This is the third and final part of our series on the remote patient monitoring (RPM) CPT codes. Make sure to read Part 1, which covers CPT Codes 99453 and 99454, and Part 2, which covers CPT Codes 99457, 99458, and 99091.
Since the Centers for Medicare & Medicaid Services (CMS) began providing standalone reimbursement for Remote Patient Monitoring in 2018, there have been a remarkable number of changes shaping how providers offer RPM services and how they get reimbursed for it. The most recent of these came in January 2021 with the implementation of the 2021 Medicare Physician Fee Schedule, which brought numerous updates to and clarifications of the CMS rules, some positive, others not so much.
Given the scope of these changes, many providers across the healthcare continuum understandably have questions about the RPM CPT codes, procedures, and reimbursement amounts. To help you navigate these changes through 2021 and beyond, we've put together a list of responses to the most frequently asked questions regarding the RPM CPT codes.
This information was compiled with the help of our the attorneys at Nixon Gwilt Law. We will note that the information outlined here does not constitute legal advice to the reader, nor is it a guarantee of reimbursement for any claims.
If you’re interested in diving deeper into the RPM billing and coding landscape, check out our free RPM Guide, which covers the CPT codes in greater detail, or get in touch with our team of RPM experts, who would be more than happy to answer your specific questions and help you determine if RPM is right for your patient population.
Yes. As with all Medicare services, patients are responsible for all applicable co-payments and cost-sharing amounts. Medicare Part B beneficiaries are typically responsible for a 20% co-pay each time a code is billed. During the COVID PHE, however, providers may waive copays for RPM services.
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.
No. Despite their original name, CPT codes 99453, 99454, 99457, and 99458 are not limited to patients who qualify for Chronic Care Management (CCM) services and are not considered CCM services under Medicare. The 2021 Medicare Physician Fee Schedule and 2021 American Medical Association CPT Codebook (the “CPT Codebook”) now refer to these services simply as “Remote Physiologic Monitoring.”
CPT code 99091 can be billed by physicians and Qualified Health Care Professionals or “QHCPs.” According to the American Medical Association, a “QHCP” 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 or her scope of practice and independently reports that professional service.”
The American Medical Association CPT Manual (the “CPT Manual”) states that CPT codes 99457 and 99091 cannot be billed in conjunction with each other. However, CMS stated in the 2021 Medicare Physician Fee Schedule that there may be instances in which it is appropriate to bill both 99457 and 99091 at the same time.
Yes. 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.
No. 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, an “episode of care” begins when the service is initiated and ends when targeted treatment goals are attained.
No. 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.
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.
Yes. For new patients or patients not seen by the billing practitioner within 1 year prior to billing CPT codes 99457 or 99091, 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).
Yes. 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.
In general, services provided on an incident-to basis must be performed under direct supervision of the billing practitioner, meaning the billing practitioner must be in the same physical office location as the clinical staff. However, for CPT code 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 suite.
This allows for an 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).
A clinical staff member is defined in the CPT Codebook as “a person who works under the supervision of a physician or other qualified healthcare professional and who is allowed by law, regulation, and facility policy to perform or assist in the performance of a specified professional service, but who does not individually report that service.” This means that the type of personnel that qualify as “clinical staff” for purposes of RPM varies by state law and providers should look to applicable scope of practice laws in the patient’s state to determine who can and cannot provide monitoring services.
No. Medicare does not pay for services provided by individuals located outside of the U.S. and major territories.
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 with the patient. Further, CPT code 99091 requires an aggregate of 30 minutes of time spent 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 their professional judgment to determine which code the provided services fall under.
Likely yes. CMS noted in the 2021 Rule that 99453 and 99454 require 16 days of readings within a 30-day period in order to be billable. What does “physiologic” mean for purposes of billing the RPM codes?
There, CMS provided some examples of physiologic data in the descriptor for CPT code 99091, including “ECG, blood pressure, [and] glucose monitoring.” Stakeholders have urged CMS to provide further clarification as to the definition of “physiologic” for purposes of RPM, but CMS has yet to do so. For now, providers should use their professional judgment in determining what constitutes “physiologic” for purposes of RPM unless and until CMS issues further guidance.
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.
Part 1: 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 (current): Remote Patient Monitoring (RPM) CPT Codes Frequently Asked Questions