM CPT codes.

Remote patient monitoring (RPM) programs have been quickly gaining momentum over the past few 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 considering an RPM program:

  • 99453
  • 99454
  • 99457
  • 99458
  • 99091

In our previous post in this series, we covered CPT codes 99453 and 99454. In this post, we’ll address everything you need to know about CPT codes 99457, 99458, and 99091.

What Do CPT Codes 99457, 99458, and 99091 Entail?

As mentioned previously, CPT codes 99453 and 99454 are associated with setup and data transmission for RPM devices. CPT codes 99457, 99458, and 99091 codes reimburse for expenses associated with the actual provision of RPM services, including management of devices and monitoring patients for physiologic conditions. These conditions could include, but are not limited to, diabetes, obesity, hypertension, and heart failure. The goal is to support patients by partnering with them to manage their conditions.

99457 allows monthly reimbursement for time spent performing duties related to monitoring physiologic data pertaining to a patient’s treatment management services. This includes activities such as reviewing patient records, analyzing data, managing devices, and communicating with patients. At least one "synchronous 2-way interaction" with the patient per month is required. This could be done by phone or video call.

CMS mandates that at least 20 minutes per calendar month be devoted to a patient (or caregiver of the patient) in order to claim reimbursement. The work can be done by the ordering provider, other qualified healthcare professional (QHCP), or clinical staff, as defined by your state.

99458 is an add-on to 99457. 99458 can be used for each additional 20 minutes of remote monitoring and treatment management services provided in a calendar month. It can also be billed on a monthly basis.

Note that 99458 cannot be billed as a standalone code. It must be used in conjunction with 99457.

99091 is for the collection and interpretation of physiologic data digitally stored and/or transmitted by the patient and/or caregiver to the physician or other QHCP. It can also be billed monthly, and has a slightly higher reimbursement rate. However, it also has more requirements than 99457 and 99458.

A minimum of 30 minutes of time spent reviewing, interpreting, and responding to RPM data must accrue each month. This could involve communicating with patients, adjusting patient care plans, and documenting recommended changes. These tasks must be performed by an MD or QHCP. More on this later.

What to Consider When Billing for 99457, 99458, and 99091

Average Medicare Reimbursement Rate for 99457, 99458, and 99091

The 2021 Medicare Physician Fee Schedule outlines reimbursement rates for RPM services as follows:

  • 99457: $48
  • 99457: $38
  • 99091: $53

Note that these are general national Medicare average reimbursement rates.

Commercial reimbursement amounts, on the other hand, can 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.

Clarification of “Interactive Communication” Requirement

In late 2020, CMS issued a clarification for CPT codes 99457 and 99458 issued a clarification for CPT codes 99457 and 99458, stating that, “ … For CPT codes 99457 and 99458, an ‘interactive communication’ is a conversation that occurs in real-time and includes synchronous, two-way interactions that can be enhanced with video or other kinds of data.” It continues, “We further clarified that the 20-minutes of time required to bill for the services of CPT codes 99457 and 99458 can include time for furnishing care management services as well as for the required interactive communication.”

In other words, there is more flexibility on the definition of “interactive communication.”

99091: Physician or Other Qualified Healthcare Professional vs. Clinical Staff

CPT code 99091 pertains specifically to time spent by a physician or other QHCP on RPM services. Time spent by clinical staff, even while providing care management services, can not be counted for non-QHCPs.

According to the American Medical Association (AMA), a QHCP is “a ‘physician or other qualified healthcare professional’ is an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his/her scope of practice and independently reports that professional service.”

Who is considered a QHCP varies depending on which state you’re in, the scope of your practice, licensing, and guidelines from CMS and other payers. The following professionals are generally classified as QHCPs:

  • Nurse practitioner (NP)
  • Certified nurse specialist (CNS)
  • Physician assistant (PA)
  • Certified nurse mid-wife (CNM)
  • Certified registered nurse anesthetist (CRNA)
  • Clinical social worker (CSW)
  • Physical therapist (PT)

However, you should consult with a regulatory expert familiar with your regulatory/payer mix before confirming.

99091's 30-Minute Minimum

As mentioned earlier, a minimum accrual of 30 minutes per month by a QHCP must be met in order to bill for 99091. Many practices can find it difficult to achieve such a high number of minutes on a monthly basis. Furthermore, 99091 cannot be billed in the same month as 99457. Therefore, many choose to focus on 99457 and 99458 instead.

Best Practices for RPM

Employ Easy-to-Use Technology for Patients

It’s essential to have equipment that is simple for patients. Devices that employ cellular communications technology, versus bluetooth, can ensure more reliable data collection and transmission. However, some patients may still prefer to use bluetooth.

If patients find the equipment cumbersome, there’s going to be a higher risk of non-compliance. So, it’s important to provide technology  options that meet the needs and preferences of your patient population.

Engage With Patients to Ensure Compliance

Automated notifications can help remind patients when to take their measurements. With busy schedules, mundane tasks are often overlooked in everyday life.

Platform alerts can notify a doctor’s office when measurements come in, or conversely, when they don’t. This can enable the care team to follow up with patients as needed.

Take Advantage of Automation in the Platform

Use the tools within your RPM platform to automatically track activities performed by physicians, QHCPs, and clinical staff. All those incremental minutes may seem small, but they can quickly add up to the required 20 or 30-minute minimum threshold.

Choose an Experienced RPM Partner

In order to develop a smoothly running RPM program, it’s important to work with a partner that has a deep understanding of your clinical and administrative workflows, can help you manage reimbursements, and understands the intricacies of regulatory compliance.

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 about how we help providers across the country to deliver clinically and financially effective RPM programs, 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: CPT Codes 99453 and 99454: What Healthcare Providers Should Know
Part 2 (current): 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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